Nursing Prioritization, Delegation and Assignment NCLEX Quiz #4 (10 Questions)

1. Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns that which immunization is a priority for the client?

Hepatitis A vaccine.

Lyme’s disease vaccine.

Hepatitis B vaccine.

Pneumococcal vaccine.

Pneumococcal vaccine is a priority immunization amongst elderly especially those with chronic illnesses. It is administered every five (5) years.

Explanation

Pneumococcal vaccine is a priority immunization amongst elderly especially those with chronic illnesses. It is administered every five (5) years.

2. You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?

Assessing the patient’s respiratory status every 4 hours

Taking vital signs and pulse oximetry readings every 4 hours

Checking the ventilator settings to make sure they are as prescribed

Observing whether the patient’s tube needs suctioning every 2 hours

Rationale: The nursing assistant’s educational preparation includes measurement of vital signs. and an experienced nursing assistant would know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient. as well as checking ventilator settings. require the additional education and skills of the RN

Explanation

Rationale: The nursing assistant’s educational preparation includes measurement of vital signs. and an experienced nursing assistant would know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient. as well as checking ventilator settings. require the additional education and skills of the RN

3. 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?

The patient has fine bibasilar crackles

The patient’s respiratory rate is 8 breaths/min.

The patient sits up and leans over the night table.

The patient has a large barrel chest.

Rationale: 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 arrest. Crackles. barrel chest. and assumption of a sitting position leaning over the night table are common in patients with chronic emphysema

Explanation

Rationale: 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 arrest. Crackles. barrel chest. and assumption of a sitting position leaning over the night table are common in patients with chronic emphysema

4. A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first?

Determine the level of consciousness.

Push the call button for help.

Turn the client face up to assess.

Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician.

Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.

Explanation

Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.

5. Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

A client scheduled for cardiac ultrasound this morning.

A client with syncope being discharged today.

A client with chronic bronchitis on nasal oxygen.

A client with diabetic foot ulcer that needs a dressing change.

A client with airway problems should be attended first.

Explanation

A client with airway problems should be attended first.

6. You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?

The patient was recently in a motor vehicle accident

The patient participated in an aerobic exercise program for 6 months

The patient gave birth to her youngest child 1 year ago

The patient was on bed rest for 6 hours after a diagnostic procedure

Rationale: Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for DVT and pulmonary embolus. but this period of bed rest was very short.

Explanation

Rationale: Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for DVT and pulmonary embolus. but this period of bed rest was very short.

7. Nurse Adonai is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best?

Ask the other nurse if she needs help.

Assess the client and let the other nurse know what should be done.

Ask the client if he is satisfied with his care.

Contact the nursing supervisor to address the situation.

The nurse should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.

Explanation

The nurse should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.

8. You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP). which action is most important to include in the plan of care?

Administer ordered antibiotics as scheduled

Hyperoxygenate the patient before suctioning

Maintain the head of the bed at a 30 – to 45-degree angle

Suction the airway when coarse crackles are audible

Rationale: Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP

Explanation

Rationale: Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP

9. You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant?

Teaching the patient about the importance of adequate of fluid intake and hydration.

Assisting the patient to a sitting position with neck flexed. shoulders relaxed. and knees flexed

Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake

Encouraging the patient to take a deep breath. hold it for 2 seconds. then cough two or three times in succession.

Rationale: A nursing assistant can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic nursing assistant. However. an experienced nursing assistant could assist the patient with positioning after the nursing assistant and the patient had been taught the proper technique. The nursing assistant would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill. and is within the scope of practice of the RN

Explanation

Rationale: A nursing assistant can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic nursing assistant. However. an experienced nursing assistant could assist the patient with positioning after the nursing assistant and the patient had been taught the proper technique. The nursing assistant would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill. and is within the scope of practice of the RN

10. Nurse Pietro receives a 11-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first?

Call for a social worker to meet with the family.

Check the child’s blood pressure. pulse. respiration. and temperature.

Administer pain medications.

Speak with the parents about how the fracture occurred.

In case of injury. especially among children. it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse.

Explanation

In case of injury. especially among children. it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse.

Nursing Prioritization, Delegation And Assignment NCLEX Quiz #4 (10 Questions)