NCLEX Exam: Nursing Prioritization, Delegation and Assignment 5

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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?

Correct! Wrong!

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

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?

Correct! Wrong!

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.

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?

Correct! Wrong!

A client with airway problems should be attended first.

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?

Correct! Wrong!

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

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?

Correct! Wrong!

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

You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient. A. Remove the inhaler cap and shake the inhaler B. Open your mouth and place the mouthpiece 1 to 2 inches away C. Tilt your head back and breathe out fully D. Hold your breath for at least 10 seconds E. Press down firmly on the canister and breathe deeply through your mouth F. Wait at least 1 minute between puffs.

Correct! Wrong!

Before each use, the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should tilt the head back and breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release one puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait for at least 1 minute between puffs from the inhaler.

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