NCLEX Exam: Nursing Prioritization, Delegation and Assignment

Question 1

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care?

Accepted Answer

Perform postural drainage and chest physiotherapy every 4 hours

Answer

Cystic fibrosis causes the production of thick, sticky mucus that obstructs airways, making patients highly susceptible to respiratory infections like pneumonia and increased shortness of breath. Postural drainage and chest physiotherapy are critical interventions for mobilizing these secretions, improving airway clearance, and preventing further lung complications. Regular performance of these activities is vital for maintaining respiratory function and reducing infection risk.

Question 2

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply.

Accepted Answer

Use a lift sheet when moving and positioning the patient in bed

Answer

Patients receiving IV heparin are at an increased risk of bleeding and bruising due to the anticoagulant's effects. Therefore, instructions to the nursing assistant must focus on minimizing trauma and preventing injury. Using a lift sheet, electric razor, and soft-bristled toothbrush reduces the risk of skin tears, cuts, and gum bleeding, while firm-soled footwear helps prevent falls that could lead to significant injury.

Question 3

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action?

Accepted Answer

Perform endotracheal intubation and initiate mechanical ventilation

Answer

Acute Respiratory Distress Syndrome (ARDS) causes severe hypoxemia that often does not respond to conventional oxygen therapy. When a patient's oxygenation remains poor despite a nonrebreather mask, it indicates a critical need for more aggressive respiratory support. Endotracheal intubation and mechanical ventilation allow for precise control of oxygen delivery, positive end-expiratory pressure (PEEP), and respiratory rate, which are essential to improve gas exchange and prevent further lung injury in ARDS.

Question 4

A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)?

Accepted Answer

Assisting the patient to sit up on the side of the bed

Answer

Assisting a patient to sit up on the side of the bed is a basic activity of daily living (ADL) that falls within the scope of practice for a nursing assistant. This position can help improve breathing for a patient with COPD by allowing for better lung expansion. Other options involve assessment, teaching, or advanced skills that require the knowledge and judgment of a licensed nurse.

Question 5

A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)?

Accepted Answer

Remind the patient to sleep on his side instead of his back

Answer

Reminding a patient to sleep on their side to alleviate sleep apnea symptoms is a routine task that reinforces established care plans and falls within the scope of a nursing assistant's responsibilities. This action does not require independent assessment, teaching of new information, or medication administration, which are typically outside the nursing assistant's scope of practice.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Exam: Nursing Prioritization, Delegation and Assignment