# A charge nurse is making assignments for the upcoming shift. Which patient assignment should the charge nurse prioritize for the most experienced registered nurse?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319555  
> language: ko  
> subject: Next Gen NCLEX

## 문제

A charge nurse is making assignments for the upcoming shift. Which patient assignment should the charge nurse prioritize for the most experienced registered nurse?

## 보기

1. A 45-year-old patient with diabetes mellitus admitted for routine glucose monitoring and medication administration.
2. A 28-year-old patient with acute respiratory distress syndrome (ARDS) requiring mechanical ventilation and critical care. **✔ 정답**
3. A 65-year-old patient recovering from an uncomplicated hip replacement surgery on post-operative day 2.
4. A 52-year-old patient with stable chronic obstructive pulmonary disease (COPD) receiving nebulizer treatments.

**정답: 2**

## 해설

The ARDS patient on mechanical ventilation requires the most experienced RN due to critical, unstable status needing complex care. Other patients have stable or routine needs manageable by less experienced staff.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question assesses the nursing management principle of appropriate patient assignment based on patient acuity and staff competency. The core concept is Key Point! **Assigning the most unstable patient with the highest need for complex, critical care interventions to the most experienced nurse**. This ensures patient safety and optimal outcomes.

**Answer Rationale**: The correct answer is the patient with Acute Respiratory Distress Syndrome (ARDS) requiring mechanical ventilation. This patient is critically ill, unstable, and requires continuous, sophisticated monitoring and intervention. Managing a ventilator involves understanding ventilator settings, alarms, suctioning, preventing ventilator-associated pneumonia (VAP), and assessing for subtle changes in respiratory status. This demands the highest level of clinical judgment and experience.

**Distractor Analysis**:

Watch out for confusion! Option ①: A patient with diabetes for routine monitoring is stable and requires standard, predictable care. This is an appropriate assignment for a less experienced nurse or a nursing assistant with RN supervision.

Option ③: A patient recovering from uncomplicated surgery on post-operative day 2 is likely stable, mobilizing, and managing pain. While post-op care is important, it is generally less acute than managing a ventilator-dependent patient.

Option ④: A patient with stable COPD receiving nebulizers has a chronic condition that is being managed. The care is routine and does not represent the same level of immediate, life-threatening instability as ARDS.

**Related Concepts**: This question integrates principles of delegation and assignment, patient acuity systems, and the nursing process (prioritization). It also touches on the specific pathophysiology of ARDS, a severe form of respiratory failure characterized by non-cardiogenic pulmonary edema and severe hypoxemia.

Concept Summary

| Concept | Description | Application to Question |
| --- | --- | --- |
| Patient Acuity | The level of patient illness or need for nursing care. Higher acuity = more nursing resources required. | The ARDS patient has the highest acuity. |
| Staff Competency | Matching the complexity of patient needs with the knowledge, skills, and experience of the nurse. | Mechanical ventilation management requires an experienced RN. |
| Delegation vs. Assignment | Assignment: Distributing patient care among staff. Delegation: Transferring a task to a competent individual. | The charge nurse is making assignments, not delegating specific tasks. |
| Prioritization (ABCs) | Airway, Breathing, Circulation. Problems with airway/breathing are always top priority. | The ARDS patient has a compromised airway (intubated) and breathing (ventilator-dependent). |

Side-by-Side Comparison!

| Patient Condition | Acuity Level | Key Nursing Needs | Appropriate Staffing Level |
| --- | --- | --- | --- |
| ARDS on Mechanical Ventilation | Critical/Unstable | Ventilator management, frequent suctioning, continuous monitoring, complex medication drips (sedatives, paralytics), prevention of complications. | Most Experienced RN |
| Stable COPD | Low/Stable | Nebulizer treatments, oxygen therapy, breathing exercises, activity pacing, patient education. | New Graduate RN or LPN with supervision |
| Uncomplicated Post-Op | Moderate/Stable | Pain management, wound care, ambulation, prevention of DVT (Deep Vein Thrombosis) and atelectasis. | Competent RN |

Anatomy, Physiology & Pharmacology Points

- **ARDS Pathophysiology**: Diffuse alveolar damage leads to increased permeability, pulmonary edema, and severe hypoxemia (low PaO2) that is refractory to oxygen therapy alone, often requiring mechanical ventilation with PEEP (Positive End-Expiratory Pressure).

- **Mechanical Ventilation**: The nurse must understand modes (e.g., AC, SIMV), settings (tidal volume, rate, FiO2, PEEP), and how to respond to alarms (high pressure = obstruction; low pressure = disconnection).

- **Related Drugs**: Patients on ventilators often require sedatives (e.g., propofol, midazolam) and analgesics (e.g., fentanyl) for comfort and to prevent fighting the ventilator. Neuromuscular blocking agents may be used in severe cases.

Memory Tips

- **Acronym: SICKEST FIRST**. When prioritizing assignments, the patient who is most unstable (Sickest) gets the most experienced nurse.

- **Think ABCs**: Any patient with an actual or potential problem with Airway, Breathing, or Circulation is a high-priority assignment.

- **Ventilator = Very Experienced Nurse**. Associate the "V" in ventilator with the need for a very skilled nurse.

High-Frequency NCLEX Topics
The NCLEX-RN constantly tests **prioritization, delegation, and assignment**. You will see many questions asking "Which patient should the nurse see first?" or "Which task should be delegated to the UAP (Unlicensed Assistive Personnel)?" The rule is: *Unstable, complex patients require RN-level judgment and should not be delegated.* Mechanical ventilation care is a classic example of an RN-only responsibility.

Watch Out for Question Variations!

- Instead of "most experienced RN," the question could ask: "Which patient should the charge nurse assign to herself/himself?" (Same answer).

- It could be flipped: "Which patient is appropriate to assign to a newly licensed nurse?" (Then you would choose the stable diabetic or post-op patient).

- It could combine with delegation: "The charge nurse assigns the ARDS patient to an experienced RN. Which task for this patient can be delegated to the LPN/LVN?" (Answer: Routine vital signs, oral care, turning—but NOT adjusting ventilator settings or assessing breath sounds for a new problem).

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**: You are the charge nurse on a medical-surgical unit that has recently admitted a patient transferred from the ICU. The patient is a 60-year-old male with ARDS secondary to pneumonia. He is intubated, on mechanical ventilation (AC mode, FiO2 60%, PEEP 10), and on a propofol drip for sedation. You have an experienced RN with 10 years of ICU experience, a new graduate RN, and two nursing assistants on your team.

**Nursing Intervention Strategy**:

- **Assessment**: The experienced RN must perform a comprehensive assessment: Monitor ventilator settings and alarms continuously. Assess breath sounds every 1-2 hours and as needed. Monitor for signs of ventilator asynchrony. Check endotracheal tube (ETT) placement and cuff pressure. Assess sedation level using a tool like the RASS (Richmond Agitation-Sedation Scale). Monitor hemodynamics (BP, HR), oxygen saturation (SpO2), and arterial blood gases (ABGs).

- **Nursing Diagnosis**: Impaired Gas Exchange related to alveolar-capillary membrane changes. Risk for Infection (Ventilator-Associated Pneumonia).

- **Planning & Implementation**: The RN will maintain the ventilator circuit, perform sterile suctioning, provide oral care with chlorhexidine every 12 hours, reposition the patient every 2 hours, and manage the sedation drip to keep the patient comfortable but assessable. The RN will also collaborate with respiratory therapy.

- **Evaluation**: Evaluate ABG results, SpO2 trends, and chest X-ray findings. Evaluate for successful weaning parameters when the patient's condition improves.

**Patient Safety and Precautions**:

- Key Point! Always have a bag-valve-mask (BVM) at the bedside in case of ventilator failure or disconnection.

- Prevent VAP by maintaining the head of bed at 30-45 degrees unless contraindicated.

- Never leave a patient on a ventilator unattended for long periods. Alarms must be answered immediately.

- Use two nurses to verify and administer high-alert medications like sedatives and paralytics.

Nursing Procedure & Medication Flow
**Managing a Sedation Drip (e.g., Propofol)**:

- **Assessment**: Assess sedation level (RASS) and pain before initiating or titrating.

- **Administration**: Administered via a dedicated IV line as a continuous infusion using an IV pump. The dose is titrated to achieve the prescribed sedation goal (e.g., RASS -2 to 0).

- **Monitoring**: Monitor for hypotension (common side effect), bradycardia, and hypertriglyceridemia with prolonged use. Monitor for signs of propofol infusion syndrome (metabolic acidosis, rhabdomyolysis) – rare but serious.

- **Calculation**: Be proficient in calculating mcg/kg/min doses. Example: Order: Propofol 10 mcg/kg/min. Patient weight: 70 kg. Concentration: 10 mg/mL. Flow rate = (10 mcg/kg/min * 70 kg * 60 min/hr) / (10 mg/mL * 1000 mcg/mg) = 4.2 mL/hr.

A Word from Your Senior Nurse
"Making safe assignments is one of the most critical skills a charge nurse develops. It's not just about fairness; it's about protecting your patients and supporting your team. When you look at the board, always ask yourself: 'Who is the sickest? Who could deteriorate fastest?' That patient belongs with your strongest nurse. Remember, your new grads are the future of nursing—give them patients they can learn from safely, not patients that will overwhelm them. This balance is the art of nursing leadership, and it starts with solid clinical judgment on questions just like this one."

## 핵심 개념

- **Acuity** — The level of a patient's illness or need for nursing care and resources. High-acuity patients require more intensive monitoring and intervention.
- **Mechanical Ventilation** — The use of a machine (ventilator) to move air in and out of the lungs for a patient who is physically unable to breathe or is breathing insufficiently. Requires specialized nursing knowledge for management and complication prevention.
- **ARDS (Acute Respiratory Distress Syndrome)** — A life-threatening condition of severe, widespread inflammation in the lungs leading to fluid buildup in the alveoli, causing refractory hypoxemia and often requiring mechanical ventilation.
- **Delegation** — The process by which a nurse directs another person (e.g., LPN, UAP) to perform nursing tasks and activities while retaining accountability for the outcome. Must follow the 5 Rights: Right Task, Right Circumstance, Right Person, Right Direction/Communication, Right Supervision/Evaluation.
- **Patient Assignment** — The distribution of patient care among available nursing staff members (RNs, LPNs, UAPs) based on patient needs and staff competencies. The charge nurse is responsible for making safe and appropriate assignments.

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