NCLEX Exam: Nursing Prioritization, Delegation and Assignment 2

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?

Accepted Answer

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

Answer

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?

Accepted Answer

Decontaminate the open wound on the client’s thigh.

Answer

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:

Accepted Answer

respiratory status.

Answer

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:

Accepted Answer

broccoli.

Answer

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?

Accepted Answer

Assist with silver nitrate application to the cervix to control bleeding.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Exam: Nursing Prioritization, Delegation and Assignment 2