NCLEX Exam: Nursing Prioritization, Delegation and Assignment 6

Question 1

You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?

Accepted Answer

Continuous bubbling in the water seal chamber

Answer

Continuous bubbling in the water seal chamber, after the initial post-insertion period, indicates an air leak within the chest tube system. This is a critical finding that requires immediate investigation and intervention, as it can prevent lung re-expansion and potentially lead to a tension pneumothorax. The nursing student must notify the RN immediately to address this serious complication.

Question 2

You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene?

Accepted Answer

Removing the inner cannula and cleaning using universal precautions

Answer

The nurse should intervene if the student is removing the inner cannula and cleaning it using only "universal precautions." While universal precautions are always necessary, cleaning a reusable inner cannula requires sterile technique to prevent infection. If it's a disposable inner cannula, it should be replaced with a new sterile one, not cleaned. Therefore, the action described is either insufficient or incorrect for proper tracheostomy care.

Question 3

You are supervising an RN who was pulled from the medical-surgical floor to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which of these directions would you clearly proved to the RN? (Select all that apply)

Accepted Answer

Apply direct lateral pressure to the nose for 5 minutes

Answer

When managing anterior epistaxis, several interventions are crucial. The nurse should instruct the patient to apply direct lateral pressure to the nose for at least 5 minutes to help stop the bleeding. Maintaining universal body substance precautions is essential due to contact with blood. Applying ice or cool compresses to the nose can promote vasoconstriction and reduce bleeding. Finally, instructing the patient not to blow their nose for several hours prevents dislodging clots and reinitiating bleeding.

Question 4

You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?

Accepted Answer

Marking the tube 1 cm from where it touches the incisor tooth or nares

Answer

The nurse must intervene immediately if the student marks the endotracheal tube 1 cm from where it touches the incisor tooth or nares. After intubation, the tube should be secured at the appropriate depth, and the measurement at the incisor or nares should be noted and documented to monitor for displacement. Marking it 1 cm away is not a standard practice and could lead to incorrect depth assessment or accidental dislodgement, compromising the patient's airway.

Question 5

You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?

Accepted Answer

The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min

Answer

The patient's blood pressure of 100/48 mm Hg and heart rate of 102 beats/min after removing 1800 mL of fluid is the most important finding to report. This indicates potential hypovolemia or a significant vasovagal response due to the rapid fluid shift, which can lead to hemodynamic instability and shock. This physiological change requires immediate medical evaluation and intervention to prevent further complications.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Exam: Nursing Prioritization, Delegation and Assignment 6