Delegation and Prioritization - NCLEX Questions

A nurse practices beneficence when teaching a class of adolescents about the risks of drinking and driving. Beneficence is best described as: A The actions one takes should promote good. B Always telling the truth C The right to self-determination D Do no harm and safeguard the client.

(The ethical issue was the inequality of treatment based strictly upon racial differences. Secondly, the drug was deliberately withheld even after results showed that the drug was working to cure the disease process in the white men for many years. So after many years, the black men were still not treated despite the outcome of the research process that showed the drug to be effective in controlling the disease early in the beginning of the research project. Therefore harm was done. Nonmaleficence, veracity, and justice were not followed.)

1. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? a) repositions side to side every 2 hours b) elevates the head of the bed 60 degrees c) auscultates the lung field every 4 hours d) encourages deep breathing exercises every 2 hours

1) B - The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures to promote lung expansion in the client with ascites, but the priority measure is the one that relieves diaphragmatic pressure.

10. A nurse is assessing a 39 year old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol of level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. The nurse would place priority on which risk factor for coronary heart disease (CHD) in this client? a) age b) hypertension c) hyperlipidemia d) glucose intolerance

10) B - Hypertension, cigarette smoking, and hyperlipidemia are major risk factors for CHD. Glucose intolerance, obesity, and response to stress are also contributing factors. An age of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 190 mg/dL and a blood glucose level of 110 mg/dL are within the normal range. The nurse places priority on major risk factors that need modification.

12. A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. The initial nursing action would be to: a) check the fetal heart rate b) check the maternal blood pressure c) maintain an open airway d) administer oxygen to the mother by face mask

12) C - The initial nursing action when a client progresses to an eclamptic state (has a seizure) is to maintain an open airway. Options A, B, and D are procedures that may be implemented but option 3 identifies the initial action.

13. A nurse is caring for a client who has wrist restraints applied. Which nursing intervention would receive highest priority regarding the wrist restraints? a) providing range-of-motion exercises to the wrists b) removing the restraints periodically per agency guidelines c) applying lotion to the skin under the restraints d) assessing color, sensation, and pulses distal to the restraint

13) D - Assessing color, sensation, and pulses distal to the restraint determines the presence of neurovascular compromise that is associated with the use of restraints. All of the other interventions should be implemented, but option 4 is the priority.

14. A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client's blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next? a) the RN need not to carry out further assessment because the LPN is very experienced and trustworthy b) the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively c) the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic d) the RN assesses the client, checks the client's surgical notes, and gathers addition data before calling the surgeon

14) D - The RN must not depend exclusively on the judgment of an LPN because the RN is responsible for supervising those to whom client care has been delegated. The client has recently had surgery, and there is the potential for complications, which may be signaled by alterations in vital signs and respiratory status. An analgesic may be needed, but in order to make that determination, the RN must have more information. A call to the surgeon may be warranted, but the RN has insufficient data at this time. In order to provide the client with the degree of care required, the nurse must assess the client, gather additional information, and analyze that information before notifying the surgeon.

15. A primigravida is admitted to the labor unit. During the assessment of the client, her membranes rupture spontaneously. The priority nursing action is which of the following? a) monitor the contraction pattern b) assess the fetal heart rate c) note the amount, color, and odor of the amniotic fluid d) check maternal vital signs

15) B - When the membranes rupture in the birth setting, the nurse immediately checks the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options A, C, and D may be a component of care but are not the priority action.

17. A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. The nurse should take which initial action? a) examine and treat the wound sites b) obtain and record a detailed history c) encourage and assist the client to ventilate feelings d) administer an anti-anxiety agent

17) A - The client has a physiological injury, and the nurse would initially examine and treat the wound sites because of bleeding. Although options B,C, and D may be appropriate at some point, the initial action would need to be to treat the wounds.

19. A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client's vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check: a) lung sounds b) vital signs c) the chest tube connections d) the amount of drainage

19) C - Constant bubbling in the water seal chamber indicates an air leak. This is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires physician intervention. Although the items in options A, B, and D need to be assessed, they should be performed after initial attempts to locate and correct the air leak.

2. A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last? a) ultrasound b) colonoscopy c) barium enema d) computed tomography

2) C - When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear visualization and accurate results of the other tests listed, if performed before the client has fully excreted the barium. For this reason, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging studies.

21. A nurse in a postanesthesia care unit (PACU) receives a client transferred from the operating room. The PACU nurse assesses the client for which of the following first? a) active bowel sounds b) adequate urine output c) orientation to the surroundings d) a patent airway

21) D - After a transfer from the operating room, the PACU nurse performs an assessment of the client. The ABCs'airway, breathing, and circulation'must be assessed first. Urine output and orientation to the surroundings might also be assessed, but these are not the first actions. The client might not have active bowel sounds at this time because of the effects of anesthesia.

25. A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim will the nurse attend to first? a) an alert victim who has numerous bruises on the arms and legs b) a victim with a partial amputation of a leg who is bleeding profusely c) a hysterical victim who received a head injury d) a victim who sustained multiple serious injuries and is deceased

25) B - The nurse determines which victim will be attended to first on the basis of the acuity level of the victims involved in the disaster. The priority victim is the one who must be treated immediately or life, limb, or vision will be threatened. This victim is categorized as emergent (option 2). The victim who requires treatment, but life, limb, or vision is not threatened if care can be provided within 1 to 2 hours is considered urgent and is the second priority (option 3). The victim who requires evaluation and possible treatment but for whom time is not a critical factor is categorized as nonurgent and is the third priority (option 1).

3. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client? a) diarrhea b) risk for aspiration c) risk for deficient flid volume d) imbalanced nutrition, less than body requirements

3) B - Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Although options 1, 3, and 4 may be a concern, these are not the priority.

4. A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to: a) obtain vital signs b) ask the client about the precipitating events c) complete an abdominal physical assessment d) insert a nasogastric (NG) tube and Hematest the emesis

4) A - The priority action is to obtain vital signs to determine whether the client is in shock from blood loss and to obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Insertion of an NG tube may be prescribed but is not the priority action. A complete abdominal physical assessment needs to be performed but is not the priority.

5. A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of depression. Upon the client's arrival, the client's therapist reports to the nurse that the clients telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts. Keeping this information in mind, the priority of the nurse is to assess for: a) interaction with peers b) the presence of suicidal thoughts c) the amount of food intake for the past 24 hours d) information regarding the past medication regimen

5) B The critical information from the therapist is that the client is having thoughts of self-harm; therefore, the nurse needs further information about present thoughts of suicide so that the treatment plan may be as appropriate as possible. The nurse must make sure the client is safe. The items in options A, C, and D should be assessed; however, evaluation for suicide potential is most important

6. A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern? a) peer support through structured groups b) finding affordable housing for the group c) setting up a 24-hour crisis center and hotline d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available

6) D - The question asks about the immediate concern. The ABCs of community health are always attending to people's basic needs of food, shelter, and clothing. Options A, B, and C are other activities that may be completed at a later time.

7. A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days. When planning forth rescue and relocation of these older residents, what is the first item that the nurse needs to consider? a) contacting the older resident's families b) attending to the emotional needs of the older residents c) arranging for ambulance transportation for the oldest residents d) attending to the nutritional status and basic needs of the older residents

7) D - The question asks about the first thing that the nurse needs to consider. The ABCs of community health are always attending to people's basic needs of food, shelter, and clothing. Options A, B, and C are other activities that may or may not be needed at a later date.

8. A client is scheduled for an arteriogram using a radiopaque dye. The nurse assesses which most critical item before the procedure? a) vital signs b) intake and output c) height and weight d) allergy to iodine or shellfish

8) D - Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary, because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although options A, B, and C are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical.

9. A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on: a) the comfort level b) activity tolerance c) the level of consciousness d) the hydration and nutrition status

9) D- Many of the diagnostic studies to identify GI disorders require that the GI tract be cleaned (usually with laxatives and enemas) before testing. In addition, the client most often takes nothing by mouth before and during the testing period. Because the studies may be done over a period that exceeds 24 hours, the client may become dehydrated and/or malnourished. Although options A, B, and C may be components of the assessment, option D is the priority.

The nurse plans care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first? A. Respiratory status B. Level of consciousness C. Level of pain D. Reflexes and movement of extremities

A. Respiratory status Remember the ABCs of nursing.

Select all the task you could delegate to a nursing assistant as the RN: A. Wound dressing change B. IV flush C. Collecting vital signs D. Weighing a patient E. Mouth care F. Suctioning a patient G. Applying oxygen to a patient H. Connecting a patient to their IV fluids I. Assisting a patient with a bath J. Applying denture paste to dentures K. Checking blood pressure

Answers C, D, E, I, J, and K. These are all tasks the RN could delegate to a nursing assistant.

After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics. D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.

D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator. The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications

The nurse cares for clients on the medical/surgical unit. After receiving report, which of the following clients should the nurse see FIRST? 1. An elderly client 2 days postop after a total hip replacement who slipped out of bed when trying to stand. 2. An elderly client with a history of cardiomyopathy who aspirated cooked cereal at breakfast. 3. An elderly client diagnosed with a right-sided CVA who requires assistance going to the bathroom. 4. An elderly client diagnosed with heart failure (HF) who has been vomiting for 3 days.

Strategy: Determine the most unstable client. (2) CORRECT— ensure that client has patent airway; at risk to develop pneumonia (1) assess whether dislocation of prosthesis has occurred; airway takes priority (3) ensure client's safety; client with impaired airway takes priority (4) assess this client second; may have digitalis toxicity; circulatory problem

The nurse learns that patients from a motor vehicle accident are being transferred to the emergency department (ED). The nurse performs triage in the ED. Which of the following patients should the nurse see FIRST? 1. A patient with ecchymosis and lacerations to the facial area. 2. A patient complaining of shortness of breath and pressure in the chest. 3. A patient with blood pressure of 90/60 and apical pulse of 120 bpm. 4. A patient complaining of dizziness and nervousness.

Strategy: Determine the most unstable patient. (3) CORRECT— vital signs indicate shock; most unstable patient (1) does not require immediate attention (2) potential problems; not the most unstable (4) most stable patient of the four; use Maslow hierarchy of needs theory to prioritize; physiological needs take priority; use ABCs