NCLEX Exam: Nursing Prioritization, Delegation and Assignment

Question 1

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care?

Accepted Answer

Perform postural drainage and chest physiotherapy every 4 hours

Answer

Allow the patient to decide whether she needs aerosolized medications

Answer

Place the patient in a private room to decrease the risk of further infection

Answer

Plan activities to allow at least 8 hours of uninterrupted sleep

Question 2

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply.

Accepted Answer

Use a lift sheet when moving and positioning the patient in bed

Answer

Use a rectal thermometer to obtain a more accurate body temperature

Question 3

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action?

Accepted Answer

Perform endotracheal intubation and initiate mechanical ventilation

Answer

Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth

Answer

Administer furosemide (Lasix) 100 mg IV push stat

Answer

Call a code for respiratory arrest

Question 4

A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)?

Accepted Answer

Assisting the patient to sit up on the side of the bed

Answer

Instructing the patient to cough effectively

Answer

Teaching the patient to use incentive spirometry

Answer

Auscultation of breath sounds every 4 hours

Question 5

A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)?

Accepted Answer

Remind the patient to sleep on his side instead of his back

Answer

Discuss weight-loss strategies such as diet and exercise with the patient

Answer

Teach the patient how to set up the BiPAP machine before sleeping

Answer

Administer modafinil (Provigil) to promote daytime wakefulness

Question 6

After change of shift, you are assigned to care for the following patients. Which patient should you assess first?

Accepted Answer

A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

Answer

A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab

Answer

A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation

Answer

A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics

Question 7

After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately?

Accepted Answer

Tympanic temperature of 101.4 F (38.6 C)

Answer

Heart rate of 98 beats/min

Answer

Respiratory rate of 24 breaths/min

Answer

Blood pressure of 168/90 mm Hg

Question 8

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply.

Accepted Answer

Auscultate breath sounds

Answer

Complete in-depth admission assessment

Answer

Initiate the nursing care plan

Answer

Evaluate the patient’s technique for using MDI’s

Question 9

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit?

Accepted Answer

A 72-year old who needs teaching about the use of incentive spirometry

Answer

A 58-year old on airborne precautions for tuberculosis (TB)

Answer

A 68-year old just returned from bronchoscopy and biopsy

Answer

A 69-year old with COPD who is ventilator dependent

Question 10

The ventilator of a patient sounds the high-pressure alarm. The oxygen saturation meter in the patient's room indicates 87% when you walk in to evaluate the ARDS patient, who is also having trouble sitting up. Which move ought to you make next?

Accepted Answer

Manually ventilate the patient while assessing possible reasons for the high-pressure alarm

Answer

Reassure the patient that the ventilator will do the work of breathing for him

Answer

Insert an oral airway to prevent the patient from biting on the endotracheal tube

Answer

Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia.Which nursing activity is most important to include in the patient’s care?

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia.
Which nursing activity is most important to include in the patient’s care?