Test Strategies, Prioritization, &
Delegation
Archer Review Crash Course
Welcome!
● If you have a question please enter it in the chat! I will do my
best to answer questions as we go, but if I miss one will always
circle back to you!
● We will take 1-2 breaks throughout the class
● Handouts & powerpoint slides are located in the ‘Handouts’
section of your GoToWebinar control panel. You can download
and print them from here!
● If you have any technical issues or questions about streaming,
handouts, etc. please email
, Prioritization
ABC’s
Airway Circulation
● Breathing
○ Are they getting good
Foreign body in the airway ○ Adequate respirations blood flow to their
Obstruction RR is sufficient
tissues.
Edema Shallow? Bilateral ○ Providing oxygen to
Goal is a patent airway breath sounds organs
No patent airway? ○ Good air entry ○ Good pulses Brisk cap-
Intubate Breathing insufficient? ○
refill Warm skin
○
Trach Breathe for them. ○
Appropriate color
○
BMV ○
Insufficient circulation?
○
Fluids
Pressors
,NCLEX Question
A client in septic shock in the intensive care unit is receiving a
Dopamine infusion. Upon assessment, the nurse notices that the
client’s; blood pressure is 195/120 mm Hg. Which initial nursing
action would the nurse implement?
a. Discontinue dopamine.
b. Notify the physician
c. Administer Furosemide.
d. Assess the clients’ GCS
Answer: A
A is correct. The initial action for the nurse is to discontinue Dopamine,
which is a vasoconstrictor, the medication that causes the client’s high
blood pressure. B is incorrect. The nurse needs to notify the physician
in order to arrange an adjustment of the medication dosage. However,
this should not be the initial action of the nurse. C is incorrect. The
nurse can give Furosemide to decrease the patient's blood pressure.
But the nurse should terminate the exact cause of hypertension which
is Dopamine. D is incorrect. The nurse can assess the client's GCS, but
the nurse should decrease the client's blood pressure.
, NCLEX Question
A client in his early 60s is brought to the ER complaining of
shortness of breath. Initial assessment findings include crackles,
finger clubbing, and dry cough. The client states that he has
previously worked in construction for 15 years. The ER physician
suspects asbestosis. Which nursing problem should the nurse
prioritize in the client?
a. Impaired gas exchange
b. Imbalanced nutrition: Less than body requirements
c. Fatigue
d. Ineffective airway clearance
Answer: A
A is correct. In asbestosis, there is filling and inflammation of lung spaces with
asbestos fibers. These fibers move into the alveolar space and cause fibrosis,
leading to increased production in secretions impairing gas exchange. This
should be a priority problem for the nurse. B is incorrect. There is imbalanced
nutrition on the patient because of his difficulty of breathing and intolerance
to activity. However, it should not be prioritized over the gas exchange. C is
incorrect. Because of the client’s impaired oxygenation, there is not enough
oxygen that reaches the muscles to sustain activity. However, this problem
must not take priority over the gas exchange. D is incorrect. Due to the
increased secretions brought about by the asbestos fibers, there is an
ineffective airway clearance. Although equally crucial with gas exchange, the
nurse should prioritize impaired gas exchange over airway clearance because
treatment for asbestosis is focused on the relief of symptoms. Oxygen
delivery to the cells holds more importance.
Delegation
Archer Review Crash Course
Welcome!
● If you have a question please enter it in the chat! I will do my
best to answer questions as we go, but if I miss one will always
circle back to you!
● We will take 1-2 breaks throughout the class
● Handouts & powerpoint slides are located in the ‘Handouts’
section of your GoToWebinar control panel. You can download
and print them from here!
● If you have any technical issues or questions about streaming,
handouts, etc. please email
, Prioritization
ABC’s
Airway Circulation
● Breathing
○ Are they getting good
Foreign body in the airway ○ Adequate respirations blood flow to their
Obstruction RR is sufficient
tissues.
Edema Shallow? Bilateral ○ Providing oxygen to
Goal is a patent airway breath sounds organs
No patent airway? ○ Good air entry ○ Good pulses Brisk cap-
Intubate Breathing insufficient? ○
refill Warm skin
○
Trach Breathe for them. ○
Appropriate color
○
BMV ○
Insufficient circulation?
○
Fluids
Pressors
,NCLEX Question
A client in septic shock in the intensive care unit is receiving a
Dopamine infusion. Upon assessment, the nurse notices that the
client’s; blood pressure is 195/120 mm Hg. Which initial nursing
action would the nurse implement?
a. Discontinue dopamine.
b. Notify the physician
c. Administer Furosemide.
d. Assess the clients’ GCS
Answer: A
A is correct. The initial action for the nurse is to discontinue Dopamine,
which is a vasoconstrictor, the medication that causes the client’s high
blood pressure. B is incorrect. The nurse needs to notify the physician
in order to arrange an adjustment of the medication dosage. However,
this should not be the initial action of the nurse. C is incorrect. The
nurse can give Furosemide to decrease the patient's blood pressure.
But the nurse should terminate the exact cause of hypertension which
is Dopamine. D is incorrect. The nurse can assess the client's GCS, but
the nurse should decrease the client's blood pressure.
, NCLEX Question
A client in his early 60s is brought to the ER complaining of
shortness of breath. Initial assessment findings include crackles,
finger clubbing, and dry cough. The client states that he has
previously worked in construction for 15 years. The ER physician
suspects asbestosis. Which nursing problem should the nurse
prioritize in the client?
a. Impaired gas exchange
b. Imbalanced nutrition: Less than body requirements
c. Fatigue
d. Ineffective airway clearance
Answer: A
A is correct. In asbestosis, there is filling and inflammation of lung spaces with
asbestos fibers. These fibers move into the alveolar space and cause fibrosis,
leading to increased production in secretions impairing gas exchange. This
should be a priority problem for the nurse. B is incorrect. There is imbalanced
nutrition on the patient because of his difficulty of breathing and intolerance
to activity. However, it should not be prioritized over the gas exchange. C is
incorrect. Because of the client’s impaired oxygenation, there is not enough
oxygen that reaches the muscles to sustain activity. However, this problem
must not take priority over the gas exchange. D is incorrect. Due to the
increased secretions brought about by the asbestos fibers, there is an
ineffective airway clearance. Although equally crucial with gas exchange, the
nurse should prioritize impaired gas exchange over airway clearance because
treatment for asbestosis is focused on the relief of symptoms. Oxygen
delivery to the cells holds more importance.
