NCLEX -prio/dele
A nursing instructor asks a nursing student to define a critical path. Which statement made by the student indicates a need for further teaching regarding critical paths?
"They are nursing care plans and use the steps of the nursing process."
The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?
As-needed medications given that shift
A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity should be part of it?
Documenting task completion at the end of the day
The nurse is planning the client assignments for the day. Which is an appropriate assignment for the unlicensed assistive personnel (UAP)?
A client who requires a 24-hour urine collection
The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?
A client who requires frequent ambulation
The nurse in charge of a rehabilitation center is planning the client assignments for the day. Which client should the nurse assign to the unlicensed assistive personnel?
A client on strict bed rest and a 24-hour urine collection
The nurse has received a 7 am change of shift report on four clients. Which client should the nurse check first?
A client admitted early this morning with right lower quadrant abdominal pain and an elevated leukocyte count
The nurse has received the following client assignments. In which priority order should the clients be seen based on the clients' needs? Arrange the clients in the order that they should be seen. All options must be used.
A client with an arm cast for 1 day complaining of excruciating pain in the casted arm A client being transferred from the intensive care unit (ICU), 1 day post-coronary artery bypass graft surgery, complaining of incisional pain A client admitted 4 days ago following a myocardial infarction (MI), complaining of a headache A client 1 day postoperative following an open reduction and internal fixation to the wrist, complaining of pain localized to the pin sites A client who is 3 days postoperative abdominal surgery, complaining of pain when taking a deep breath
The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. The student correctly identifies which aspect of care as a priority of care?
Actual or life-threatening concerns
A hospitalized client with type 1 diabetes mellitus received NPH and regular insulin 2 hours ago at 7:30 am. The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8:00 and is due to eat lunch at noon. List in order of priority the actions that the nurse should take. Arrange the actions in the order that they should be performed. All options must be used.
Check the client's blood glucose level. Give the client half a cup of fruit juice to drink. Take the client's vital signs. Retest the client's blood glucose level. Give the client a small snack of carbohydrate and protein. Document the client's complaints, the actions taken, and the outcome.
The nurse is giving a bed bath to an assigned client. An unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which?
Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.
A 7-year-old child is admitted to the pediatric unit with acute exacerbation of asthma due to infection. The health care provider has written the following prescriptions. In which priority order should the nurse implement the prescriptions? Arrange the actions in the order that they should be performed. All options must be used.
High-Fowler's position O2 via nasal cannula at 2 L/min Erythromycin ethylsuccinate (EryPed) 200 mg orally every 6 hours Chest x-ray Clear liquids PO as tolerated
A licensed practical nurse (LPN) has been assigned to assist a community nurse, who is the leader of a task force, to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the group members express concern that more information is needed to determine appropriate measures for the target teenagers. The LPN makes which suggestion to the community nurse to direct the group most effectively?
Prepare a survey that can be distributed to community members to determine their understanding of the drug abuse problem.
A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?
Private room within sight of the nurses' station
The nurse is assigned to assist in working with food services in a rural, poor school setting. A goal for the school dietary program is to avoid nutritional deficiencies and enhance the children's nutritional status through healthy dietary practices. In implementing interventions by levels of prevention, which primary prevention intervention should the nurse suggest to use?
Providing educational programs, literature, and posters to promote awareness of healthy eating
A client has just been treated with cardioversion. The nurse should check which measure first?
Status of airway
A nursing instructor asks a nursing student to identify situations that indicate a secondary level of prevention in health care. Which statement made by the student indicates a need for further study of the levels of prevention?
Teaching a stroke client how to use a walker
The nurse has received a client assignment for the day. In which priority order should the nurse see the clients? Arrange the clients in the order that they should be seen. All options must be used.
The 4-year-old client with heart failure (HF) who had to increase the elevation of the head of the bed to sleep because of dyspnea The 2-year-old client receiving digoxin (Lanoxin) with a heart rate of 70 beats per minute The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching
The nurse is assisting in working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are examples of which type of prevention?
The tertiary level of prevention
Several clients are awaiting treatment in an outpatient mental health crisis treatment center. Which client should be treated first?
A client who says that voices sponsored by the FBI are telling him to stab his roommates
A nurse working in a long-term care facility is assigned to care for four clients on the hospice unit. In planning client rounds, which client should the nurse collect data on first?
A client who was complaining of severe back pain on the previous shift
A licensed practical nurse (LPN) has received the assignment for the day shift. After making rounds and checking all of the assigned clients, which client will the LPN plan to care for first?
A client with a fever who is diaphoretic and restless
A client in labor is experiencing dystocia. In delivering care to this client, the nurse should place the highest priority on which ongoing nursing interventions?
Monitoring of the status of both mother and fetus
The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which is a characteristic of this type of nursing model of practice?
Nursing staff are led by the nurse when providing care to a group of clients.
The nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which first?v
Respiratory status
The licensed practical nurse (LPN) renders aid at an automobile accident where several victims sustained injury. Which actions should the LPN take to offer first aid assistance? Select all that apply.
1.Look for Medic-Alert bracelets. 2.Attend the most seriously injured first. 3.Try to determine the mechanism of injury.
The nurse is planning the client assignments for the day. The assignment that the nurse communicates to the unlicensed assistive personnel (UAP) includes which clients? Select all that apply
A 9-year-old client with cystic fibrosis who requires assistance with toileting A 12-month-old client admitted 3 days ago with respiratory syncytial virus (RSV) who requires a bath A 10-month-old admitted for spasmodic laryngitis croup who is scheduled for discharge the following day who requires feeding
The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse collect data on first?
A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift
The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?
A client requiring frequent ambulation with a walker
The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first?
A client who is dependent on a ventilator
The nurse on the day shift receives client assignments for the day. Which assigned client should the nurse check first?
A client who was admitted during the night because of a severe exacerbation of asthma
A nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse must assign four clients and has a licensed practical nurse (LPN) and three unlicensed assistive personnel (UAP) on a nursing team. To which client should the nurse assign the LPN?
A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours
A client will be undergoing a colonoscopy in the morning. Which task is appropriate to delegate to the unlicensed assistive personnel?
Answering the call light promptly after the enema has been given
The nurse is planning the client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?
Assisting a child who is profoundly developmentally disabled to eat lunch
The nurse is assisting in planning client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?
Assisting a profoundly developmentally disabled child to eat lunch
An unlicensed assistive personnel (UAP) tells the nurse that she is becoming very frustrated trying to communicate with an older client who is severely hard of hearing and does not have his hearing aid. Which instructions should the nurse recommend to improve communication between the UAP and the client? Select all that apply.
1.Make sure the environment is well lit. 2.Face the client and speak slowly and clearly. 3.Ask the client to restate what has been said. 4. Turn the television volume down while communicating.
The licensed practical nurse (LPN) employed in a long-term care facility is asked to assist in planning implementation of a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The LPN understands that which is the initial step in the process of change?
Identify the inefficiency that needs improvement or correction.
The nurse on the day shift is assigned to care for the following six clients. List in order of priority how the nurse should plan to check the assigned clients. Arrange the actions in the order that they should be performed. All options must be used.
Client who has a tracheostomy and is on a mechanical ventilator Client who requires before-breakfast insulin Client who is scheduled for a cardiac catheterization at 9:00 am Client who requires medications at 10:00 am Client who has been diagnosed with diabetes mellitus and who is scheduled for discharge to home Client who is scheduled for physical therapy in the afternoon
