NCLEX Exam: Nursing Prioritization, Delegation and Assignment 6
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?
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.
You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene?
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.
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)
Please select 4 correct answers
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
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?
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.
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?
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
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?
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.
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?
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:
The nurse should modify the care plan in response to the patient's condition and wishes. It is important to respect the patient's autonomy and preferences while providing care. If the patient refuses to walk due to fear of falling, the nurse should reassess the situation and collaborate with the patient to develop a revised plan that addresses their concerns and promotes their safety.
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?
Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status
The patient's presentation of anxiety, labored respirations at a rate of 38 breaths/min, and an oxygen saturation of 90% indicates significant respiratory distress and hypoxemia. The current oxygen delivery at 6 L/min via nasal cannula is not providing sufficient oxygenation to meet the patient's needs.