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.
Examples are: guaranteeing the availability of necessary equipment, collaborating with other healthcare professionals, and reporting a change in shift
Indirect care refers to activities and tasks performed by healthcare professionals that support the delivery of direct patient care. It includes administrative tasks, documentation, communication, collaboration with other healthcare members, and ensuring the availability of necessary equipment and supplies. Change of shift report and collaborating with other healthcare members are forms of communication and coordination that facilitate the continuity of care. Ensuring the availability of needed equipment is essential for providing efficient and effective care to patients. These activities are crucial in maintaining the overall functioning of a healthcare facility and optimizing patient outcomes.
Planning for the day begins as soon as the medical-surgical nurse receives the report. When determining care priorities, which nurse intervention should be the main one?
When prioritizing care as a medical-surgical nurse, the primary nursing intervention should be assessing client situations.
Assessing client situations involves gathering information about the patients' conditions, identifying their needs, and determining the urgency and priority of care. This step is crucial for developing an effective plan of care and allocating resources appropriately. By assessing client situations, the nurse can identify any changes or deterioration in the patients' conditions, anticipate potential complications, and prioritize interventions accordingly.
Chronic obstructive pulmonary disease patient (COPD). Which airway management procedure should a nursing assistant (PCT) handle?
When considering airway management for a patient with chronic obstructive pulmonary disease (COPD), there are certain interventions that can be delegated to a nursing assistant or patient care technician (PCT). One such intervention that can be delegated is assisting the patient to sit up on the side of the bed.
Which of the nurse's assessments needs to be addressed first?
When caring for a patient with chronic obstructive pulmonary disease (COPD), the assessment of shortness of breath should be addressed as a priority. Shortness of breath, also known as dyspnea, is a common and significant symptom in patients with COPD. It can indicate worsening respiratory function, inadequate oxygenation, or the potential for an acute exacerbation.
The nurse is assisting a nursing assistant in giving a comatose patient in concert a bath. Which of the following actions warrants the nurse's intervention?
If the nurse observes that the nursing assistant answers the phone while wearing gloves, it is appropriate for the nurse to intervene. Answering the phone while wearing gloves poses a risk of cross-contamination.
Gloves are used as personal protective equipment (PPE) to prevent the transmission of pathogens and protect both the healthcare worker and the patient from infection. Gloves should be worn when there is a risk of contact with blood, body fluids, mucous membranes, or non-intact skin. However, gloves should be removed and discarded appropriately before touching non-contaminated surfaces or objects.
What kind of nurse intervention is medication administration?
Medication administration is considered a dependent nursing intervention.
Dependent nursing interventions are those actions and procedures that require an order, prescription, or direction from a licensed healthcare provider (such as a physician or advanced practice nurse) before they can be carried out. These interventions are performed by nurses based on the healthcare provider's orders and are within the scope of nursing practice.
A patient who is getting ready for back surgery is watching the nurse as she demonstrates how to properly do deep breathing and coughing exercises. What stage of nursing care is the nurse providing?
The implementation step entails starting particular nursing interventions and treatments that are intended to assist the patient in achieving predetermined outcomes. Patient care information is acquired during the assessment process by observation, interviews, and physical evaluation. Patient data are evaluated, verified, and clustered to discover patient issues during the diagnosis stage. Each issue is then described using standardized terminology as a distinct nursing diagnostic to ensure that all healthcare professionals can understand it. The nurse decides whether the patient's goals have been reached, assesses the efficacy of interventions, and decides whether the plan of care should be abandoned, continued, or modified during the evaluation stage.