NCLEX Exam: Nursing Prioritization, Delegation and Assignment 4

Question 1

The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?

Accepted Answer

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

Answer

A high-pressure alarm on a ventilator, coupled with decreased oxygen saturation and patient distress, indicates an immediate and life-threatening respiratory emergency. The priority is to ensure adequate oxygenation and ventilation without delay. Manually ventilating the patient provides immediate respiratory support, bypassing the malfunctioning ventilator and allowing time to assess and troubleshoot the cause of the alarm.

Question 2

The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?

Accepted Answer

Suggest that the patient’s oxygen be humidified

Answer

Oxygen delivered via nasal cannula, especially at higher flow rates like 6 L/min, can be very drying to the mucous membranes of the nasal passages, leading to discomfort and irritation. Humidification adds moisture to the oxygen, which helps prevent this dryness and improves patient comfort. This is a common and effective intervention for this specific problem.

Question 3

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?

Accepted Answer

Observe how well the patient performs pursed-lip breathing

Answer

Observing a patient's technique for a learned skill like pursed-lip breathing falls within the scope of practice for an experienced LPN, as it involves data collection and monitoring an established intervention. LPNs are trained to reinforce teaching and assess patient performance of basic nursing skills. Planning comprehensive care, assisting with complex ADLs, or consulting with other departments typically requires the broader assessment and critical thinking skills of a Registered Nurse.

Question 4

The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?

Accepted Answer

Oral temperature of 101.2 F (38.4C)

Answer

A temperature of 101.2 F (38.4C) indicates a fever, which is a significant sign of infection. Patients with COPD are highly susceptible to respiratory infections, and an unvaccinated status further increases this risk. Given the potential for rapid deterioration in COPD patients with infection, this finding requires immediate reporting to the RN for prompt assessment and intervention.

Question 5

To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS?

Accepted Answer

Surfactant (Exosurf)

Answer

Respiratory Distress Syndrome (RDS) in newborns is primarily caused by a deficiency of pulmonary surfactant, which is essential for reducing surface tension in the alveoli and preventing lung collapse. Administering exogenous surfactant directly addresses this physiological deficiency, improving lung compliance and gas exchange. Theophylline and Albuterol are bronchodilators, and Dexamethasone is a steroid, which are not the primary treatment for surfactant deficiency.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Exam: Nursing Prioritization, Delegation and Assignment 4