1. An experienced LPN/LVN, under the supervision of the team leader RN, is providing
nursing care for a patient with a respiratory problem. Which
... [Show More] actions are appropriate to
the scope of practice of an experienced LPN/LVN? (Select all that apply.)
1. Auscultating breath sounds
2. Administering medications via metered-dose inhaler (MDI)
3. Completing in-depth admission assessment
4. Checking oxygen saturation using pulse oximetry
5. Developing the nursing care plan
6. Evaluating the patient's technique for using MDIs - ANS-1. Ans: 1, 2, 4
1. Auscultating breath sounds
2. Administering medications via metered-dose inhaler (MDI)
4. Checking oxygen saturation using pulse oximetry
The experienced LPN/LVN is capable of gathering data and making observations,
including noting breath sounds and performing pulse oximetry. Administering
medications, such as those delivered via MDIs, is within the scope of practice of the
LPN/LVN. Independently completing the admission assessment, developing the nursing
care plan, and evaluating a patient's abilities require additional education and skills
within the scope of practice of the professional RN. Focus: Delegation, supervision
2. You are evaluating and assessing a patient with a diagnosis of chronic emphysema.
The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding
concerns you immediately?
1. Fine bibasilar crackles
2. Respiratory rate of 8 breaths/min
3. The patient sitting up and leaning over the nightstand
4. A large barrel chest - ANS-2. Ans: 2. Respiratory rate of 8 breaths/min
For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen
level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is
too high and is causing a high serum oxygen level, which results in a decreased
respiratory rate. If you do not intervene, the patient is at risk for respiratory arrest.
Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand
are common in patients with chronic emphysema. Focus: Prioritization
3. The UAP tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by
nasal cannula is reporting nasal passage discomfort. What intervention should you
suggest to improve the patient's comfort for this problem?
1. Humidify the patient's oxygen.
2. Use a simple face mask instead of a nasal cannula.
3. Provide the patient with an extra pillow.
4. Have the patient sit up in a chair at the bedside. - ANS-3. Ans: 1. Humidify the
patient's oxygen.
When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried
out. The best treatment is to add humidification to the oxygen delivery system. Applying
water-soluble jelly to the nares can also help decrease mucosal irritation. None of the
other options will treat the problem. Focus: Prioritization
4. You are supervising a student nurse who is performing tracheostomy care for a
patient. Which action by the student would cause you to intervene?
1. Suctioning the tracheostomy tube before performing tracheostomy care
2. Removing old dressings and cleaning off excess secretions
3. Removing the inner cannula and cleaning using standard precautions
4. Replacing the inner cannula and cleaning the stoma site - ANS-4. Ans: 3. Removing
the inner cannula and cleaning using standard precautions
When tracheostomy care is performed, a sterile field is set up and sterile technique is
used. Standard precautions such as washing hands must also be maintained but are
not enough when performing tracheostomy care. The presence of a tracheostomy tube
provides direct access to the lungs for organisms, so sterile technique is used to
prevent infection. All of the other steps are correct and appropriate. Focus: Delegation,
supervision
5. You are supervising an RN who floated from the medical-surgical unit to the
emergency department. The nurse is providing care for a patient admitted with anterior
epistaxis (nosebleed). Which directions would you clearly provide to the RN? (Select all
that apply.)
1. Position the patient supine and turned on his side.
2. Apply direct lateral pressure to the nose for 5 minutes.
3. Maintain standard body substance precautions.
4. Apply ice or cool compresses to the nose.
5. Instruct the patient not to blow the nose for several hours. - ANS-5. Ans: 2, 3, 4, 5
2. Apply direct lateral pressure to the nose for 5 minutes.
3. Maintain standard body substance precautions.
4. Apply ice or cool compresses to the nose.
5. Instruct the patient not to blow the nose for several hours.
The correct position for a patient with an anterior nosebleed is upright and leaning
forward to prevent blood from entering the stomach and to avoid aspiration. All of the
other instructions are appropriate according to best practice for emergency care of a
patient with an anterior nosebleed. Focus: Delegation, supervision, assignment
6. A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to
disrupted sleep cycle. Which action should you delegate to the UAP?... [Show Less]