1. What is the FIRST priority in nursing using ABCs?
AIRWAY — Always address airway first before breathing and circulation. Use Maslow's hierarchy: physiological needs first.
2. Which tasks can be delegated to UAP?
UAP CAN do: vital signs on stable patients, bathing, grooming, feeding, ambulation of stable patients, I&O measurement. UAP CANNOT do: assessment, medication admin, teaching, or evaluation.
3. A patient has chest pain. Another patient needs pain medication. Who do you see FIRST?
Chest pain patient FIRST — potential cardiac emergency (life-threatening). Pain medication is important but not immediately life-threatening.
4. What are the 5 Rights of Delegation?
1. Right TASK\n2. Right CIRCUMSTANCE\n3. Right PERSON\n4. Right DIRECTION/COMMUNICATION\n5. Right SUPERVISION
5. Acute vs Chronic — which is priority?
ACUTE problems always take priority over chronic conditions. Example: New onset chest pain (acute) vs chronic back pain.
6. What is the FIRST nursing action when a patient has a seizure?
Protect the patient from injury — position on side, clear the area, do NOT restrain, do NOT put anything in mouth, time the seizure, call for help.
7. Which patient is highest priority? A) BP 150/90 B) O2 sat 88% C) Pain 8/10 D) Glucose 200
B) O2 sat 88% — respiratory compromise (Breathing in ABCs). Low oxygen is immediately life-threatening. The others need attention but are not immediately life-threatening.
8. What does ADPIE stand for?
A — Assessment\nD — Diagnosis\nP — Planning\nI — Implementation\nE — Evaluation\nThis is the nursing process — the foundation of all nursing practice.
9. A patient refuses a blood transfusion for religious reasons. What do you do?
Respect patient autonomy. Competent adults have the right to refuse ANY treatment including life-saving treatment. Document the refusal, ensure patient is informed of risks, notify provider.
10. What is the priority assessment after a patient returns from surgery?
ABC assessment: Airway patency, Breathing (rate, depth, O2 sat), Circulation (BP, HR, bleeding at surgical site), then Level of consciousness, pain, IV site, urinary output.