Friday, September 2, 2016

NCLEX Exam: Nursing Prioritization, Delegation and Assignment 2 (15 Items)

http://www.nclexrnlab.com/2016/09/nclex-exam-nursing-prioritization.html
Here’s another set of NCLEX questions about Nursing Delegation and Prioritization! Let’s do another set, this time with 15 challenging questions. Also, take the first part of this exam via this link.
When you delegate work to the member of the team, your job is to clearly frame success and describe the objectives. —Steven Sinofsky

Topics

Included topics in this exam are:
  • Prioritization
  • Delegation and Assignment

Guidelines

Follow the guidelines below to make the most out of this exam:
  • Read each question carefully and choose the best answer.
  • You are given one minute per question. Spend your time wisely!
  • Answers and rationales are given below. Be sure to read them.
  • If you need more clarifications, please direct them to the comments section.
 NCLEX Exam: Nursing Prioritization, Delegation and Assignment 2 (15 Items)
 Just Scroll Down For All questions and answers
In Text Mode: All questions and answers are given for reading and answering at your own pace. You can also copy this exam and make a print out.



1. 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. A client with a cast for a fractured femur and who has numbness and discoloration of the toes.
B. A client with balanced skeletal traction and needs assistance with morning care.
C. A client who had an above-the-knee amputation yesterday and has currently has a temperature of 101.4ºF.
D. A client who had a total hip replacement two days ago and needs blood glucose monitoring.


2. 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?
A. Decontaminate the client’s clothing.
B. Decontaminate the open wound on the client’s thigh.
C. Decontaminate the examination room the client is placed in.
D. Save the client’s vomitus for analysis by the radiation safety staff.


3. The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client’s:
A. respiratory status.
B. level of consciousness.
C. level of pain.
D. reflexes and movement of extremities.


4. 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:
A. fiber.
B. broccoli.
C. yogurt.
D. simple carbohydrates.


5. 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?
A. Discuss the client’s fear regarding potential cervical cancer.
B. Assist with silver nitrate application to the cervix to control bleeding.
C. Give instructions regarding douching and sexual relations.
D. Administer pain medications.


6. Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?
A. A client with diabetes being discharged today.
B. A 35-year-old male with tracheostomy and copious secretions.
C. A teenager scheduled for physical therapy this morning.
D. A 78-year-old female client with pressure ulcer that needs dressing change.


7. Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?
A. Call for help to get the client back in bed.
B. Establish whether the client is responsive.
C. Assist the client back to bed.
D. Ask the client what happened.



8. 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:
A. Role modeling behaviors of the preceptor.
B. The philosophy of the new nurse’s school of nursing.
C. The orientation provided to the new nurse.
D. Lack of trust to the members of the healthcare team.


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:
A. pain.
B. wound infection.
C. depression.
D. thrombophlebitis.


10. 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?
A. Administer pain medications.
B. Administer IV fluids.
C. Administer dopamine.
D. Administer oxygen via nasal cannula.


11. 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?
A. Call for a social worker to meet with the family.
B. Check the child’s blood pressure, pulse, respiration, and temperature.
C. Administer pain medications.
D. Speak with the parents about how the fracture occurred.


12. 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. A client scheduled for cardiac ultrasound this morning.
B. A client with syncope being discharged today.
C. A client with chronic bronchitis on nasal oxygen.
D. A client with diabetic foot ulcer that needs a dressing change.


13. 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?
A. Determine the level of consciousness.
B. Push the call button for help.
C. Turn the client face up to assess.
D. Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician.


14. 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?
A. Ask the other nurse if she needs help.
B. Assess the client and let the other nurse know what should be done.
C. Ask the client if he is satisfied with his care.
D. Contact the nursing supervisor to address the situation.


15. 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?
A. Hepatitis A vaccine.
B. Lyme’s disease vaccine.
C. Hepatitis B vaccine.
D. Pneumococcal vaccine.



Answers and Rationale

1. Answer: D. 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.

2. Answer: B. Decontaminate the open wound on the client’s thigh.
Decontaminating an open wound is the first priority for the client. This minimizes absorption of radiation in the client’s body.

3. Answer: A. respiratory status.
Assessing respiratory status is the first priority. Remember ABC.

4. Answer: B. Broccoli.
Broccoli are gas forming and therefore, should be avoided.

5. Answer: B. Assist with silver nitrate application to the cervix to control bleeding.
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.

6. Answer: C. A 35-year-old male with tracheostomy and copious secretions.
The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority.

7. Answer: B. Establish whether the client is responsive.
Assess first for responsiveness.


8. Answer: D. Lack of trust to the members of the healthcare team.
Lack of trust is the common reason for reluctance in delegation of tasks.

9. Answer: B. wound infection.
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. Answer: D. 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.

11. Answer: D. 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.

12. Answer: C. A client with chronic bronchitis on nasal oxygen.
A client with airway problems should be attended first.

13. Answer: A. Determine the level of consciousness.
Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.

14. Answer: D. 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.

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

See Also

If you enjoyed this quiz, check out the rest of them below: