NCLEX Exam: Nursing Prioritization, Delegation and Assignment 6

Question 1

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?

Accepted Answer

Continuous bubbling in the water seal chamber

Answer

Chest tube drainage of 10 to 15 mL/hr

Answer

Complaints of pain at the chest tube site

Answer

Chest tube dressing dated yesterday

Question 2

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

Accepted Answer

Removing the inner cannula and cleaning using universal precautions

Answer

Suctioning the tracheostomy tube before performing tracheostomy care

Answer

Removing old dressings and cleaning off excess secretions

Answer

Replacing the inner cannula and cleaning the stoma site.

Answer

Changing the soiled tracheostomy ties and securing the tube in place

Question 3

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)

Accepted Answer

Apply direct lateral pressure to the nose for 5 minutes

Answer

Position the patient supine and turned on his side

Question 4

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?

Accepted Answer

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

Answer

Assessing for bilateral breath sounds and symmetrical chest movements

Answer

Auscultating over the stomach to rule out esophageal intubation

Answer

Ordering a chest radiograph to verify that tube placement is correct

Question 5

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?

Accepted Answer

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

Answer

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

Answer

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

Answer

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

Question 6

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?

Accepted Answer

Frequent swallowing

Answer

Hypotonic bowel sounds

Answer

Complaints of a sore throat

Answer

Heart rate of 112 beats/min

Question 7

You are acting as preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply.

Accepted Answer

A 63-year old with a tracheostomy needing tracheostomy care every shift.

Answer

A 38-year old with moderate persistent asthma awaiting discharge

Answer

A 56-year old with lung cancer who has just undergone left lower lobectomy

Answer

A 49-year old just admitted with a new diagnosis of esophageal cancer.

Question 8

A patient who is getting oxygen through a nasal cannula at a flow rate of 6 L/min complains of nasal passage irritation, the nursing assistant informs you. What course of action might you recommend to enhance the patient's comfort in light of this issue?

Accepted Answer

Suggest that the patient's oxygen be humidified

Answer

Suggest that a simple face mask be used instead of a nasal cannula

Answer

Suggest that the patient be provided with an extra pillow

Answer

Suggest that the patient sit up in a chair at the bedside

Question 9

The following notation is made by the nurse on the patient's care plan: "Not achieved. Patient says, "I'm frightened of falling," and refuses to walk." The nurse needs to:

Accepted Answer

modify the care plan in response to the patient's condition and wishes.

Answer

ignore the patient's concern in evaluating goal attainment.

Answer

document the patient's unwillingness to continue the plan of care.

Answer

continue the plan of care as originally agreed upon.

Question 10

A 22-year-old patient who underwent emergency surgery and many transfusions three days prior is examined, and you discover that the patient appears agitated and is breathing laboriously at a rate of 38 breaths per minute. 90% oxygen saturation is achieved with a 6 L/min nasal cannula oxygen supply. Which course of action is best?

Accepted Answer

Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status

Answer

Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs

Answer

Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes

Answer

Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation