Nursing Prioritization, Delegation and Assignment NCLEX Quiz #5 (10 Questions)

1.

You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient’s only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician?

A.

The patient says that her right leg aches all night
B.

The right calf is warm to the touch and is larger than the left calf
C.

The patient is unable to remember her husband’s first name
D.

There are multiple ecchymotic areas on the patient’s arms

Correct Answer
C. The patient is unable to remember her husband’s first name

Explanation
Rationale: Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the physician needs to be called.

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1

2.

Avoid foods prepared with monosodium glutamate (MSG)

A.

Avoid potential environmental asthma triggers such as smoke
B.

Use the inhaler 30 minutes before exercising to prevent bronchospasm
C.

Wash all bedding in cold water to reduce and destroy dust mites.
D.

Be sure to get at least 8 hours of rest and sleep every night.
E.

Avoid foods prepared with monosodium glutamate (MSG)

Correct Answer(s)
A. Avoid potential environmental asthma triggers such as smoke
B. Use the inhaler 30 minutes before exercising to prevent bronchospasm
D. Be sure to get at least 8 hours of rest and sleep every night.
E. Avoid foods prepared with monosodium glutamate (MSG)

Explanation
Rationale: Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.

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3.

You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal CPAP ventilation. What complications should you monitor for this infant?

A.

Pulmonary embolus
B.

Bronchitis
C.

Pneumothorax
D.

Pneumonia

Correct Answer
C. Pneumothorax

Explanation
Rationale: The most common complications after birth for infants with RDS is pneumothorax. Alveoli rupture and air leaks into the chest and compresses the lungs. which makes breathing difficult

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4.

You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given a nursing diagnosis of Activity Intolerance. Which action should you delegate to the nursing assistant?

A.

Instructing the patient to alternate rest and activity periods
B.

Encouraging. monitoring. and recording nutritional intake
C.

Monitoring cardiorespiratory response to activity
D.

Planning activities for periods when the patient has the most energy

Correct Answer
B. Encouraging. monitoring. and recording nutritional intake

Explanation
Rationale: The nursing assistant’s training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy. the nursing assistant can remind and encourage the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill. and are appropriate to the RN’s scope of practice. Monitoring the patient’s cardiovascular response to activity is a complex process requiring additional education. training. and skill. and falls within the RN’s scope of practice

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5.

You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?

A.

Chest tube drainage of 10 to 15 mL/hr
B.

Continuous bubbling in the water seal chamber
C.

Complaints of pain at the chest tube site
D.

Chest tube dressing dated yesterday

Correct Answer
B. Continuous bubbling in the water seal chamber

Explanation
Rationale: Continuous bubbling indicates an air leak that must be identified. With the physician’s order you can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops. the air leak may be at the chest tube insertion. which will require you to notify the physician. If the air bubbling does not stop when you apply the padded clamp. the air leak is between the clamp and the drainage system. and you must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient’s complaints of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak.

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6.

You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you 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 universal precautions
D.

Replacing the inner cannula and cleaning the stoma site.
E.

Changing the soiled tracheostomy ties and securing the tube in place

Correct Answer
D. Replacing the inner cannula and cleaning the stoma site.

Explanation
Rationale: 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.

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7.

You are supervising an RN who was pulled from the medical-surgical floor to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which of these directions would you clearly proved 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 universal body substances precautions.
D.

Apply ice or cool compresses to the nose
E.

Instruct the patient not to blow the nose for several hours.

Correct Answer(s)
B. Apply direct lateral pressure to the nose for 5 minutes
C. Maintain universal body substances precautions.
D. Apply ice or cool compresses to the nose
E. Instruct the patient not to blow the nose for several hours.

Explanation
Rationale: The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed

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8.

You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?

A.

Assessing for bilateral breath sounds and symmetrical chest movements
B.

Auscultating over the stomach to rule out esophageal intubation
C.

Marking the tube 1 cm from where it touches the incisor tooth or nares
D.

Ordering a chest radiograph to verify that tube placement is correct

Correct Answer
C. Marking the tube 1 cm from where it touches the incisor tooth or nares

Explanation
Rationale: The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after endotracheal placement. The priority at this time is to verify that the tube has been correctly placed.

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9.

You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?

A.

The patient starts crying and says she can’t go on with treatment much longer
B.

The patient complains of sharp. stabbing chest pain with every deep breath
C.

The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min
D.

The patient’s dressing at the thoracentesis site has 1 cm of bloody drainage

Correct Answer
C. The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min

Explanation
Rationale: Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space. causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring and/or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure

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10.

You have obtained the following assessment information about a 3-year old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up?

A.

Frequent swallowing
B.

Hypotonic bowel sounds
C.

Complaints of a sore throat
D.

Heart rate of 112 beats/min

Correct Answer
A. Frequent swallowing

Explanation
Rationale: Frequent swallowing after a tonsillectomy may indicate bleeding. You should inspect the back of the throat for evidence of bleeding. The other assessment results are not unusual in a 3-year old after surgery

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Nursing Prioritization, Delegation And Assignment NCLEX Quiz

You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient’s only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician?

Avoid foods prepared with monosodium glutamate (MSG)

You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal CPAP ventilation. What complications should you monitor for this infant?

You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given a nursing diagnosis of Activity Intolerance. Which action should you delegate to the nursing assistant?

You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?

You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene

You are supervising an RN who was pulled from the medical-surgical floor to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which of these directions would you clearly proved to the RN? (Select all that apply)

You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?

You have obtained the following assessment information about a 3-year old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up?