NCLEX Exam: Nursing Prioritization, Delegation and Assignment 5

Question 1

A client presents to the emergency room with dyspnea, chest pain, and syncope.
The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33.
The client is also anxious and fearing death.
Which action should the nurse take first?

Accepted Answer

Administer oxygen via nasal cannula.

Answer

Administer pain medications.

Answer

Administer IV fluids.

Answer

Administer dopamine.

Question 2

Nurse Pietro receives a 11-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first?

Accepted Answer

Speak with the parents about how the fracture occurred.

Answer

Call for a social worker to meet with the family.

Answer

Check the child’s blood pressure, pulse, respiration, and temperature.

Answer

Administer pain medications.

Question 3

Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

Accepted Answer

A client with chronic bronchitis on nasal oxygen.

Answer

A client scheduled for cardiac ultrasound this morning.

Answer

A client with syncope being discharged today.

Answer

A client with diabetic foot ulcer that needs a dressing change.

Question 4

A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first?

Accepted Answer

Determine the level of consciousness.

Answer

Push the call button for help.

Answer

Turn the client face up to assess.

Answer

Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician.

Question 5

Nurse Adonai is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best?

Accepted Answer

Contact the nursing supervisor to address the situation.

Answer

Ask the other nurse if she needs help.

Answer

Assess the client and let the other nurse know what should be done.

Answer

Ask the client if he is satisfied with his care.

Question 6

You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient. A. Remove the inhaler cap and shake the inhaler B. Open your mouth and place the mouthpiece 1 to 2 inches away C. Tilt your head back and breathe out fully D. Hold your breath for at least 10 seconds E. Press down firmly on the canister and breathe deeply through your mouth F. Wait at least 1 minute between puffs.

Accepted Answer

A, C, B, E, D, F.

Answer

A, C, B, D, E, F.

Answer

C, A, B, E, D, F.

Answer

C, A, B, D, E, F.

Question 7

After getting the change-of-shift report, whose client should the nurse evaluate first?

Accepted Answer

A client with heart failure who is complaining of shortness of breath

Answer

A client with type 1 diabetes mellitus with blood glucose of 82​ mg/dL

Answer

A client with a bowel obstruction who is complaining of nausea

Answer

A client with hypertension with a blood pressure of​ 168/88 mmHg

Question 8

Multiple clients' vital signs are evaluated by the nurse. Which client condition and assessment will worry the nurse the most?

Accepted Answer

The adult client receiving patient controlled administration of morphine who has a respiratory rate of 9 breaths/minute.

Answer

The adult client admitted through the ED following a car accident with a pulse rate of 92 beats/minute.

Answer

The postoperative client medicated 3 hours prior for pain with a blood pressure of 194/88 mm Hg.

Answer

The older adult client diagnosed with bacterial pneumonia with a temperature of 100.8°F (38.2°C).

Question 9

A patient's blood glucose level must be known by the nurse before a medication can be given. She enquires about the nursing assistant's training in fingersticks. The nursing assistant claims she has performed the task numerous times but has not received formal training. Was the nurse supposed to do?

Accepted Answer

Watch the nursing assistant perform a fingerstick to validate her ability

Answer

Ask another nurse to perform the fingerstick

Answer

Let the nursing assistant perform the fingerstick unsupervised

Answer

Perform the fingerstick herself

Question 10

A nurse's initial interview and evaluation of a patient must include: (Select all that apply.)

Accepted Answer

ensure the coordination of the patient's care

Answer

Take the patient's vital signs.

Answer

weigh the patient using a bed scale.