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

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?

Accepted Answer

Taking vital signs and pulse oximetry readings every 4 hours

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Exam: Nursing Prioritization, Delegation and Assignment 3