NCLEX Exam: Nursing Prioritization, Delegation and Assignment 3

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?

Accepted Answer

The patient was recently in a motor vehicle accident

Answer

The patient participated in an aerobic exercise program for 6 months

Answer

The patient gave birth to her youngest child 1 year ago

Answer

The patient was on bed rest for 6 hours after a diagnostic procedure

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?

Accepted Answer

Taking vital signs and pulse oximetry readings every 4 hours

Answer

Assessing the patient’s respiratory status every 4 hours

Answer

Checking the ventilator settings to make sure they are as prescribed

Answer

Observing whether the patient’s tube needs suctioning every 2 hours

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?

Accepted Answer

Maintain the head of the bed at a 30 – to 45-degree angle

Answer

Administer ordered antibiotics as scheduled

Answer

Hyperoxygenate the patient before suctioning

Answer

Suction the airway when coarse crackles are audible

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?

Accepted Answer

The patient’s respiratory rate is 8 breaths/min.

Answer

The patient has fine bibasilar crackles

Answer

The patient sits up and leans over the night table.

Answer

The patient has a large barrel chest.

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?

Accepted Answer

Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake

Answer

Teaching the patient about the importance of adequate of fluid intake and hydration.

Answer

Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed

Answer

Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.

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?

Accepted Answer

The patient is unable to remember her husband’s first name

Answer

The patient says that her right leg aches all night

Answer

The right calf is warm to the touch and is larger than the left calf

Answer

There are multiple ecchymotic areas on the patient’s arms

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)

Accepted Answer

Avoid potential environmental asthma triggers such as smoke

Answer

Wash all bedding in cold water to reduce and destroy 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?

Accepted Answer

Pneumothorax

Answer

Pulmonary embolus

Answer

Bronchitis

Answer

Pneumonia

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?

Accepted Answer

Encouraging, monitoring, and recording nutritional intake

Answer

Instructing the patient to alternate rest and activity periods

Answer

Monitoring cardiorespiratory response to activity

Answer

Planning activities for periods when the patient has the most energy

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?

Accepted Answer

The patient turns one ear toward the nurse during conversation

Answer

The patient frequently cleans out his ears with a cotton swab

Answer

The patient asks the nurse to speak loudly during conversations

Answer

The patient isolates himself from social situations

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?

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?