NCLEX Exam: Nursing Prioritization, Delegation and Assignment 3 — Questions and Answers
Question 1: You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
- The patient was recently in a motor vehicle accident (Correct answer)
- The patient participated in an aerobic exercise program for 6 months
- The patient gave birth to her youngest child 1 year ago
- The patient was on bed rest for 6 hours after a diagnostic procedure
Correct answer: The patient was recently in a motor vehicle accident
A recent motor vehicle accident is a significant risk factor for developing a pulmonary embolus (PE). Trauma, especially with associated immobility or injury to blood vessels, can lead to the formation of deep vein thrombosis (DVT), which can then dislodge and travel to the lungs, causing a PE. The other options are either not direct risk factors or are less significant in comparison.
Question 2: You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?
- Assessing the patient’s respiratory status every 4 hours
- Taking vital signs and pulse oximetry readings every 4 hours (Correct answer)
- Checking the ventilator settings to make sure they are as prescribed
- Observing whether the patient’s tube needs suctioning every 2 hours
Correct answer: Taking vital signs and pulse oximetry readings every 4 hours
Taking vital signs and pulse oximetry readings are routine data collection tasks that fall within the scope of practice for an experienced nursing assistant. These tasks do not require the advanced assessment skills, clinical judgment, or critical thinking that are necessary for assessing respiratory status, checking ventilator settings, or determining the need for suctioning, which are responsibilities of the registered nurse.
Question 3: You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?
- Administer ordered antibiotics as scheduled
- Hyperoxygenate the patient before suctioning
- Maintain the head of the bed at a 30 – to 45-degree angle (Correct answer)
- Suction the airway when coarse crackles are audible
Correct answer: Maintain the head of the bed at a 30 – to 45-degree angle
Maintaining the head of the bed at a 30- to 45-degree angle is a critical intervention to prevent ventilator-associated pneumonia (VAP). This semi-Fowler's position helps reduce the risk of aspiration of gastric contents and oral secretions into the lungs, which are common pathways for bacterial entry and subsequent infection in mechanically ventilated patients. It is a fundamental component of VAP prevention bundles.
Question 4: You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately?
- The patient has fine bibasilar crackles
- The patient’s respiratory rate is 8 breaths/min. (Correct answer)
- The patient sits up and leans over the night table.
- The patient has a large barrel chest.
Correct answer: The patient’s respiratory rate is 8 breaths/min.
A respiratory rate of 8 breaths/min is dangerously low (bradypnea) and indicates severe respiratory depression. In a patient with COPD, who may be sensitive to high oxygen levels, this finding is particularly concerning as it could signal carbon dioxide narcosis or impending respiratory failure. This requires immediate intervention, as it represents a critical compromise in breathing, a top priority in patient assessment.
Question 5: You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant?
- Teaching the patient about the importance of adequate of fluid intake and hydration.
- Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
- Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake (Correct answer)
- Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.
Correct answer: Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
Reminding a patient to use an incentive spirometer is a task that involves reinforcement of a previously taught skill and monitoring compliance, which can be safely delegated to a nursing assistant. The nursing assistant can prompt the patient and document their use. Teaching about fluid intake, assisting with specific coughing positions, and instructing on effective coughing techniques require nursing assessment, judgment, and teaching skills, which are outside the scope of a nursing assistant.
Question 6: You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient’s only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician?
- The patient says that her right leg aches all night
- The right calf is warm to the touch and is larger than the left calf
- The patient is unable to remember her husband’s first name (Correct answer)
- There are multiple ecchymotic areas on the patient’s arms
Correct answer: The patient is unable to remember her husband’s first name
A sudden change in cognitive status, such as being unable to remember a spouse's name, is a significant neurological finding that requires immediate communication to the physician. This could indicate a new or worsening condition, such as a cerebral embolism, stroke, or other acute neurological event, which is a medical emergency. While the other findings are important, they do not represent the same level of acute, life-threatening change as a sudden cognitive deficit.
Question 7: You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? (Select all that apply)
- Avoid potential environmental asthma triggers such as smoke (Correct answer)
- Use the inhaler 30 minutes before exercising to prevent bronchospasm (Correct answer)
- Wash all bedding in cold water to reduce and destroy dust mites.
- Be sure to get at least 8 hours of rest and sleep every night. (Correct answer)
- Avoid foods prepared with monosodium glutamate (MSG) (Correct answer)
Correct answer: Avoid potential environmental asthma triggers such as smoke
For a patient with newly diagnosed asthma, key teaching points include avoiding environmental triggers like smoke to prevent exacerbations. It's also important to use a bronchodilator inhaler 30 minutes before exercise to prevent exercise-induced bronchospasm. Additionally, ensuring adequate rest and sleep supports overall health, and avoiding known food triggers like MSG can help manage symptoms for sensitive individuals. Washing bedding in *hot* water, not cold, is recommended to effectively reduce dust mites.
Question 8: You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal CPAP ventilation. What complications should you monitor for this infant?
- Pulmonary embolus
- Bronchitis
- Pneumothorax (Correct answer)
- Pneumonia
Correct answer: Pneumothorax
Newborn infants with respiratory distress syndrome (RDS) receiving nasal CPAP ventilation are at increased risk for pneumothorax. The positive pressure delivered by CPAP can cause barotrauma, leading to air leaks from the fragile lungs into the pleural space. The nurse must closely monitor for signs of pneumothorax, such as sudden worsening of respiratory distress, asymmetry of chest movement, or decreased breath sounds, as it is a serious and potentially life-threatening complication.
Question 9: You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given a nursing diagnosis of Activity Intolerance. Which action should you delegate to the nursing assistant?
- Instructing the patient to alternate rest and activity periods
- Encouraging, monitoring, and recording nutritional intake (Correct answer)
- Monitoring cardiorespiratory response to activity
- Planning activities for periods when the patient has the most energy
Correct answer: Encouraging, monitoring, and recording nutritional intake
Encouraging, monitoring, and recording a patient's nutritional intake are appropriate tasks to delegate to a nursing assistant. These activities involve observation, reinforcement of the care plan, and documentation, which are within the scope of a UAP. Instructing the patient, monitoring cardiorespiratory responses to activity, and planning activities require the assessment skills, clinical judgment, and teaching abilities of a registered nurse.
Question 10: With regard to their incapacity to understand spoken language, a patient with disturbed auditory perception is being cared for by a nurse. Which examination of the patient would reveal a coping mechanism for the sensory deficit?
- The patient turns one ear toward the nurse during conversation (Correct answer)
- The patient frequently cleans out his ears with a cotton swab
- The patient asks the nurse to speak loudly during conversations
- The patient isolates himself from social situations
Correct answer: The patient turns one ear toward the nurse during conversation
A patient turning one ear toward the nurse during conversation is a classic coping mechanism for disturbed auditory perception or hearing impairment. This action indicates the patient is attempting to optimize sound reception by positioning their better ear towards the source of sound. It demonstrates an active effort to compensate for their sensory deficit and engage in communication.
Question 11: A newly graduated nurse is having trouble setting priorities for care and finishing the shift on time. The nurse manager observes that after a recent event in which the new nurse assigned an improper assignment to a UAP, the new nurse rarely assigns duties to the unlicensed assistance persons (UAP). Which of the nurse manager's options would be the most effective in resolving this issue?
- Reminding the nurse that she will quickly burn out if she does not delegate some care to the UAP
- Reviewing state and facility guidelines concerning delegation with the nurse (Correct answer)
- Encouraging the nurse not to let the recent experience impact future actions
- Having the UAP discuss with the nurse appropriate activities that he can do to assist the nurse with client care
Correct answer: Reviewing state and facility guidelines concerning delegation with the nurse
The most effective option for a nurse manager to address a new nurse's reluctance to delegate, especially after an improper assignment, is to review state and facility guidelines concerning delegation. This provides the nurse with the foundational knowledge of what can be safely and legally delegated to UAPs, clarifying roles and responsibilities. This education empowers the nurse to delegate appropriately, building confidence and ensuring patient safety, rather than simply encouraging or having the UAP discuss tasks.
Question 12: The patient assignment for today is being created by the nurse manager. Five nursing technicians (NAs), two licensed practical nurses (LPNs), and five registered nurses (RNs) are slated to work with her. The nurse manager needs to keep the following in mind when determining the assignment:
- nursing practice is clearly delineated and is standard across the country.
- RNs are responsible for all care delegated to unlicensed nursing personnel. (Correct answer)
- delegation is considered direct intervention for patient care.
- LPNs operate independently and may delegate patient care.
Correct answer: RNs are responsible for all care delegated to unlicensed nursing personnel.
When creating patient assignments and delegating tasks, the nurse manager must always remember that Registered Nurses (RNs) retain ultimate accountability for all care delegated to unlicensed nursing personnel (UAP). While UAPs perform tasks, the RN is responsible for assessing the patient, determining what can be delegated, supervising the UAP, and evaluating the outcomes of the delegated care. This principle ensures patient safety and quality of care.
Question 13: Examples of: Repositioning a patient, giving cleanliness, and active listening
- Counseling
- Dependent interventions
- Independent nursing interventions (Correct answer)
- Standing orders
Correct answer: Independent nursing interventions
Repositioning a patient, providing personal cleanliness, and active listening are all examples of independent nursing interventions. These are actions that a nurse can initiate and perform based on their own assessment, clinical judgment, and nursing knowledge, without requiring a physician's order. They are fundamental aspects of holistic patient care, promoting comfort, hygiene, and emotional support.
Question 14: When a nurse walks into a room, the patient is sitting up in bed sobbing. How might the nurse approach this scenario with a critical thinking attitude?
- Set a box of tissues at the patient's bedside before leaving the room
- Tell the patient she'll be back in 30 minutes
- Limit visitors while patient is upset
- Ask the patient why she is crying (Correct answer)
Correct answer: Ask the patient why she is crying
When a patient is visibly distressed, the nurse's initial critical thinking step is to gather more information to understand the situation. Asking 'why she is crying' directly addresses the patient's emotional state and opens a channel for communication, allowing the nurse to assess the underlying cause and plan appropriate interventions. This approach demonstrates empathy and is crucial for a patient-centered care plan.
Question 15: Advance orders for a patient who is expected to be admitted from the emergency room have been given to the nurse (ER). Herman Goldstein is the patient's name. The nurse switches the patient's diet from "Regular" to "Kosher" in an effort to do her job faster. The nurse learns that the patient is Catholic even though his father is Jewish when the patient arrives at the unit. The nurse is accountable for caving in to
- An erroneous assumption (Correct answer)
- Illogical thinking
- A bias
- Closed-mindedness
Correct answer: An erroneous assumption
The nurse made an assumption about the patient's dietary needs based solely on his name and his father's religion, without verifying the information directly with the patient. This is an erroneous assumption because it's a belief taken for granted without sufficient evidence or confirmation. Critical thinking requires nurses to gather facts and avoid making judgments based on stereotypes or incomplete information.
Question 16: A patient's pain history for the last three days is being reviewed by the nurse, who observes that the pain level has not changed. The nurse confirms the patient's level of pain before deciding to call the doctor for more instructions. The nurse is employing the following procedure in this case:
- Problem Solving
- Judgement (Correct answer)
- Reasoning
- Decision making
Correct answer: Judgement
Judgement in nursing involves evaluating information and forming a conclusion or opinion based on clinical data. The nurse reviewed the patient's pain history, confirmed the current pain level, and then made a clinical determination to contact the doctor for further instructions. This process of assessing data and deciding on a course of action is a clear example of employing clinical judgment.
NCLEX Exam: Nursing Prioritization, Delegation and Assignment 3
You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out.
The patient’s history and assessment reveal all of these findings.
Which finding supports the diagnosis of pulmonary embolus?