NCLEX Exam: Nursing Prioritization, Delegation and Assignment 2 — Questions and Answers

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

Correct answer: A client who had a total hip replacement two days ago and needs blood glucose monitoring.

A client two days post-total hip replacement who needs blood glucose monitoring represents a relatively stable patient with a common, predictable task. Blood glucose monitoring is a skill familiar to any medical-surgical nurse, and a hip replacement patient two days post-op is typically past the immediate critical post-operative phase. The other options involve more complex assessments, specialized equipment, or acute, potentially unstable conditions, which are less suitable for a floating nurse with no orthopedic experience.

Question 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?

Decontaminate the client’s clothing.
Decontaminate the open wound on the client’s thigh. (Correct answer)
Decontaminate the examination room the client is placed in.
Save the client’s vomitus for analysis by the radiation safety staff.

Correct answer: Decontaminate the open wound on the client’s thigh.

In a radiological incident, the primary goal is to prevent further absorption of radioactive material and minimize exposure to others. Decontaminating an open wound is the utmost priority because it provides a direct pathway for radioactive substances to enter the bloodstream and spread throughout the body. Rapid wound decontamination prevents systemic absorption and reduces the risk of internal contamination, which is more dangerous than external contamination of clothing or the environment.

Question 3: The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client’s:

respiratory status. (Correct answer)
level of consciousness.
level of pain.
reflexes and movement of extremities.

Correct answer: respiratory status.

In the Post-Anesthesia Care Unit (PACU), the ABCs (Airway, Breathing, Circulation) are always the top priority. Anesthesia and sedatives can depress respiratory drive, and the airway can become obstructed. Therefore, assessing respiratory status (patency of airway, respiratory rate, depth, and oxygen saturation) is the most critical initial assessment to ensure the patient is adequately oxygenating and ventilating before addressing other concerns like consciousness or pain.

Question 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:

fiber.
broccoli. (Correct answer)
yogurt
simple carbohydrates.

Correct answer: broccoli.

The symptoms of intermittent abdominal pain, bloating, and flatulence are characteristic of Irritable Bowel Syndrome (IBS) or general gastrointestinal sensitivity. Broccoli, along with other cruciferous vegetables, is known to produce significant gas and bloating due to its high fiber content and specific carbohydrates (FODMAPs) that are poorly digested by some individuals. Avoiding such gas-producing foods can help alleviate these uncomfortable symptoms.

Question 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?

Discuss the client’s fear regarding potential cervical cancer.
Assist with silver nitrate application to the cervix to control bleeding. (Correct answer)
Give instructions regarding douching and sexual relations.
Administer pain medications.

Correct answer: Assist with silver nitrate application to the cervix to control bleeding.

After a colposcopy, especially if biopsies were taken, bleeding from the cervix is a common occurrence. The nurse's first action should be to assist with controlling this bleeding, often using agents like silver nitrate. This ensures client safety and prevents complications, making it the immediate priority over discussing fears, giving discharge instructions, or administering pain medication, which typically follow once immediate physical stability is addressed.

Question 6: Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?

A client with diabetes being discharged today.
A 35-year-old male with tracheostomy and copious secretions. (Correct answer)
A teenager scheduled for physical therapy this morning.
A 78-year-old female client with pressure ulcer that needs dressing change.

Correct answer: A 35-year-old male with tracheostomy and copious secretions.

When prioritizing client assessments, the nurse should always follow the ABC (Airway, Breathing, Circulation) framework. A client with a tracheostomy and copious secretions is at immediate risk for airway obstruction and respiratory compromise, which is a life-threatening situation. Addressing this potential airway issue takes precedence over discharge planning, routine physical therapy, or a dressing change for a pressure ulcer.

Question 7: Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?

Call for help to get the client back in bed.
Establish whether the client is responsive. (Correct answer)
Assist the client back to bed.
Ask the client what happened.

Correct answer: Establish whether the client is responsive.

When finding a client on the floor, the nurse's immediate priority is to assess their safety and physiological status. Establishing responsiveness is the crucial first step in a rapid assessment, as it determines the client's level of consciousness and guides subsequent actions, such as checking for breathing and pulse. Only after ensuring the client's immediate safety and stability can the nurse proceed with calling for help, asking what happened, or assisting them back to bed.

Question 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:

Role modeling behaviors of the preceptor.
The philosophy of the new nurse’s school of nursing.
The orientation provided to the new nurse.
Lack of trust to the members of the healthcare team. (Correct answer)

Correct answer: Lack of trust to the members of the healthcare team.

New nurses often feel reluctant to delegate tasks due to a lack of established trust in the abilities and judgment of other healthcare team members, such as unlicensed assistive personnel (UAPs). This can stem from a desire to maintain control, ensure tasks are done correctly, or a lack of familiarity with the team's competencies. Building trust and understanding the scope of practice for each team member is essential for effective delegation.

Question 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:

pain
wound infection. (Correct answer)
depression.
thrombophlebitis.

Correct answer: wound infection.

After bariatric surgery, clients are at a significantly increased risk for wound infection due to factors such as obesity, large incision size, and potential for impaired healing. Preventing wound infection is a critical priority as it can lead to severe complications, prolonged hospitalization, and increased morbidity. While pain, depression, and thrombophlebitis are also concerns, wound infection poses an immediate and substantial threat to recovery.

Question 10: Examples are: guaranteeing the availability of necessary equipment, collaborating with other healthcare professionals, and reporting a change in shift

Direct care
Indirect care (Correct answer)
Delegation
Referrals

Correct answer: Indirect care

Indirect care refers to nursing activities performed away from the client but on their behalf, supporting the effectiveness of direct care. Examples include ensuring the availability of necessary equipment, collaborating with other healthcare professionals, and reporting changes in shift. These actions are crucial for efficient and safe client care, even though they don't involve direct physical interaction with the patient.

Question 11: Planning for the day begins as soon as the medical-surgical nurse receives the report. When determining care priorities, which nurse intervention should be the main one?

Assessing client situations (Correct answer)
Analyzing collected data
Ascertaining interventions
Assigning staff to clients

Correct answer: Assessing client situations

When determining care priorities, the nurse's main intervention should always be assessing client situations. A thorough and ongoing assessment provides the foundational data needed to identify client needs, potential risks, and changes in condition. Without accurate assessment, the nurse cannot effectively analyze data, ascertain appropriate interventions, or assign staff, making it the critical first step in the nursing process.

Question 12: Chronic obstructive pulmonary disease patient (COPD). Which airway management procedure should a nursing assistant (PCT) handle?

Teaching the patient to use incentive spirometry
Auscultation of breath sounds every 4 hours
Assisting the patient to sit up on the side of the bed (Correct answer)
Instructing the patient to cough effectively

Correct answer: Assisting the patient to sit up on the side of the bed

A nursing assistant (PCT) can safely and appropriately assist a patient with positioning, such as helping them sit up on the side of the bed. This is a basic care activity that promotes comfort and facilitates breathing for a COPD patient. Teaching, auscultating breath sounds, and instructing on effective coughing require advanced assessment skills, clinical judgment, and patient education, which are within the scope of a licensed nurse, not a PCT.

Question 13: Which of the nurse's assessments needs to be addressed first?

Drainage from surgical incision
Reddened area to coccyx
Decreased urinary output
Shortness of breath (Correct answer)

Correct answer: Shortness of breath

When prioritizing nursing assessments, the nurse should always address issues related to airway, breathing, and circulation (ABCs) first. Shortness of breath indicates a potential compromise in breathing, which is an immediate life-threatening concern. This takes precedence over less urgent issues like surgical incision drainage, a reddened coccyx, or decreased urinary output, which do not pose an immediate threat to the patient's life.

Question 14: The nurse is assisting a nursing assistant in giving a comatose patient in concert a bath. Which of the following actions warrants the nurse's intervention?

The nursing assistant positions the client on the left side, head elevated.
The nursing assistant answers the phone while wearing gloves. (Correct answer)
The nursing assistant log-rolls the client to provide back care.
The nursing assistant places an incontinence diaper under the client.

Correct answer: The nursing assistant answers the phone while wearing gloves.

Answering the phone while wearing gloves that have been used for patient care is a critical breach of infection control. The gloves are considered contaminated and can transfer microorganisms from the patient to the phone, and subsequently to other surfaces or the nursing assistant's ungloved hands. The nurse must intervene immediately to prevent the spread of infection and reinforce proper glove use and hygiene.

Question 15: What kind of nurse intervention is medication administration?

Dependent (Correct answer)
Independent
Interdisciplinary
Collaborative

Correct answer: Dependent

Medication administration is classified as a dependent nursing intervention because it requires a direct order or prescription from a physician or other licensed independent practitioner. Nurses administer medications based on these orders, making it an action that depends on the authority of another healthcare professional. Independent interventions, in contrast, are actions nurses can initiate on their own based on their scope of practice and clinical judgment.

Question 16: A patient who is getting ready for back surgery is watching the nurse as she demonstrates how to properly do deep breathing and coughing exercises. What stage of nursing care is the nurse providing?

Implementation (Correct answer)
Diagnosis
Evaluation
Assessment

Correct answer: Implementation

The nurse is providing instruction and demonstrating an activity (deep breathing and coughing exercises) to the patient. This action falls under the implementation phase of the nursing process, where the nurse carries out the planned interventions to achieve client outcomes. The nurse is actively putting the care plan into action by educating and guiding the patient.

NCLEX Exam: Nursing Prioritization, Delegation and Assignment 2

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?