NSG223 Delegation & Prioritization
Which of the statements made by the patient are significant when considering a
problem with perfusion?
Vital signs: Temperature 36.6°C (98°F) Pulse 82 beats/min Blood Pressure 134/90
mmHg Respirations 18 breaths/min Oxygen Saturation 97%. - answer1. Dyspnea on
exertion indicates inadequate circulation interfering with oxygen transport to the tissues.
2. Orthopnea results from a buildup of pressure in the pulmonary circulation that can be
caused by hypertension. 3. Excessive fluid in the interstitial spaces indicates fluid
overload that can be caused by heart disease or renal disease. 5. Lightheadedness on
arising indicates inadequate blood flow to the brain, 6. Fatigue is caused by inadequate
blood flow through the coronary arteries.
An 80-year-old patient on the coronary step-down unit tells the nurse, "I do not need to
take that docusate. I never get constipated!" Which action by the nurse is most
appropriate? - answerExplain that his decreased activity level may cause constipation.
A patient seen in the clinic with shortness of breath and fatigue is being evaluated for a
possible diagnosis of heart failure. Which laboratory result will be most useful to
monitor? - answerB-type natriuretic peptide
The emergency department nurse is caring for a patient who was just admitted with left
anterior chest pain, suggesting possible acute myocardial infarction (MI). Which action
will the nurse take first? - answerAdminister sublingual nitroglycerin.
Which patient is best for the coronary care charge nurse to assign to a float RN who has
come for the day from the general medical-surgical unit? - answerPatient receiving IV
furosemide to treat acute left ventricular failure
The nurse is preparing to administer the following medications to a patient with multiple
health problems who has been hospitalized with deep vein thrombosis. Which
medication is most important to double-check with another licensed nurse? -
answerWarfarin 2.5 mg PO
When the nurse is monitoring a 53-year-old patient who is undergoing a treadmill stress
test, which finding will require the most immediate action? - answerThree premature
ventricular contractions (PVCs) in a row
The nurse makes a home visit to evaluate a hypertensive patient who has been taking
enalapril. Which finding is most important to report to the health care provider? -
answerPatient complains about a frequent dry cough.
, The RN in an emergency room has triaged four patients who arrived simultaneously.
List the order in which the patients should be see - answer1. A 54-year-old obese male
with a history of diabetes presenting with dyspnea, nausea, and indigestion. He reports
that he has had the flu all week. Vital signs are T 38°C (100.4°F), P 84 irregular, R 22,
O2 Sat 95% on room air, and BP 140/92.
2. A 24-year-old female with a history of mitral valve prolapse presenting with vomiting
and diarrhea. She reports the symptoms started after breakfast 2 hours ago and
complains of being somewhat lightheaded. Vital signs are T 39°C (102.2°F), P 110
regular, R 18, O2 Sat 93% room air, and BP 94/62.
3. A 14-year-old healthy male presenting with a swollen, discolored, and painful ankle (7
on a scale of 1-10). He reports he fell off his all-terrain vehicle. Vital signs are
temperature (T) 37°C (98.6°F), pulse (P) 90 regular, respiratory rate (R) 20, oxygen
saturation (O2 Sat) 98% room air, and blood pressure (BP) 130/90.
4. An 80-year-old female with a history of congestive heart failure presenting with
constipation. She reports that she hasn't had a bowel movement in 2 weeks and is
uncomfortable. Vital signs are T 36.4°C (97.5°F), P 77 irregular, R 16, O2 Sat 95% on
room air, and BP 120/70.
The nurse is working with an experienced assistive personnel (AP) and an LPN/LVN on
the telemetry unit. A patient who had an acute myocardial infarction 3 days ago has
been reporting fatigue and chest discomfort when ambulating. Which nursing activity
included in the care plan is best assigned to the LPN/ LVN? - answerAdministering
nitroglycerin 0.4 mg sublingually if chest discomfort occurs during patient activities
While reviewing a hospitalized patient's medical record, the nurse obtains this
information about cardiovascular risk factors. Which interventions will be important to
include in the discharge plan for this patient? Select all that apply. - answerReferral to
community programs that assist in smoking cessation
Teaching about the impact of family history on cardiovascular risk
Teaching about the signs of hypokalemia and foods to supplement potassium loss
At 9:00 pm, the nurse admits a 63-year-old patient with a diagnosis of acute myocardial
infarction. Which finding is most important to communicate to the health care provider
who is considering the use of fibrinolytic therapy with tissue plasminogen activator
(alteplase) for the patient? - answerThe patient reports having continuous chest pain
since 8:00 am.
Two weeks ago, a patient with heart failure received a new prescription for carvedilol
12.5 mg orally. Which finding by the nurse who is evaluating the patient in the
cardiology clinic is of most concern? - answerSinus bradycardia at a rate of 48
beats/min.
Which of the statements made by the patient are significant when considering a
problem with perfusion?
Vital signs: Temperature 36.6°C (98°F) Pulse 82 beats/min Blood Pressure 134/90
mmHg Respirations 18 breaths/min Oxygen Saturation 97%. - answer1. Dyspnea on
exertion indicates inadequate circulation interfering with oxygen transport to the tissues.
2. Orthopnea results from a buildup of pressure in the pulmonary circulation that can be
caused by hypertension. 3. Excessive fluid in the interstitial spaces indicates fluid
overload that can be caused by heart disease or renal disease. 5. Lightheadedness on
arising indicates inadequate blood flow to the brain, 6. Fatigue is caused by inadequate
blood flow through the coronary arteries.
An 80-year-old patient on the coronary step-down unit tells the nurse, "I do not need to
take that docusate. I never get constipated!" Which action by the nurse is most
appropriate? - answerExplain that his decreased activity level may cause constipation.
A patient seen in the clinic with shortness of breath and fatigue is being evaluated for a
possible diagnosis of heart failure. Which laboratory result will be most useful to
monitor? - answerB-type natriuretic peptide
The emergency department nurse is caring for a patient who was just admitted with left
anterior chest pain, suggesting possible acute myocardial infarction (MI). Which action
will the nurse take first? - answerAdminister sublingual nitroglycerin.
Which patient is best for the coronary care charge nurse to assign to a float RN who has
come for the day from the general medical-surgical unit? - answerPatient receiving IV
furosemide to treat acute left ventricular failure
The nurse is preparing to administer the following medications to a patient with multiple
health problems who has been hospitalized with deep vein thrombosis. Which
medication is most important to double-check with another licensed nurse? -
answerWarfarin 2.5 mg PO
When the nurse is monitoring a 53-year-old patient who is undergoing a treadmill stress
test, which finding will require the most immediate action? - answerThree premature
ventricular contractions (PVCs) in a row
The nurse makes a home visit to evaluate a hypertensive patient who has been taking
enalapril. Which finding is most important to report to the health care provider? -
answerPatient complains about a frequent dry cough.
, The RN in an emergency room has triaged four patients who arrived simultaneously.
List the order in which the patients should be see - answer1. A 54-year-old obese male
with a history of diabetes presenting with dyspnea, nausea, and indigestion. He reports
that he has had the flu all week. Vital signs are T 38°C (100.4°F), P 84 irregular, R 22,
O2 Sat 95% on room air, and BP 140/92.
2. A 24-year-old female with a history of mitral valve prolapse presenting with vomiting
and diarrhea. She reports the symptoms started after breakfast 2 hours ago and
complains of being somewhat lightheaded. Vital signs are T 39°C (102.2°F), P 110
regular, R 18, O2 Sat 93% room air, and BP 94/62.
3. A 14-year-old healthy male presenting with a swollen, discolored, and painful ankle (7
on a scale of 1-10). He reports he fell off his all-terrain vehicle. Vital signs are
temperature (T) 37°C (98.6°F), pulse (P) 90 regular, respiratory rate (R) 20, oxygen
saturation (O2 Sat) 98% room air, and blood pressure (BP) 130/90.
4. An 80-year-old female with a history of congestive heart failure presenting with
constipation. She reports that she hasn't had a bowel movement in 2 weeks and is
uncomfortable. Vital signs are T 36.4°C (97.5°F), P 77 irregular, R 16, O2 Sat 95% on
room air, and BP 120/70.
The nurse is working with an experienced assistive personnel (AP) and an LPN/LVN on
the telemetry unit. A patient who had an acute myocardial infarction 3 days ago has
been reporting fatigue and chest discomfort when ambulating. Which nursing activity
included in the care plan is best assigned to the LPN/ LVN? - answerAdministering
nitroglycerin 0.4 mg sublingually if chest discomfort occurs during patient activities
While reviewing a hospitalized patient's medical record, the nurse obtains this
information about cardiovascular risk factors. Which interventions will be important to
include in the discharge plan for this patient? Select all that apply. - answerReferral to
community programs that assist in smoking cessation
Teaching about the impact of family history on cardiovascular risk
Teaching about the signs of hypokalemia and foods to supplement potassium loss
At 9:00 pm, the nurse admits a 63-year-old patient with a diagnosis of acute myocardial
infarction. Which finding is most important to communicate to the health care provider
who is considering the use of fibrinolytic therapy with tissue plasminogen activator
(alteplase) for the patient? - answerThe patient reports having continuous chest pain
since 8:00 am.
Two weeks ago, a patient with heart failure received a new prescription for carvedilol
12.5 mg orally. Which finding by the nurse who is evaluating the patient in the
cardiology clinic is of most concern? - answerSinus bradycardia at a rate of 48
beats/min.
