Prioritization & delegation worksheet with answers

Which finding should a nursing assistant report to the nurse at once?

1. AA patient who wants to shower in the evening
2. BA pulse of 42/min in a patient whose usual pulse is 76/min
3. CA patient who would like tea instead of coffee
4. DA patient whose weight is unchanged from yesterday

Which maneuver opens the airway of an unresponsive adult with no suspected spinal injury?

1. ATurning the head sharply to one side
2. BRaising the legs above the heart
3. CJaw thrust without head tilt
4. DHead-tilt, chin-lift

In mass-casualty triage, which category does a green tag usually mark?

1. AImmediate: needs treatment at once
2. BMinor injuries: the “walking wounded”
3. CDeceased or expectant
4. DDelayed: serious but currently stable injuries

A nursing assistant refuses a delegated task, saying they have not been trained to do it. What is the best response from the nurse?

1. AThank the assistant, make sure the task is done safely and arrange training
2. BLeave the task for the next shift, when someone trained is on
3. CReport the assistant to the manager for refusing a task
4. DTell the assistant it is in the job description and must be done

A nurse teaches a patient with COPD pursed-lip breathing. Which statement shows a need for further teaching?

1. A“I will make my breath out about twice as long as my breath in.”
2. B“I will breathe in through my mouth and out quickly through my nose.”
3. C“I will breathe out slowly through pursed lips.”
4. D“I will breathe in slowly through my nose.”

Which newborn finding needs prompt reporting?

1. AMilia (small white spots) on the nose
2. BMild jaundice that first appears on the third day
3. CJaundice that appears within the first 24 hours
4. DBluish hands and feet in the first hours

At the end of a shift, the nurse’s relief has not arrived and the patients are acutely ill. What should the nurse do?

1. AStay and tell the charge nurse, and hand over before leaving
2. BAsk a nursing assistant to watch the patients until someone comes
3. CLeave on time, because the shift has officially ended
4. DLeave a written note at the station and go home

Two hours after a femoral cardiac catheterization, the nurse sees blood spreading from the puncture site. What is the first action?

1. AApply firm, direct pressure just above the puncture site
2. BAsk the patient to bend the leg at the hip to stop the bleeding
3. CRemove the dressing and leave the site open to the air
4. DRaise the head of the bed so the patient can sit up