Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination

1. In caring for a 3-year-old with pain, which assessment question would be the most useful? 1. " Can you point to the pain with one finger and tell me what that pain feels like inside of you?" 2. " If number 1 were a little pain and number 10 were a big pain, what number would your pain be?" 3. " The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" 4. " One chip is 'a little bit of hurt' and four chips are 'the most hurt.' How many chips would you take for your hurt?"

1. Ans: 3 Pain rating scales using faces (depicting smiling, neutral, frowning, crying, etc.) are appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and the use of advanced vocabulary. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition.

1. You are preparing to review a teaching plan for a patient with type 2 diabetes mellitus. To determine the patient's level of compliance with his prescribed diabetic regimen, which value would you be sure to review? 1. Fasting glucose level 2. Oral glucose tolerance test results 3. Glycosylated hemoglobin (HgbA1c) level 4. Fingerstick glucose findings for 24 hours

1. Ans: 3 The higher the blood glucose level is over time, the more glycosylated the hemoglobin becomes. The HgbA1c level is a good indicator of the average blood glucose level over the previous 120 days. Fasting glucose and oral glucose tolerance tests are important diagnostic tools. Fingerstick blood glucose monitoring provides information that allows adjustment of the patient's therapeutic regimen. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 189). Elsevier Health Sciences. Kindle Edition.

1. You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? 1. An advanced practice nurse and an experienced LPN/ LVN 2. An experienced LPN/ LVN and an inexperienced RN 3. An experienced RN and an inexperienced RN 4. An experienced RN and an experienced UAP

1. Ans: 3 Triage requires at least one experienced RN. Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/ LVN is not qualified to perform the initial client assessment or decision making. Pairing an experienced RN with an experienced UAP is the second best option, because the UAP can measure vital signs and assist in transporting. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 204). Elsevier Health Sciences. Kindle Edition.

1. You are initiating a nursing care plan for a patient with osteoporosis. All of these nursing interventions apply to the nursing diagnosis Risk for Falls. Which intervention should you delegate to the UAP? 1. Identifying environmental factors that increase risk for falls 2. Monitoring gait, balance, and fatigue level with ambulation 3. Collaborating with the physical therapist (PT) to provide the patient with a walker 4. Assisting the patient with ambulation to the bathroom and in the halls

1. Ans: 4 Assisting with activities of daily living (ADLs) is within the scope of the UAP's practice. The other three interventions require additional educational preparation and are within the scope of practice of licensed nurses. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition.

1. You are providing nursing care for a 24-year-old female patient admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP? 1. Teaching the patient how to secure a clean-catch urine sample 2. Assessing the patient's urine for color, odor, and sediment 3. Reviewing the nursing care plan and add nursing interventions 4. Providing the patient with a clean-catch urine sample container

1. Ans: 4 Providing the equipment that the patient needs to collect the urine sample is within the scope of practice of a UAP. Teaching, planning, and assessing all require additional education and skill, which is appropriate to the scope of practice of professional nurses. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition.

2. You are preparing to teach a patient with a new diagnosis of osteoporosis about strategies to prevent falls. Which teaching points will you be sure to include? (Select all that apply.) 1. Wear a hip protector when ambulating. 2. Remove throw rugs and other obstacles at home. 3. Exercise to help build your strength. 4. Expect a few bumps and bruises when you go home. 5. Rest when you are tired.

2. Ans: 1, 2, 3, 5 The purpose of the teaching is to help the patient prevent falls. The hip protector can prevent hip fractures if the patient falls. Throw rugs and obstacles in the home increase the risk of falls. Patients who are tired are also more likely to fall. Exercise helps to strengthen muscles LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition.

2. Which pediatric pain patient should be assigned to a newly-graduated RN? 1. Adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose 2. Child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures 3. Child who is receiving palliative end-of-life care; the child is receiving narcotics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness 4. Child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful

2. Ans: 2 The set of circumstances is least complicated for the child with the fracture, and this would be the best patient for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management the anxiety will resolve. The other three children have more complex social and psychological issues related to pain management. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition.

2. You are working in the triage area of an ED, and the following four clients approach the triage desk at the same time. List the order in which you will assess these clients. 1. Ambulatory, dazed 25-year-old man with a bandaged head wound 2. Irritable infant with a fever, petechiae, and nuchal rigidity 3. 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity 4. 50-year-old woman with moderate abdominal pain and occasional vomiting _____, _____, _____, _____

2. Ans: 2, 1, 4, 3 An irritable infant with fever and petechiae should be further assessed for other signs of meningitis. The client with the head wound needs additional history taking and assessment for intracranial pressure. The client with moderate abdominal pain is in discomfort, but her condition is not unstable at this point. For the ankle injury, medical evaluation could be delayed up to 24 to 48 hours if necessary, but the client should receive the appropriate first aid. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 204). Elsevier Health Sciences. Kindle Edition.

2. Which laboratory result is of most concern to you for an adult patient with cystitis? 1. Serum white blood cell (WBC) count of 9000/ mm3 2. Urinalysis results showing 1 or 2 WBCs present 3. Urine bacteria count of 100,000 colonies per milliliter 4. Serum hematocrit of 36%

2. Ans: 3 The presence of 100,000 bacterial colonies per milliliter of urine or the presence of many white blood cells (WBCs) and red blood cells (RBCs) indicates a urinary tract infection. The WBC count is within normal limits and the hematocrit is a little low, which may need follow-up. Neither of these results indicates infection. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition.

2. You would be most concerned about an order for a total parenteral nutrition (TPN) fat emulsion for a client with which condition? 1. Gastrointestinal (GI) obstruction 2. Severe anorexia nervosa 3. Chronic diarrhea and vomiting 4. Fractured femur

2. Ans: 4 A client with a fractured femur is at risk for fat embolism, so a fat emulsion should be used with caution. Vomiting may be a problem if the emulsion is infused too rapidly. TPN is commonly used in clients with GI obstruction, severe anorexia nervosa, and chronic diarrhea or vomiting. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition.

2. While performing a breast examination on a 22-year-old client, you obtain the following data. Which finding is of most concern? 1. Both breasts have many nodules in the upper outer quadrants. 2. The client reports bilateral breast tenderness with palpation. 3. The breast on the right side is slightly larger than the left breast. 4. An irregularly shaped, nontender lump is palpable in the left breast.

2. Ans: 4 Irregularly shaped and nontender lumps are consistent with a diagnosis of breast cancer, so this client needs immediate referral for diagnostic tests such as mammography or ultrasound. The other information is not unusual and does not indicate the need for immediate action. Focus: Prioritization

28. The UAP tells you that a patient who is receiving oxygen at a flow rate of 6 L/ min by nasal cannula is reporting nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem? 1. Humidify the patient's oxygen. 2. Use a simple face mask instead of a nasal cannula. 3. Provide the patient with an extra pillow. 4. Have the patient sit up in a chair at the bedside.

3. Ans: 1 When the oxygen flow rate is higher than 4 L/ min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 175). Elsevier Health Sciences. Kindle Edition.

3. A nursing diagnosis for a patient with newly-diagnosed diabetes is Risk for Injury related to sensory alterations. Which key points should you include in the teaching plan for this patient? (Select all that apply.) 1. " Clean and inspect your feet every day." 2. " Be sure that your shoes fit properly." 3. " Nylon socks are best to prevent friction on your toes from shoes." 4. " Only a podiatrist should trim your toenails." 5. " Report any nonhealing skin breaks to your health care provider."

3. Ans: 1, 2, 5 Sensory alterations are the major cause of foot complications in diabetic patients, and patients should be taught to examine their feet on a daily basis. Properly-fitted shoes protect the patient from foot complications. Broken skin increases the risk of infection. Cotton socks are recommended to absorb moisture. Patients, family, or health care providers may trim toenails. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (pp. 189-190). Elsevier Health Sciences. Kindle Edition.

3. You are working in the obstetric triage area, and several patients have just come in. Which patient should you assess first? 1. A 17-year-old gravida 1, para 0 (G1P0) woman at 40 weeks' gestation with contractions every 6 minutes who is crying loudly and is surrounded by anxious family members 2. A 22-year-old G3P2 woman at 38 weeks' gestation with contractions every 3 minutes who is requesting to go to the bathroom to have a bowel movement 3. A 32-year-old G4P3 woman at 27 weeks' gestation who noted vaginal bleeding today following intercourse 4. A 27-year-old G2P1 woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago but feels no contractions

3. Ans: 2 A multiparous patient in active labor with an urge to have a bowel movement will probably give birth imminently. She needs to be the first assessed, the provider must be notified immediately, and she must be moved to a safe location for the birth. She should not be allowed up to the bathroom at this time. The other patients all have needs requiring prompt assessment, but the imminent birth takes priority. Vaginal bleeding after intercourse could be due to cervical irritation or a vaginal infection, or could have a more serious cause such as placenta previa. This patient should be the second one assessed. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition.

3. For a patient with hyperthyroidism, which task will you delegate to an experienced UAP? 1. Instructing the patient to report any occurrence of palpitations, dyspnea, vertigo, or chest pain 2. Monitoring the apical pulse, blood pressure, and temperature every 4 hours 3. Drawing blood to measure levels of thyroid-stimulating hormone, triiodothyronine, and thyroxine 4. Teaching the patient about side effects of the drug propylthiouracil

3. Ans: 2 Monitoring vital signs and recording their values are within the education and scope of practice of UAPs. An experienced UAP should have been taught how to monitor the apical pulse. However, a nurse should observe the UAP to be sure that the UAP has mastered this skill. Instructing and teaching patients, as well as performing venipuncture to obtain laboratory samples, are more suited to the education and scope of practice of licensed nurses. In some facilities, an experienced UAP may perform venipuncture, but only after special training. Focus: Delegation, supervision, assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition.

3. Your assessment reveals all of these data when you are admitting a patient with Paget disease. Which finding should you notify the physician about first? 1. There is a bowing of both legs and the knees are asymmetrical. 2. The base of the skull is invaginated (platybasia). 3. The patient is only 5 feet tall and weighs 120 lb. 4. The skull is soft, thick, and larger than normal.

3. Ans: 2 Platybasia (basilar skull invagination) causes brainstem manifestations that threaten life. Patients with Paget disease are usually short and often have bowing of the long bones that results in asymmetrical knees or elbow deformities. The skull is typically soft, thick, and enlarged. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition.

3. When a primary survey of a trauma client is conducted, what is considered one of the priority actions? 1. Obtain a complete set of vital sign measurements. 2. Palpate and auscultate the abdomen. 3. Perform a brief neurologic assessment. 4. Check the pulse oximetry reading.

3. Ans: 3 A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse oximetry readings are considered part of the secondary survey. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 204). Elsevier Health Sciences. Kindle Edition.

4. A 19-year-old G1P0 patient at 40 weeks' gestation who is in labor is being treated with magnesium sulfate for seizure prophylaxis in preeclampsia. Which are priority assessments with this medication? (Select all that apply.) 1. Check deep tendon reflexes. 2. Observe for vaginal bleeding. 3. Check the respiratory rate. 4. Note the urine output. 5. Monitor for calf pain.

4. Ans: 1, 3, 4 Magnesium sulfate toxicity can cause fatal cardiovascular events and/ or respiratory depression or arrest, so monitoring of respiratory rate is of utmost importance. The drug is excreted by the kidneys, and therefore monitoring for adequate urine output is essential. Deep tendon reflexes disappear when serum magnesium is reaching a toxic level. Vaginal bleeding is not associated with magnesium sulfate use. Calf pain can be a sign of a deep vein thrombosis, but is not associated with magnesium sulfate therapy. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition.

4. You are working with a UAP to care for a client who has had a right breast lumpectomy and axillary lymph node dissection. Which nursing action can you delegate to the UAP? 1. Teaching the client why blood pressure measurements are taken on the left arm 2. Elevating the client's arm on two pillows to promote lymphatic drainage 3. Assessing the client's right arm for lymphedema 4. Reinforcing the dressing if it becomes saturated

4. Ans: 2 Positioning the client's arm is a task within the scope of practice for UAP working on a surgical unit. Client teaching and assessment are RN-level skills. The RN should reinforce dressings as necessary, because this requires assessment of the surgical site and possible communication with the surgeon. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 196). Elsevier Health Sciences. Kindle Edition.

4. As the shift begins, you are assigned to care for the following patients. Which patient should you assess first? 1. 38-year-old with Graves disease and a heart rate of 94 beats/ min 2. 63-year-old with type 2 diabetes and fingerstick glucose level of 137 mg/ dL 3. 58-year-old with hypothyroidism and a heart rate of 48 beats/ min 4. 49-year-old with Cushing disease and dependent edema rated as 1 +

4. Ans: 3 Although patients with hypothyroidism often have cardiac problems that include bradycardia, a heart rate of 48 beats/ min may have significant implications for cardiac output and hemodynamic stability. Patients with Graves disease usually have a rapid heart rate, but 94 beats/ min is within normal limits. The diabetic patient may need sliding-scale insulin dosing. This is important but not urgent. Patients with Cushing disease frequently have dependent edema. Focus: Prioritization 5. Ans: 1 Patients with hypofunction of the adrenal gland often have hypotension and should be instructed to change positions slowly. Once a patient has been so instructed, it is appropriate for the UAP to remind the patient of those instructions. Assessing, teaching, and planning nursing care require more education and should be done by licensed nurses. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition.

4. The charge nurse observes an LPN/ LVN providing all of these interventions for a patient with Paget disease. Which action requires that the charge nurse intervene? 1. Administering 600 mg of ibuprofen (Advil) to the patient 2. Encouraging the patient to perform PT-recommended exercises 3. Applying ice and gentle massage to the patient's lower extremities 4. Reminding the patient to drink milk and eat cottage cheese

4. Ans: 3 Applying heat, not ice, is the appropriate measure to help reduce the patient's pain. Ibuprofen is useful to manage mild to moderate pain. Exercise prescribed by the PT would be nonimpact in nature and provide strengthening for the patient. A diet rich in calcium promotes bone health. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition.

4. An LPN/ LVN's assessment of two diabetic patients reveals all of these findings. Which would you instruct the LPN/ LVN to report immediately? 1. Fingerstick glucose reading of 185 mg/ dL 2. Numbness and tingling in both feet 3. Profuse perspiration 4. Bunion on the left great toe

4. Ans: 3 Profuse perspiration is a symptom of hypoglycemia, a complication of diabetes that requires urgent treatment. A glucose level of 185 mg/ dL will need coverage with sliding-scale insulin, but this is not urgent. Numbness and tingling, as well as bunions, are related to the chronic nature of diabetes and are not urgent problems. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 190). Elsevier Health Sciences. Kindle Edition.

4. A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. What is the priority action? 1. Initiate continuous electrocardiographic monitoring. 2. Notify the ED physician. 3. Administer oxygen via nasal cannula. 4. Establish IV access.

4. Ans: 3 The priority goal is to increase myocardial oxygenation. The other actions are also appropriate and should be performed immediately after administering oxygen. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 205). Elsevier Health Sciences. Kindle Edition.

4. You are performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps of the care plan in the order in which each should be accomplished. 1. Apply silver sulfadiazine (Silvadene) ointment. 2. Obtain specimens for aerobic and anaerobic wound cultures. 3. Administer morphine sulfate 10 mg IV. 4. DÃ © bride the wound of eschar using gauze sponges. 5. Cover the wound with a sterile gauze dressing. _____, _____, _____, _____, _____

4. Ans: 3, 4, 2, 1, 5 Pain medication should be administered before changing the dressing, because changing dressings for partial-thickness burns is painful, especially if the dressing change involves removal of eschar. The wound should be dà © brided before obtaining wound specimens for culture to avoid including bacteria that are skin contaminants rather than causes of the wound infection. Culture specimens should be obtained prior to the application of antibacterial creams. The antibacterial cream should then be applied to the area after dà © bridement to gain the maximum effect. Finally, the wound should be covered with a sterile dressing. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition.

4. You are caring for a client with peptic ulcer disease. Which assessment finding is the most serious? 1. Projectile vomiting 2. Burning sensation 2 hours after eating 3. Coffee-ground emesis 4. Boardlike abdomen with shoulder pain

4. Ans: 4 A boardlike abdomen with shoulder pain is a symptom of a perforation, which is the most lethal complication of peptic ulcer disease. A burning sensation is a typical complaint and can be controlled with medications. Projectile vomiting can signal an obstruction. Coffee-ground emesis is typical of slower bleeding, and the client will require diagnostic testing. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition.

4. A 6-year-old who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is your best response to this behavior? 1. Remind the child that foods tasted good today and will help the body to get strong. 2. Allow the mother and child time alone to review and control the behavior. 3. Ask the mother to leave until the child can finish eating and then invite her back. 4. Explain to the mother that the behavior could be a normal expression of anger.

4. Ans: 4 Help the mother to understand that the child may be angry about being left in the hospital or about her inability to prevent the illness and protect the child. Reminding the child about the food and the purpose of the food does not address the strong emotions underlying the outburst. Allowing the mother and child time alone is a possibility, but the assumption would be that the mother understands the child's behavior and is prepared to deal with the behavior in a constructive manner. Asking the mother to leave the child suggests that the mother is a source of stress. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition.

9. Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions are needed for patients who must be placed on bleeding precautions? (Select all that apply.) a. Provide mouthwash with alcohol for oral rinsing. b. Use paper tape on fragile skin. c. Provide a soft toothbrush or oral sponge. d. Gently insert rectal suppositories. e. Avoid aspirin or aspirin-containing products. f. Avoid overinflation of blood pressure cuffs. g. Pad sharp corners of furniture.

4. Ans: b,c, e, f, g Mouthwash should not include alcohol, because it has a drying action that leaves mucous membranes more vulnerable. Insertion of suppositories, probes, or tampons into the rectal or vaginal cavity is not recommended. All other options are appropriate.

5. A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should you delegate to a UAP? 1. Reminding the patient to change positions slowly 2. Assessing the patient for muscle weakness 3. Teaching the patient how to collect a 24-hour urine sample 4. Revising the patient's nursing plan of care

5. Ans: 1 Patients with hypofunction of the adrenal gland often have hypotension and should be instructed to change positions slowly. Once a patient has been so instructed, it is appropriate for the UAP to remind the patient of those instructions. Assessing, teaching, and planning nursing care require more education and should be done by licensed nurses. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition.

5. A client is admitted through the ED for treatment of a strangulated intestinal obstruction with perforation. What interventions do you anticipate for this emergency condition? (Select all that apply.) 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics 7. Morphine via a client-controlled analgesia device

5. Ans: 1, 3, 4, 5, 6 Strangulated intestinal obstruction is a surgical emergency. The NG tube is for decompression of the intestine. Abdominal radiography is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance and allow IV delivery of medication. IV broad-spectrum antibiotics are usually ordered. Pain medications are likely to be withheld during the initial period to prevent masking of peritonitis or perforation. In addition, morphine slows gastric motility. A barium enema examination is not ordered if perforation is suspected. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 205). Elsevier Health Sciences. Kindle Edition.

5. You are taking an initial history for a client seeking surgical treatment for obesity. Which finding should be called to the attention of the surgeon before proceeding with additional history taking or physical assessment? 1. Obesity for approximately 5 years 2. History of counseling for body dysmorphic disorder 3. Failure to reduce weight with other forms of therapy 4. Body weight 100% above the ideal for age, gender, and height

5. Ans: 2 Body dysmorphic disorder is a preoccupation with an imagined physical defect. Corrective surgery can exacerbate this disorder when the client continues to feel dissatisfied with the results. The other findings are criterion indicators for this treatment. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition.

5. Which action would best demonstrate evidence-based nursing practice in the care of a patient who is 1 day postpartum and reporting nipple soreness while breast-feeding? 1. Give the baby a bottle after 5 minutes of nursing to allow soreness to resolve. 2. Assess the mother-baby couplet for nursing position and latch, and correct as indicated. 3. Advise the use of a breast pump until nipple soreness resolves. 4. Advise alternating breast and bottle feedings to avoid excess sucking at the nipple.

5. Ans: 2 It is recommended to avoid artificial nipples and pacifiers while establishing breast feeding unless medically indicated. Improper latch and position are common causes of nipple soreness and can be corrected with assessment and assistance to the mother. This practice supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition.

5. You are the nurse manager in the burn unit. Which client is best to assign to an RN who has floated from the oncology unit? 1. 23-year-old who has just been admitted with burns over 30% of the body after a warehouse fire 2. 36-year-old who requires discharge teaching about nutrition and wound care after having skin grafts 3. 45-year-old with infected partial-thickness back and chest burns who has a dressing change scheduled 4. 57-year-old with full-thickness burns on both arms who needs assistance in positioning hand splints

5. Ans: 3 A nurse from the oncology unit would be familiar with dressing changes and sterile technique. The charge RN in the burn unit would work closely with the float RN to provide partners to assist in providing care and to answer any questions. Admission assessment and development of the initial care plan, discharge teaching, and splint positioning in burn clients all require expertise in caring for clients with burns. These clients should be assigned to RNs who regularly work on the burn unit. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition.

5. A patient is being admitted to rule out interstitial cystitis. What should your plan of care for this patient include? 1. Take daily urine samples for urinalysis. 2. Maintain accurate intake and output records. 3. Obtain an admission urine sample to determine electrolyte levels. 4. Teach the patient about the cystoscopy procedure.

5. Ans: 4 A cystoscopy is needed to accurately diagnose interstitial cystitis. Urinalysis may show WBCs and RBCs, but no bacteria. The patient will probably need a urinalysis upon admission, but daily samples do not need to be obtained. Intake and output may be assessed, but results will not contribute to the diagnosis. Cystitis does not usually affect urine electrolyte levels. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition.

35. While admitting a client, you obtain this information about her cardiovascular risk factors: Her mother and two siblings have had myocardial infarctions (MIs). The client smokes and has a 20 pack-year history of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol (Lopressor) for hypertension, and her blood pressure has been in the range of 130/ 60 to 138/ 85 mm Hg. Which interventions will be important to include in the discharge plan for this client? (Select all that apply.) a. Referral to community programs that assist in smoking cessation b. Teaching about the impact of family history on cardiovascular risk c. Education about the need for a change in antihypertensive therapy d. Assistance in reducing the stress associated with her cardiovascular risk 5. Discussion of the risks associated with having a sedentary lifestyle

a., b. The client's major modifiable risk factor is her ongoing smoking. The family history is significant, and she should be aware that this increases her cardiovascular risk. The goal when treating hypertension with medications is reduction of blood pressure to under 140/ 90 mm Hg. There is no indication that stress is a risk factor for this client. The client's work involves moderate physical activity; although leisure exercise may further decrease her cardiac risk, this is not an immediate need for this client. Focus: Prioritization

18. The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/ LVN being supervised by a nurse? (Select all that apply.) a. Reminding the client to avoid commercial mouthwashes b. Encouraging mouth rinsing with warm saline c. Observing the lips, tongue, and mucous membranes d. Providing mouth care every 2 hours while the client is awake e. Seeking a dietary consult to increase fluids on meal trays

a., b., c., d. The LPN/ LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/ LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician. Focus: Delegation, supervision

26. An experienced LPN/ LVN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/ LVN? (Select all that apply.) a. Auscultating breath sounds b. Administering medications via metered-dose inhaler (MDI) c. Completing in-depth admission assessment d. Checking oxygen saturation using pulse oximetry e. Developing the nursing care plan f. Evaluating the patient's technique for using MDIs

a., b., d. The experienced LPN/ LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/ LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN.

48. Which clients would be best to assign to the most experienced nurse in an ambulatory care center that specializes in vision problems and eye surgery? (Select all that apply.) a. Client who requires postoperative instructions after cataract surgery b. Client who needs an eye pad and a metal shield applied c. Client who requests a home health referral for dressing changes and eyedrop instillation d. Client who needs teaching about self-administration of eyedrops e. Client who requires an assessment for recent and sudden loss of sight f. Client who requires preoperative teaching for laser trabeculoplasty

a., c., e., f. give instructions, making home health referrals, and assessing for needs related to loss of vision should be done by an experienced nurse who can give specific details and specialized information about follow-up eye care and adjustment to loss. The principles of applying an eye pad and shield and teaching the administration of eyedrops are basic procedures that should be familiar to all nurses. Focus: Assignment

33. The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/ LVN who is working with you in the ED? (Select all that apply.) a. Attaching cardiac monitor leads b. Giving heparin 5000 units IV push c. Administering morphine sulfate 4 mg IV d. Obtaining a 12-lead electrocardiogram (ECG) e. Asking the client about pertinent medical history f. Having the client chew and swallow aspirin 162 mg

a., d., f. Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/ LVNs. An experienced ED LPN/ LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/ LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice. Focus: Delegation

7. Which patient is at greatest risk for pancreatic cancer? a. An elderly African-American man who smokes b. young white obese woman with gallbladder disease c. A young African-American man with type 1 diabetes d. An elderly white woman who has pancreatitis

a: Pancreatic cancer is more common in African-Americans, males, and smokers. Other associated factors include alcohol use, diabetes, obesity, history of pancreatitis, exposure to organic chemicals, consumption of a high-fat diet, and previous abdominal irradiation.

50. Which tasks are appropriate to delegate to an LPN/ LVN who is functioning under the supervision of an RN? (Select all that apply.) a. Assessing the sexual implications for a client with oculogenital-type Chlamydia trachomatis infection b. Administering sulfacetamide sodium 10% (Sulf-10 Ophthalmic) to a child with conjunctivitis c. Reviewing hand-washing and hygiene practices with clients who have eye infections d. Showing clients how to gently cleanse eyelid margins to remove crusting e. Assessing nutritional factors for a client with age-related macular degeneration f. Reviewing the health history of a client to identify risk for ocular manifestations g. Performing a routine check of a client's visual acuity using the Snellen eye chart

b, c, d, g Administering medications, reviewing and demonstrating standard procedures, and performing standardized assessments with predictable outcomes in noncomplex cases are within the scope of the LPN/ LVN. Assessing for systemic manifestations and behaviors, risk factors, and nutritional factors is the responsibility of the RN. Focus: Delegation

40. As charge nurse, you are making the daily assignments on the medical-surgical unit. Which patient is best assigned to a float nurse who has come from the postanesthesia care unit (PACU)? a. 30-year-old patient with thalassemia major who has an order for subcutaneous infusion of deferoxamine (Desferal) b. 43-year-old patient with multiple myeloma who requires discharge teaching c. 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy d. 65-year-old patient with pernicious anemia who has just been admitted to the unit

c. A nurse who works in the PACU will be familiar with the monitoring needed for a patient who has just returned from a procedure such as a colonoscopy, which requires conscious sedation. Care of the other patients requires staff with more experience with various types of hematologic disorders and would be better to assign to nursing personnel who regularly work on the medical-surgical unit. Focus: Assignment 6. Ans: 1 Patients with pancytopenia are at higher risk for infection. The patient with digoxin toxicity presents the least risk of infecting the new patient. Viral pneumonia, shingles, and cellulitis are infectious processes. Focus: Prioritization

34. You make a home visit to evaluate a hypertensive client who has been taking enalapril (Vasotec). Which finding indicates that you need to contact the health care provider about a change in the drug therapy? a. Client reports frequent urination. b. Client's blood pressure is 138/ 86 mm Hg. c. Client coughs often during the visit. d. Client says, "I get dizzy sometimes."

c. A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme (ACE) inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more client teaching and ongoing monitoring but would not require a change in therapy. Focus: Prioritization

2. Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? a. " Where is the pain located, and does it radiate to other parts of your body?" b. " How would you describe the pain, and how is it affecting you?" c. " What do you believe about pain medication and drug addiction?" d. How is the pain affecting your activity level and your ability to function?" e. " What information do you need about pain, healing, and addiction?"

c. Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain.

4. Which client is most likely to receive opioids for extended periods of time? a. A client with fibromyalgia b. A client with phantom limb pain in the leg c. A client with progressive pancreatic cancer d. A client with trigeminal neuralgia

c. Cancer pain generally worsens with disease progression, and the use of opioids is more generous.

21. A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? a. Infuse normal saline at 75 mL/ hr. b. Obtain blood, urine, and sputum for cultures. c. Place the client on airborne and contact precautions. d. Give methylprednisolone (Solu-Medrol) 1 g IV.

c. Current Centers for Disease Control and Prevention (CDC) guidelines indicate that rapid implementation of standard, contact, and airborne precautions are needed for any client suspected of having SARS in order to protect other clients and health care workers. If an airborne-agent isolation (negative-pressure) room is not available in the ED, droplet precautions should be initiated until the client can be moved to a negative-pressure room. The other actions should also be taken rapidly but are not as important as preventing transmission of the disease. Focus: Prioritization

11. A few minutes after you have given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should you take first? a. Start oxygen at 4 L/ min using a nasal cannula. b. Obtain IV access with a large-bore IV catheter. c. Give epinephrine (Adrenalin) 0.3 mL intramuscularly. d. Administer 3 mL of nebulized albuterol (Proventil) 0.083%.

c. Epinephrine is the initial drug of choice for treatment of anaphylaxis. Giving epinephrine rapidly at the onset of an anaphylactic reaction may prevent or reverse cardiovascular collapse as well as airway narrowing caused by bronchospasm and inflammation. Oxygen use is also appropriate, but oxygen would be administered using a nonrebreather mask in order to achieve a fraction of inspired oxygen closer to 100%. Albuterol may also be administered to decrease airway narrowing but would not be the first therapy used for anaphylaxis. IV access will take longer to establish and should not be the first intervention.

46. You are working in an ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased lacrimation for several hours. What should you direct the caller to do first? a. " Please call your physician" (i.e., refuse to advise). b. " Apply a cool compress to your eyes." c. " If you are wearing contact lenses, remove them. d. " Take an over-the-counter antihistamine."

c. If the client is wearing contact lenses, the lenses may be causing the symptoms, and removing them will prevent further eye irritation or damage. Policies on giving telephone advice vary among institutions, and knowledge of your facility policy is essential. The other options may be appropriate, but you should gather additional information before suggesting anything else. Focus: Prioritization

43. After a client has a seizure, which action can you delegate to the UAP? a. Documenting the seizure b. Performing neurologic checks c. Taking the client's vital signs d. Restraining the client for protection

c. Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary. Focus: Delegation, supervision

47. At a community health clinic, you are teaching a community group about the prevention of accidental eye injuries. What is the most important thing to stress? a. Workplace policies for handling chemicals should be followed. b. Children and parents should be cautious about aggressive play. c. Protective eyewear should be worn during sports or hazardous work. d. Emergency eyewash stations should be established in the workplace.

c. Most accidental eye injuries (90%) could be prevented by wearing protective eyewear for sports and hazardous work. Other options should be considered in the overall prevention of injuries, but these have less impact. Focus: Prioritization

37. You are providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient who had blood loss during surgery. Which action by the new RN requires that you intervene immediately? a. Waiting 20 minutes after obtaining the PRBCs before starting the infusion b. Starting an IV line for the transfusion using a 22-gauge catheter c. Priming the transfusion set using 5% dextrose in lactated Ringer's solution d. Telling the patient that the PRBCs may cause a serious transfusion reaction

c. Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of red blood cells (RBCs). Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-bore IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although the new RN should avoid increasing patient anxiety by indicating that a serious transfusion reaction may occur, this action is not as high a concern as using an inappropriate fluid for priming the IV tubing. Focus: Prioritization

4. You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene? a. Suctioning the tracheostomy tube before performing tracheostomy care b. Removing old dressings and cleaning off excess secretions c. Removing the inner cannula and cleaning using standard precautions d. Replacing the inner cannula and cleaning the stoma site

c. When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate. Focus: Delegation, supervision

45. A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should you intervene? a. " You should avoid consumption of all forms of alcohol." b. " Wear your medical alert bracelet at all times." c. " Protect your loved one's airway during a seizure." d. " It's OK to take over-the-counter medications."

d. A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families. Focus: Delegation, supervision

19. The health care provider has written all of these orders for a client with a diagnosis of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? a. Weigh the client every morning. b. Maintain accurate intake and output records. c. Restrict fluids to 1500 mL/ day. d. Administer furosemide (Lasix) 40 mg IV push.

d. Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important, but are not urgent. Focus: Prioritization

36. You are reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the physician before surgery? a. Hematocrit of 33% b. Hemoglobin level of 10.9 g/ dL c. Platelet count of 426,000/ mm3 d. White blood cell count of 16,000/ mm3

d. Centers for Disease Control and Prevention (CDC) guidelines for the prevention of surgical site infections indicate that surgery should be postponed when there is evidence of a pre-existing infection such as an elevation in white blood cell count. The other values are slightly abnormal, but would not be likely to cause postoperative problems for knee arthroscopy. Focus: Prioritization

32. You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client finding will require the most immediate action? a. Blood pressure of 152/ 88 mm Hg b. Heart rate of 134 beats/ min c. Oxygen saturation of 91% d. Chest pain level of 3 (on a scale of 10)

d. Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization

15. After interviewing an HIV-positive patient who is considering starting highly active antiretroviral therapy (HAART), which patient information concerns you the most? a. The patient has been HIV positive for 8 years and has never taken any drug therapy for the HIV infection. b. The patient tells you, "I have never been very consistent about taking medications." c. The patient is sexually active with multiple partners and says "I always use a condom." d. The patient has many questions and concerns regarding the effectiveness and safety of the medications.

d. Drug therapy for HIV infection requires taking medications very consistently. Failure to take the medications daily can lead to mutations and the emergence of more virulent forms of the virus. Although the other data indicate the need for further assessments or interventions, they will not affect the decision to initiate antiretroviral therapy for this patient. Focus: Prioritization

5. As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first? a. Make a note in the nurse's file and continue to observe clinical performance. b. Refer the new nurse to the in-service education department. c. Quiz the nurse about knowledge of pain management and pharmacology. d. Give praise for correctly charting the dose and time and discuss the deficits in charting.

d. In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed.

5. An 8-year-old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to the UAP? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting an anesthetic mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Helping the patient to eat a bland, moist, soft diet

5. Ans: 4 Helping the patient to eat is within the scope of responsibilities for a UAP. Assessing ability and willingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. Plain water or saline rinses are preferable if the child cannot gargle or spit out fluids. The RN should assess and administer oral preparations as needed. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition.

2. You are employed as the charge nurse in a long-term care (LTC) facility that employs RNs, LPNs/ LVNs, and UAPs. When you are planning care for a resident with a stage III sacral pressure ulcer, which nursing intervention is best to delegate to an LPN/ LVN? 1. Choosing the type of dressing to be used on the ulcer 2. Using the Norton scale to assess for pressure ulcer risk factors 3. Assisting the client in changing position at frequent intervals 4. Cleaning and changing the dressing on the ulcer every morning

2. Ans: 4 LPN/ LVN education and scope of practice includes sterile and nonsterile wound care. LPNs/ LVNs do function as wound care nurses in some LTC facilities, but the choice of dressing type and assessment for risk factors are more complex skills that are appropriate to the RN level of practice. Assisting the client to change position is a task included in UAP education and would be more appropriate to delegate to the UAP. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition.

3. You have just received a change-of-shift report for the burn unit. Which client should you assess first? 1. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain 2. Client who has just arrived from the emergency department with facial burns sustained in a house fire 3. Client who has just been transferred from the postanesthesia care unit after having skin grafts applied to the anterior chest 4. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

3. Ans: 2 Facial burns are frequently associated with airway inflammation and swelling, so this client requires the most immediate assessment. The other clients also require rapid assessment or interventions, but not as urgently as the client with facial burns. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition.

3. You are caring for several children with cancer and are reviewing morning laboratory results for all of your patients. Which of these patient conditions combined with the indicated laboratory result causes you the greatest immediate concern? 1. Nausea and vomiting with a potassium level of 3.3 mEq/ L 2. A nosebleed with a platelet count of 100,000/ mm3 3. Fever with an absolute neutrophil count of 450/ mm3 4. Fatigue with a hemoglobin level of 8 g/ dL

3. Ans: 3 National guidelines indicate that rapid treatment of infection in neutropenic patients is essential to prevent complications such as overwhelming sepsis and secondary infections; therefore, the child with fever and a low neutrophil count is the priority. A potassium level of 3.3 mEq/ L is borderline low and should be monitored. Nosebleeds are common, and the patient and parents should be taught to apply direct pressure to the nose, have the child sit upright, and not disturb the clot. Severe spontaneous hemorrhage is not expected until the platelet count drops below 20,000 mm3. Children can withstand low hemoglobin levels. The nurse should help the patient and parents regulate activity to prevent excessive fatigue. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition.

5. As charge nurse, you are making assignments for the day shift. Which patient would you assign to the nurse who was floated from the postanesthesia care unit (PACU) for the day? 1. 35-year-old with osteomyelitis who needs teaching before hyperbaric oxygen therapy 2. 62-year-old with osteomalacia who is being discharged to a long-term care facility 3. 68-year-old with osteoporosis given a new orthotic device whose knowledge of its use must be assessed 4. 72-year-old with Paget disease who has just returned from surgery for total knee replacement

5. Ans: 4 The PACU nurse is very familiar with the assessment skills necessary to monitor a patient who just underwent surgery. For the other patients, nurses familiar with musculoskeletal system- related nursing care are needed to provide teaching and assessment, and prepare a report to the long-term care facility. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition.

27. You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/ min by nasal cannula. Which finding concerns you immediately? a. Fine bibasilar crackles b. Respiratory rate of 8 breaths/ min c. The patient sitting up and leaning over the nightstand d. A large barrel chest

b. For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory rate. If you do not intervene, the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chronic emphysema. Focus: Prioritization

38. A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Which action prescribed by the health care provider will you implement first? a. Give morphine sulfate 4 to 8 mg IV every hour as needed. b. Administer 100% oxygen using a nonrebreather mask. c. Start a 14-gauge IV line and infuse normal saline at 200 mL/ hr. d. Give pneumococcal (Pneumovax) and Haemophilus influenzae (ActHIB) vaccines.

b. Hypoxia and deoxygenation of the RBCs are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control and hydration are also important interventions for this patient and should be accomplished rapidly. Vaccination may help prevent future sickling episodes by decreasing the risk of infection, but it will not help with the current sickling crisis. Focus: Prioritization

13. You are working with a student nurse to care for an HIV-positive patient with severe esophagitis caused by Candida albicans. Which action by the student indicates that you need to intervene most quickly? a. Putting on a mask and gown before entering the patient's room b. Giving the patient a glass of water after administering the ordered oral nystatin (Mycostatin) suspension c. Suggesting that the patient should order chile con carne or chicken soup for the next meal d. Placing a "No Visitors" sign on the door of the patient's room

b. Nystatin should be in contact with the oral and esophageal tissues as long as possible for maximum effect. The other actions are also inappropriate and should be discussed with the student but do not require action as quickly. HIV-positive patients do not require droplet/ contact precautions or visitor restrictions to prevent opportunistic infections. Hot or spicy foods are not usually well tolerated by patients with oral or esophageal fungal infections. Focus: Prioritization

20. You have been floated to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately? a. Sodium b. Potassium c. Magnesium d. Calcium

b. Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block. Focus: Prioritization

44. You are preparing to admit a client with a seizure disorder. Which actions can you delegate to an LPN/ LVN? a. Completing the admission assessment b. Setting up oxygen and suction equipment c. Placing a padded tongue blade at the bedside d. Padding the side rails before the client arrives

b. The LPN/ LVN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins. Focus: Delegation, supervision

16. The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? a. Administering IV fluids as prescribed by the physician b. Providing straws and offering fluids between meals c. Developing a plan for added fluid intake over 24 hours d. Teaching family members to assist the client with fluid intake

b. UAPs can reinforce additional fluid intake once it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN. Focus: Delegation, supervision

25. You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection? a. 3-year-old who has paroxysmal coughing and whose sibling has pertussis b. 5-year-old who has a new pruritic rash and a possible chickenpox infection c. 62-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection c. 74-year-old who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

b. Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the ED. The child with the rash should be quickly isolated from the other ED clients through placement in a negative-pressure room. Droplet and/ or contact precautions should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB. Focus: Prioritization

24. A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? (Select all that apply.) a. Surgical face mask b. N95 respirator c. Gown d. Gloves e. Goggles f. Shoe covers

b., c., d. Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, you should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and will not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions. Focus: Prioritization

30. You are supervising an RN who floated from the medical-surgical unit to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would you clearly provide to the RN? (Select all that apply.) a. Position the patient supine and turned on his side. b. Apply direct lateral pressure to the nose for 5 minutes. c. Maintain standard body substance precautions. d. Apply ice or cool compresses to the nose. e. Instruct the patient not to blow the nose for several hours.

b.,c.,d., e. The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed. Focus: Delegation, supervision, assignment

23. You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions? a. Remove N95 respirator. b. Take off goggles. c. Remove gloves. d. Take off gown. e. Perform hand hygiene. _____, _____, _____, _____,

c, b, d, a, e: This sequence will prevent contact of the contaminated gloves and gown with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients.

8. A 56-year-old patient comes to the walk-in clinic reporting scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history of colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis? a. Diarrhea/ Constipation related to altered bowel patterns b. Deficient Knowledge related to the disease process and diagnostic procedure c. Risk for Deficient Fluid Volume related to rectal bleeding and diarrhea d. Anxiety related to unknown outcomes and perceived threats to body integrity

d. The patient's physical condition is currently stable, but emotional needs are affecting his or her ability to receive the information required to make an informed decision. The other diagnoses are relevant, but if the patient leaves the clinic the interventions may be delayed or ignored.

1. You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? a. Check the medication administration records (MARs) for the past several days. b.Ask the nurse educator to provide in-service training about pain management. c. Perform a complete pain assessment on the client and take a pain history. d. Have a conference with the nurses responsible for the care of this client.

d: As charge nurse, you must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem.

22. You are caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza (" bird flu"). Which of these prescribed actions will you implement first? a. Start oxygen using a nonrebreather mask. b. Infuse 5% dextrose in water at 100 mL/ hr. c. Administer first dose of oseltamivir (Tamiflu). d. Obtain blood and sputum specimens for testing.

a. Because the respiratory manifestations associated with avian influenza are potentially life-threatening, the nurse's initial action should be to start oxygen therapy. The other interventions should be implemented after addressing the client's respiratory problems. Focus: Prioritization

3. A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will you advocate for first? a. Gabapentin (Neurontin) b. Corticosteroids c. Hydromorphone (Dilaudid) d. Lorazepam (Ativan)

a. Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy.

17. The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? a. Flattened neck veins when the client is in the supine position b. Full and bounding pedal and post-tibial pulses c. Pitting edema located in the feet, ankles, and calves d. Shallow respirations with crackles on auscultation

a. Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of the nursing diagnosis of Excess Fluid Volume. Focus: Prioritization

6. You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? a. Assisting the patient with oral hygiene b. Observing the patient's response to feedings c. Facilitating expression of grief or anxiety d. Initiating daily weighings

a. Oral hygiene is within the scope of duties of the UAP.

12. As the nurse manager in a public health department, you are implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will you delegate to health assistants working for the agency? a. Supplying injection drug users with sterile injection equipment such as needles and syringes b. Interviewing patients about behaviors that indicate a need for annual HIV testing c. Teaching high-risk community members about the use of condoms in preventing HIV infection d. Assessing the community to determine which population groups to target for education

a. Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with health assistant education. Assessing for high-risk behaviors, education, and community assessment are RN-level skills. Focus: Delegation

41. What is the priority nursing diagnosis for a client experiencing a migraine headache? a. Acute Pain related to biologic and chemical factors b. Anxiety related to change in or threat to health status c. Hopelessness related to deteriorating physiologic condition d. Risk for Injury related to side effects of medical therapy

a. The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of pain, which is often incapacitating. Focus: Prioritization

10. When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN/ LVN under the supervision of a team leader RN? a. A patient with severe anemia secondary to GI bleeding b. A patient who needs enemas and antibiotics to control GI bacteria c.A patient who needs preoperative teaching for bowel resection surgery d.A patient who needs central line insertion for chemotherapy

b. Administering enemas and antibiotics is within the scope of practice of LPNs/ LVNs. Although some states an facilities may allow the LPN/ LVN to administer blood, in general, administering blood, providing preoperative teaching, and assisting with central line insertion are the responsibilities of the RN. Focus: Assignment

31. You are working in the emergency department (ED) when a client arrives reporting substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether you should anticipate implementing the acute coronary syndrome (ACS) standard protocol? a. Creatine kinase MB level b. Troponin I level c. Myoglobin level d. C-reactive protein level

b. Cardiac troponin levels are elevated 3 hours after the onset of ACS (unstable angina or myocardial infarction [MI]) and are very specific to cardiac muscle injury or infarction. Although levels of creatine kinase MB and myoglobin also increase with MI, the increases occur later and/ or are not as specific to myocardial damage as troponin levels. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction. Focus: Prioritization

39. These activities are included in the care plan for a 78-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can you delegate to an experienced UAP? a. Obtaining stool specimens for fecal blood test (Hemoccult) slides b. Having the patient sign a colonoscopy consent form c. Giving the prescribed polyethylene glycol electrolyte solution (GoLYTELY) d. Checking for allergies to contrast dye or shellfish

a. An experienced UAP will have been taught how to obtain a stool specimen for the Hemoccult slide test, because this is a common screening test for hospitalized patients. Having the patient sign an informed consent form should be done by the physician who will be performing the colonoscopy. Administering medications and checking for allergies are within the scope of practice of licensed nursing staff. Focus: Delegation

1. A patient is admitted to the medical unit with possible Graves disease (hyperthyroidism). Which assessment finding supports this diagnosis? 1. Periorbital edema 2. Bradycardia 3. Exophthalmos 4. Hoarse voice

1. Ans: 3 Exophthalmos (abnormal protrusion of the eyes) is characteristic of patients with hyperthyroidism due to Graves disease. Periorbital edema, bradycardia, and hoarse voice are all characteristics of patients with hypothyroidism. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition.

106

...

1. You are caring for a client who has just had a squamous cell carcinoma removed from the face. Which activity can you delegate to an experienced LPN/ LVN? 1. Teaching the client about risk factors for squamous cell carcinoma 2. Showing the client how to care for the surgical site at home 3. Monitoring the surgical site for swelling, bleeding, or pain 4. Discussing the reasons for avoiding aspirin use for a week after surgery

1. Ans: 3 An LPN/ LVN who is experienced in working with postoperative clients will know how to monitor for pain, bleeding, or swelling and will notify the supervising RN. Client teaching requires more education and a broader scope of practice and is appropriate for RN staff members. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition.

1. When a client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to the UAP? 1. Explaining the need for a clear liquid diet 1 to 3 days before the procedure 2. Reinforcing "nothing by mouth" status 8 hours before the procedure 3. Administering laxatives 1 to 3 days before the procedure 4. Administering an enema the night before the procedure

1. Ans: 2 The UAP can reinforce dietary and fluid restrictions after the RN has explained the information to the client. It is also possible that the UAP can administer the enema; however, special training is required, and policies may vary among institutions. Medication administration should be performed by licensed personnel. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition.

1. You are assessing a long-term-care client with a history of benign prostatic hyperplasia (BPH). Which information will require the most immediate action? 1. The client states that he always has trouble starting his urinary stream. 2. The chart shows an elevated level of prostate-specific antigen. 3. The bladder is palpable above the symphysis pubis and the client is restless. 4. The client says he has not voided since having a glass of juice 4 hours ago.

1. Ans: 3 A palpable bladder and restlessness are indicators of urinary retention, which would require action (such as insertion of a catheter) to empty the bladder. The other data would be consistent with the client's diagnosis of BPH. More detailed assessment may be indicated, but no immediate action is required. Focus: Prioritization

1. A patient with a diagnosis of hypochondriasis has made multiple clinic visits and undergone diagnostic tests for "cancer," with no evidence of organic disease. Today he declares, "I have a brain tumor. I can feel it growing. My appointment is tomorrow, but I can't wait!" What is the most therapeutic response? 1. Present reality: "Sir, you have been seen many times in this clinic and had many diagnostic tests. The results have always been negative." 2. Encourage expression of feelings: "Let me spend some time with you. Tell me about what you are feeling and why you think you have a brain tumor." 3. Set boundaries: "Sir, I will take your vital signs, but then I am going to call your case manager so that you can discuss the scheduled appointment." 4. Respect the patient's wishes: "Sir, sit down and I will make sure that you see the physician right away. Don't worry; we will take care of you."

1. Ans: 3 The case manager has a relationship with the patient, knows the specific details of agreements made with the patient, and is the most capable of helping him to decrease anxiety and preoccupation with physical symptoms. In general, presenting reality does not have an impact on patients with hypochondriasis. Encouraging expression of feelings and giving in to the patient's wishes contribute to secondary gains of maintaining the sick role. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 207). Elsevier Health Sciences. Kindle Edition.

1. A 30-year-old woman with type 1 diabetes mellitus comes to the clinic for preconception care. What is the priority education for her at this time? 1. Her insulin requirements will likely increase during the second and third trimesters of pregnancy. 2. Infants of diabetic mothers can be macrosomic, which can result in more difficult delivery and higher likelihood of cesarean section. 3. Breast feeding is highly recommended, and insulin use is not a contraindication. 4. Achievement of optimal glycemic control at this time is of utmost importance in preventing congenital anomalies.

1. Ans: 4 The incidence of congenital anomalies is three times higher in the offspring of diabetic women. Good glycemic control during preconception and early pregnancy significantly reduces this risk and would be the highest priority message to this patient at this point. The other responses are correct but are not of greatest importance at this time. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition.

2. Which change in vital signs would you instruct the UAP to report immediately for a patient with hyperthyroidism? 1. Rapid heart rate 2. Decreased systolic blood pressure 3. Increased respiratory rate 4. Decreased oral temperature

2. Ans: 1 The cardiac problems associated with hyperthyroidism include tachycardia, increased systolic blood pressure, and decreased diastolic blood pressure. Patients with hyperthyroidism also may have increased body temperature related to increased metabolic rate. Respiratory changes are usually not symptomatic of this condition. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition.

2. Which task could be appropriately assigned to the UAP working with you at the obstetric clinic? 1. Checking the blood pressure of a patient who is 36 weeks pregnant and reports a headache 2. Removing the adhesive skin closure strips of a patient who had a cesarean section 2 weeks ago 3. Giving community resource information and emergency numbers to a prenatal patient whom you suspect is experiencing domestic violence 4. Dispensing a breast pump with instruction to a lactating patient having trouble with milk supply 4 weeks postpartum

2. Ans: 1 The UAP can check the blood pressure of this patient and report it to the RN. The RN would include this information in her full assessment of the patient, who may be showing signs of preeclampsia. The other tasks listed require nursing assessment, analysis, and planning, and should be performed by the RN. Provision of accurate and supportive education about breastfeeding and breast pumping supports the Perinatal Core Measure of increasing the percentage of women who exclusively breast-feed. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition.

2. You are caring for a patient in whom a conversion disorder was recently diagnosed. She is experiencing a sudden loss of vision after witnessing a violent fight between her husband and adult-age son. What is the priority therapeutic approach to use with this patient? 1. Reassure her that her blindness is temporary and will resolve with time 2. Gently point out that she seems to be able to see well enough to function independently 3. Encourage expression of feelings and link emotional trauma to the blindness 4. Teach ways to cope with blindness, such as methodically arranging personal items

2. Ans: 4 Patients with conversion disorders are experiencing symptoms, even though there is no identifiable organic cause; therefore, they should be assisted in learning ways to cope and live with the disability. Encouraging the expression of feelings is okay, but it is premature to expect the patient to link the fight to her blindness. It is likely that the sudden onset of blindness will quickly resolve, and the patient may also be physically able to see, but presenting facts would not be helpful at this time. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 207). Elsevier Health Sciences. Kindle Edition.

2. A patient has newly-diagnosed type 2 diabetes. Which task should you delegate to a UAP? 1. Arranging a consult with the dietitian 2. Assessing the patient's insulin injection technique 3. Teaching the patient to use a glucometer to monitor glucose at home 4. Reminding the patient to check glucose level before each meal

2. Ans: 4 The UAP's role includes reminding patients about interventions that are already part of the plan of care. Arranging for a consult with the dietitian is appropriate for the unit clerk. Teaching and assessing require additional education and should be carried out by licensed nurses. Focus: Delegation, supervision, assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 189). Elsevier Health Sciences. Kindle Edition.

42. You are creating a teaching plan for a client with newly-diagnosed migraine headaches. Which key items will you include in the teaching plan? (Select all that apply.) a.Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. b. Drugs such as nitroglycerin (Nitrostat) and nifedipine (Procardia) should be avoided. c. Abortive therapy is aimed at eliminating the pain during the aura. d. A potential side effect of medications is rebound headache. e. Complementary therapies such as biofeedback and relaxation may be helpful. f. Estrogen therapy should be continued as prescribed by your physician.

2. Ans: a.,b.,c.,d.,e. Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate. Focus: Prioritization

3. After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit (PACU). Which nursing action is best to delegate to an experienced LPN/ LVN? 1. Monitoring the client's dressing for any signs of bleeding 2. Documenting the initial assessment on the client's chart 3. Communicating the client's status report to the charge nurse on the surgical unit 4. Teaching the client about the importance of using pain medication as needed

3. Ans: 1 An LPN/ LVN working in a PACU would be expected to check dressings for bleeding and alert RN staff members if bleeding occurs. The other tasks are more appropriate for nursing staff with RN-level education and licensure. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 196). Elsevier Health Sciences. Kindle Edition.

3. As charge nurse, you would assign the nursing care of which patient to an LPN/ LVN, working under the supervision of an RN? 1. 48-year-old with cystitis who is taking oral antibiotics 2. 64-year-old with kidney stones who has a new order for lithotripsy 3. 72-year-old with urinary incontinence who needs bladder training 4. 52-year-old with pyelonephritis who has severe acute flank pain

3. Ans: 1 The patient with cystitis who is taking oral antibiotics is in stable condition with predictable outcomes, and caring for this patient is therefore appropriate to the scope of practice of an LPN/ LVN under the supervision of an RN. The patient with a new order for lithotripsy will need teaching about the procedure, which should be accomplished by the RN. The patient in need of bladder training will need the RN to plan this intervention. The patient with flank pain needs careful and skilled assessment by the RN. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition.

3. As the charge nurse, you are reviewing the assignment sheet for an acute psychiatric unit. Which experienced team member should be reassigned? 1. Male LVN assigned to a male patient with chronic depression and excessive rumination 2. Young male mental health assistant assigned to a female adolescent with anorexia nervosa 3. Female RN assigned to a newly admitted female patient who has command hallucinations and delusions of persecution 4. Older female RN with medical-surgical experience assigned to a male patient with Alzheimer disease

3. Ans: 2 Teenagers, in general, are self-conscious in the presence of members of the opposite sex, and teens with anorexia are overly concerned with their appearance; therefore, it would be better to assign this patient to a mature female staff member. An experienced LVN, regardless of gender pairing, is able to set boundaries and to assist patients with chronic health problems. An experienced RN should be assigned to new admissions, particularly if there are acute safety issues. An RN with medical-surgical experience would be well acquainted with care issues related to dementia. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 207). Elsevier Health Sciences. Kindle Edition.

3. You are preparing to administer TPN through a central line. Place the following steps for administration in the correct order. 1. Use aseptic technique when handling the injection cap. 2. Thread the IV tubing through an infusion pump. 3. Check the solution for cloudiness or turbidity. 4. Connect the tubing to the central line. 5. Select and flush the correct tubing and filter. 6. Set the infusion pump at the prescribed rate. 7. Confirm the order for TPN prior to administration. _____, _____, _____, _____, _____, _____, _____

3. Ans: 7, 3, 5, 2, 1, 4, 6 Always check the order before administering TPN; generally, each bag is individually prepared by the pharmacist. The solution should not be cloudy or turbid. Prepare the equipment by priming the tubing and threading the pump. To prevent infection, scrub the hub and use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. Set the pump at the prescribed rate. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition.

4. You are admitting a 66-year-old male patient suspected of having a urinary tract infection (UTI). Which piece of the patient's medical history supports this diagnosis? 1. Patient's wife had a UTI 1 month ago 2. Followed for prostate disease for 2 years 3. Intermittent catheterization 6 months ago 4. Kidney stone removal 1 year ago

4. Ans: 2 Prostate disease increases the risk of UTIs in men because of urinary retention. The wife's UTI should not affect the patient. The times of the catheter usage and kidney stone removal are too distant to cause this UTI. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition.

4. You arrive home and find that the house of your neighbor (Jane) is on fire. A fireman is physically restraining her from running back into the house. What is the best response? 1. " Jane, come and sit in my house until this is over with." 2. " Jane, calm down and let the fireman do his job." 3. " Jane, look at me and hold my hand." 4. " Jane, tell me why you are struggling so hard."

4. Ans: 3 Jane is experiencing a panic level of anxiety and initially she needs very simple and direct instructions. Instruct her to look at you first, to make a connection and to get her attention, then you can continue with your instructions. Telling her to calm down is not useful at this point, and she may or may not be able to articulate why she is trying to go back into the house. Regardless of her reason, she cannot be allowed to run back into the house. Directing her to go to your house is kind and therapeutic, but it may be difficult to remove her from the scene until her anxiety is more under control. Focus: Prioritization 5. Ans: 3 This patient has trouble LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 207). Elsevier Health Sciences. Kindle Edition.

5. The plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to a UAP? 1. Checking to make sure that the patient's bath water is not too hot 2. Discussing community resources for diabetic outpatient care 3. Teaching the patient to perform daily foot inspection 4. Assessing the patient's technique for drawing insulin into a syringe

5. Ans: 1 Checking the bath water temperature is part of assisting with activities of daily living and is within the education and scope of practice of the UAP. Discussing community resources, teaching, and assessing require a higher level of education and are appropriate to the scope of practice of licensed nurses. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 190). Elsevier Health Sciences. Kindle Edition.

5. There is a patient on the medical-surgical unit who has been there for several months. He is hostile, rude, and belligerent, and no one likes to interact with him. How should you handle the assignment? 1. Rotate the assignment schedule so that no one has to care for him more than once or twice a week. 2. Pair a float nurse and a nursing student and assign the patient to that team because they will have a fresh perspective toward the patient. 3. Identify two or three experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions. 4. Assign yourself as primary caregiver so that you can role-model how patients should be treated.

5. Ans: 3 This patient has trouble with interpersonal interactions, so consistent caregivers who use psychosocial interventions have the best chance of being able to develop a relationship with this difficult individual. Rotating the assignment sheet to give the staff a break and using float staff are frequent strategies that are employed, but these are not necessarily the best for the patient. Taking the patient yourself may seem like the easiest solution, but in the long run strengthening and supporting the staff are better strategies than trying to do all of the hard tasks yourself. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 207). Elsevier Health Sciences. Kindle Edition.

5. You obtain the following assessment data about your client who has had a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. Which finding indicates the most immediate need for nursing intervention? 1. The client states that he feels a continuous urge to void. 2. The catheter drainage is light pink with occasional clots. 3. The catheter is taped to the client's thigh. 4. The client reports painful bladder spasms.

5. Ans: 4 The bladder spasms may indicate that blood clots are obstructing the catheter, which would indicate the need for irrigation of the catheter with 30 to 50 mL of normal saline using a piston syringe. The other data would all be normal after a TURP, but the client may need some teaching about the usual post-TURP symptoms and care. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 197). Elsevier Health Sciences. Kindle Edition.

49. Place the following steps for eyedrop administration in the correct order. 1. Gently press on the lacrimal duct for 1 minute 2. Gently pull the tissue underneath the eye downward to expose the lower conjunctival sac. 3. Have the client gently close the eye and move it around. 4. Have the client look up while you instill the number of prescribed drops. 5. Hold the dropper and stabilize your hand on the client's forehead. 6. Have the client sit down and tilt his or her head slightly backward. _____, _____, _____, _____, _____, _____

6, 2, 5, 4, 3, 1 Have the client sit with the head tilted back. Pulling down the lower conjunctival sac creates a small pocket for the drops. Stabilizing the hand prevents accidentally poking the client's eye. Having the client look up prevents the drops from falling on the cornea and stimulating the blink reflex. When the client gently moves the eye, the medication is distributed. Pressing on the lacrimal duct prevents systemic absorption. Focus: Prioritization

14. You are evaluating an HIV-positive patient who is receiving IV pentamidine (Pentam) as a treatment for Pneumocystis jiroveci (PCP) pneumonia. Which information is most important to communicate to the physician? a. The patient is reporting pain at the site of the infusion. b. The patient is not taking in an adequate amount of oral fluids. c. Blood pressure is 104/ 76 mm Hg after pentamidine administration. d. Blood glucose level is 55 mg/ dL after medication administration.

d. Pentamidine can cause fatal hypoglycemia, so the low blood glucose level indicates a need for a change in therapy. The low blood pressure suggests that the pentamidine infusion rate may need to be slowed. The other responses indicate a need for independent nursing actions (such as establishing a new IV site and encouraging oral intake) but are not associated with pentamidine infusion. Focus: Prioritization