NCLEX

NCLEX Exam: Nursing Prioritization, Delegation And Assignment 6

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You are the RN's preceptor while she completes the critical care unit orientation process. A patient with ARDS who has just undergone intubation in preparation for mechanical ventilation is being cared for by the RN. You see the nurse doing each of these things. What action requires your immediate intervention?

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The point where the endotracheal tube hits the incisor teeth or nares should be marked. To ensure that the tube hasn't shifted, look for this mark. If the patient is wearing an endotracheal tube, look for accidental extubation as well as tube slippage into the right mainstem bronchus.

A nursing student under your supervision is attending to a patient who has had thoracotomy and has a chest tube. What conclusions would you demand the nursing student to immediately report to you?

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A persistent bubble suggests an air leak that needs to be located. You can attach a cushioned clamp to the drainage tubing near the occlusive dressing with the doctor's approval. If the bubbling ceases, the air leak may have occurred during the insertion of the chest tube, in which case you must inform the doctor. If you apply the padded clamp and the air bubbling does not cease, there is an air leak between the clamp and the drainage system, and you must thoroughly examine the system to find the leak.

You've just finished helping the doctor perform a thoracentesis on a patient who has recurring lung cancer-related left pleural effusion. 1800 mL of fluid were extracted during thoracentesis. Which patient evaluation data needs to be given to the doctor?

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Large-scale fluid removal from the pleural space may result in fluid shifting from the circulation into the pleural space, which may result in hypotension and tachycardia. To remedy this, the patient might need to get IV fluids.

Following a tonsillectomy, a 3-year-old patient has just returned to the pediatric ward, and you have been provided with the assessment data listed below. Which discovery needs the most immediate attention?

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After a tonsillectomy, frequent swallowing could be a sign of bleeding. Look for any signs of bleeding on the back of the throat. The other evaluation results are typical for a 3-year-old following surgery.

A patient who is getting oxygen through a nasal cannula at a flow rate of 6 L/min complains of nasal passage irritation, the nursing assistant informs you. What course of action might you recommend to enhance the patient's comfort in light of this issue?

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Trying to meet patients' needs is what the nursing process entails. Therefore, it:

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A continuous nursing procedure is used to try to address the needs of the patient. The nursing process is dynamic and cyclical in character rather than linear, always reacting to the health status of a patient. A patient's health may worsen or get better, necessitating changes to the care plan. The Joint Commission mandates ongoing evaluation of patient care plans.

The nursing care plan for a patient includes the sentences below. Which of the following sentences best describes a goal and an outcome?

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The nurse is aware that a collaborative nursing intervention is also known as a ____ intervention.

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A collaborative nursing intervention refers to actions or activities that involve the cooperation and coordination of multiple healthcare providers to achieve desired patient outcomes. It involves working together with other members of the healthcare team, such as physicians, physical therapists, social workers, and pharmacists, to provide comprehensive and holistic care.

A patient with a rash across the trunk and extremities is brought into the emergency room. The client complains of weakness, chest tightness, and breathing difficulties. Blood pressure is 96/70 mmHg, pulse is 90 beats per minute and thready, and respirations are 24 breaths per minute. The client reports using sulfasalazine for the past five days and having a recent history of a urinary tract infection. Which nursing assessment for this client is of the utmost importance?

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The priority nursing assessment for this client is airway patency. The client's report of difficulty breathing and chest tightness, along with the presence of rash and other symptoms, suggests a potential allergic reaction or anaphylaxis. In severe cases, anaphylaxis can cause airway swelling and obstruction, leading to respiratory distress and compromised breathing.

Assignments are being made for the upcoming shift by the charge nurse. Which patient should be given to the newly transferred surgical unit to medical unit nurse, who has only had six months of experience?

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Assigning the fairly new nurse, with 6 months of experience and pulled from the surgical unit, to a patient who needs teaching about the use of incentive spirometry may not be the most appropriate assignment. Teaching patients about the use of incentive spirometry requires knowledge and experience in respiratory care and patient education.

You are in charge of the post-surgery treatment of a patient who underwent a thoracotomy. Activity Intolerance has been diagnosed as the patient's condition by the nurse. Which task ought to you assign the nursing assistant?

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Monitoring and documenting intake and output are skills that the nursing assistant learns during training. The nursing assistant can remind and encourage the patient to consume enough food once the nurse has explained the significance of proper nutritional intake for energy.

An RN that was transferred from the medical-surgical floor to the emergency room is under your supervision. A patient with anterior epistaxis who has been admitted is receiving care from the nurse (nosebleed). Which of these instructions could you convince the RN of clearly? Please check all that apply.

Please select 4 correct answers

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Nasal bleeding, or epistaxis, is somewhat common but seldom fatal. Digital pressure, moderate chemical cauterization, or nasal packing are the typical treatments for anterior hemorrhage. Less frequently occurring posterior bleeding is characterized by substantial, initially bilateral bleeding that might be more challenging to control.

A 22-year-old patient who underwent emergency surgery and many transfusions three days prior is examined, and you discover that the patient appears agitated and is breathing laboriously at a rate of 38 breaths per minute. 90% oxygen saturation is achieved with a 6 L/min nasal cannula oxygen supply. Which course of action is best?

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Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status

The patient's presentation of anxiety, labored respirations at a rate of 38 breaths/min, and an oxygen saturation of 90% indicates significant respiratory distress and hypoxemia. The current oxygen delivery at 6 L/min via nasal cannula is not providing sufficient oxygenation to meet the patient's needs.

The nurse is debating whether to get the patient's consent before include the patient's family in the patient's lesson plan. Which of the following justifications for this involvement is strongest?

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The best rationale to support involving the patient's family members in the teaching plan is that it empowers both the patient and their support system.

The following notation is made by the nurse on the patient's care plan: "Not achieved. Patient says, "I'm frightened of falling," and refuses to walk." The nurse needs to:

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The nurse should modify the care plan in response to the patient's condition and wishes. It is important to respect the patient's autonomy and preferences while providing care. If the patient refuses to walk due to fear of falling, the nurse should reassess the situation and collaborate with the patient to develop a revised plan that addresses their concerns and promotes their safety.

You are overseeing a student nurse who is caring for a patient's tracheostomy. Which student behavior calls for your intervention?

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A sterile field is established and sterile procedure is applied when providing tracheostomy care. While necessary, standard procedures like hand washing are insufficient for providing tracheostomy care. In order to prevent infection, sterile technology is needed because the presence of a tracheostomy tube gives microorganisms direct access to the lungs. The other stages are all appropriate and correct.