Nursing Prioritization, Delegation And Assignment NCLEX Quiz #3 (10 Questions)

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1. Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?

A client with diabetes being discharged today.

A 35-year-old male with tracheostomy and copious secretions.

A teenager scheduled for physical therapy this morning.

A 78-year-old female client with pressure ulcer that needs dressing change.

The patient with problem of the airway should be given highest priority. Remember Airway. Breathing. and Circulation (ABC) is a priority.

Explanation

The patient with problem of the airway should be given highest priority. Remember Airway. Breathing. and Circulation (ABC) is a priority.

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Nursing Prioritization, Delegation And Assignment NCLEX Quiz #3 (10 Questions) - Quiz

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2. Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?

Call for help to get the client back in bed.

Establish whether the client is responsive.

Assist the client back to bed.

Ask the client what happened.

Assess first for responsiveness.

Explanation

Assess first for responsiveness.

3. A client presents to the emergency room with dyspnea. chest pain. and syncope. The nurse assesses the client and notes that the following assessment cues: pale. diaphoretic. blood pressure of 90/60. respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first?

Administer pain medications.

Administer IV fluids.

Administer dopamine.

Administer oxygen via nasal cannula.

Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.

Explanation

Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.

4. The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client's:

Respiratory status.

Level of consciousness.

Level of pain.

Reflexes and movement of extremities.

Assessing respiratory status is the first priority. Remember ABC.

Explanation

Assessing respiratory status is the first priority. Remember ABC.

5. Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience on working on. Which client should be assigned to her?

A client with a cast for a fractured femur and who has numbness and discoloration of the toes.

A client with balanced skeletal traction and needs assistance with morning care.

A client who had an above-the-knee amputation yesterday and has currently has a temperature of 101.4ºF.

A client who had a total hip replacement two days ago and needs blood glucose monitoring.

A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with stable condition as those have care similar to her training and experience. A client who is in postoperative state is more likely to be on a stable condition.

Explanation

6. Paige is a nurse preceptor who is working with a new nurse Joyce. She notes that the Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is mostly likely due to:

Role modeling behaviors of the preceptor.

The philosophy of the new nurse’s school of nursing.

The orientation provided to the new nurse.

Lack of trust to the members of the healthcare team.

Lack of trust is the common reason for reluctance in delegation of tasks.

Explanation

Lack of trust is the common reason for reluctance in delegation of tasks.

7. Nurse Jackie is reviewing the diet of a 28-year-old female who reports several months of intermittent abdominal pain. abdominal bloating. and flatulence. The nurse should tell the client to avoid:

Fiber.

Broccoli.

Yogurt.

Simple carbohydrates.

Broccoli are gas forming and therefore. should be avoided.

Explanation

Broccoli are gas forming and therefore. should be avoided.

8. Sally is a nurse working in an emergency department and receives a client after a radiological incident. Which task is utmost priority for the nurse to do first?

Decontaminate the client’s clothing.

Decontaminate the open wound on the client’s thigh.

Decontaminate the examination room the client is placed in.

Save the client’s vomitus for analysis by the radiation safety staff.

Decontaminating an open wound is the first priority for the client. This minimizes absorption of radiation in the client’s body.

Explanation

Decontaminating an open wound is the first priority for the client. This minimizes absorption of radiation in the client’s body.

9. Nurse Paul is developing a care plan for a client after bariatric surgery for morbid obesity. The nurse should include which of the following on the care plan as the priority complication to prevent:

Pain.

Wound infection.

Depression.

Thrombophlebitis.

Wound infection is the most common complication among obese clients who had undergone surgery. This is due to their poor blood supply in their adipose tissues.

Explanation

Wound infection is the most common complication among obese clients who had undergone surgery. This is due to their poor blood supply in their adipose tissues.

10. Nurse Joriz of Nurseslabs Medical Center is planning care for a client who will undergo a colposcopy. Which of the following actions should Joriz take first?

Discuss the client’s fear regarding potential cervical cancer.

Assist with silver nitrate application to the cervix to control bleeding.

Give instructions regarding douching and sexual relations.

Administer pain medications.

The priority nursing action when caring for a client who underwent colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix.

Explanation

The priority nursing action when caring for a client who underwent colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix.

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Jul 31, 2017

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