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You are caring for a heart failure patient who suddenly developed symptoms that include shortness of
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nurse?
A. Insert a foley catheter.
B. Morphine sulfate 2mg IV push
C. Check vital signs every 15 minutes.
D. Start an IV.
Answer: A
Explanation:
The RN should delegate the task to the LPN that does not require assessment. Inserting the
foley catheter is the least likely to require immediate assessment. The RN should insert the IV and
immediately give IV medications. Vital signs that are taken on a deteriorating patient should be taken by
the RN so that immediate assessment can be made.
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C. Each layer in the hierarchy can perform the functions of the other layers.
D. Having three physical tiers is a strict requirement.
E. The network can have two tiers of switches combined into one.
Answer: A,E
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