NCLEX Exam: Nursing Prioritization, Delegation and Assignment 2
Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience on working on. Which client should be assigned to her?
A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with stable condition as those have care similar to her training and experience. A client who is in postoperative state is more likely to be on a stable condition.
Sally is a nurse working in an emergency department and receives a client after a radiological incident. Which task is utmost priority for the nurse to do first?
Decontaminating an open wound is the first priority for the client. This minimizes absorption of radiation in the client’s body.
The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client’s:
Assessing respiratory status is the first priority. Remember ABC.
Nurse Jackie is reviewing the diet of a 28-year-old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. The nurse should tell the client to avoid:
Broccoli are gas forming and therefore, should be avoided.
Nurse Joriz of Nurseslabs Medical Center is planning care for a client who will undergo a colposcopy. Which of the following actions should Joriz take first?
The priority nursing action when caring for a client who underwent colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix.
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?
The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority.
Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?
Assess first for responsiveness.
Paige is a nurse preceptor who is working with a new nurse Joyce. She notes that the Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is mostly likely due to:
Lack of trust is the common reason for reluctance in delegation of tasks.
Nurse Paul is developing a care plan for a client after bariatric surgery for morbid obesity. The nurse should include which of the following on the care plan as the priority complication to prevent:
Wound infection is the most common complication among obese clients who had undergone surgery. This is due to their poor blood supply in their adipose tissues.
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?
Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.
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?
In case of injury, especially among children, it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse.
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?
A client with airway problems should be attended first.
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?
Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.
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?
The nurse should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.
Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns that which immunization is a priority for the client?
Pneumococcal vaccine is a priority immunization amongst elderly especially those with chronic illnesses. It is administered every five (5) years.
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