Nursing Prioritization, Delegation And Assignment NCLEX Quiz

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

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.

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.

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

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

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.

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

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

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.

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.