NCSBN - National Council of State Boards of Nursing Prioritization and Delegation Questions and Answers

Question 1

A nurse on a medical-surgical unit receives the change-of-shift report. Which of the following clients should the nurse assess first?

Accepted Answer

A client admitted 2 hours ago with a suspected small bowel obstruction who is now reporting sudden, sharp abdominal pain and has a rigid abdomen.

Answer

A client with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 91% on 2 liters of oxygen via nasal cannula.

Answer

A client postoperative day 2 following a total knee replacement who is requesting pain medication for pain rated 6 on a 0-10 scale.

Answer

A client with type 2 diabetes mellitus who has a fasting blood glucose level of 180 mg/dL and is awaiting a breakfast tray.

Question 2

The registered nurse (RN) is creating the daily assignment for a team that includes a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which task is most appropriate to delegate to the UAP?

Accepted Answer

Assisting a stable client who is 2 days postoperative with personal hygiene and ambulation.

Answer

Administering a scheduled subcutaneous insulin injection for a client with stable blood glucose levels.

Answer

Performing a sterile dressing change on a client's central line.

Answer

Developing the plan of care for a newly admitted client.

Question 3

A charge nurse is making assignments on a telemetry unit. Which client is the most appropriate to assign to a licensed practical nurse (LPN)?

Accepted Answer

A client with chronic heart failure who is stable and requires administration of routine oral diuretics and monitoring of daily weights.

Answer

A client newly admitted with chest pain who requires an initial cardiac assessment and administration of intravenous nitroglycerin.

Answer

A client who requires discharge teaching about a new anticoagulation medication regimen.

Answer

A client who experienced a sudden change in level of consciousness and requires frequent neurological assessments.

Question 4

A nurse is caring for a client who suddenly develops dyspnea, tachypnea, and uses accessory muscles to breathe. What is the nurse's priority action?

Accepted Answer

Raise the head of the bed to a high-Fowler's position.

Answer

Notify the respiratory therapist.

Answer

Obtain a full set of vital signs.

Answer

Administer oxygen via a non-rebreather mask.

Question 5

A registered nurse (RN) is supervising a newly hired unlicensed assistive personnel (UAP). Which action by the UAP requires immediate intervention by the RN?

Accepted Answer

The UAP is observed applying a moisturizing lotion to the feet of a client with peripheral vascular disease.

Answer

The UAP reports a client's blood pressure of 110/70 mmHg to the nurse.

Answer

The UAP documents a client's oral intake and urinary output on the flowsheet.

Answer

The UAP ambulates a stable postoperative client in the hallway.

Question 6

The nurse is planning care for four clients. Which client's needs should the nurse prioritize as the most immediate?

Accepted Answer

An elderly client with dementia who is agitated and repeatedly trying to get out of bed without assistance.

Answer

A client with a new diagnosis of diabetes who requires initial education on insulin administration.

Answer

A client who is 24 hours post-appendectomy and reports their incisional pain is 5/10.

Answer

A client with pneumonia whose family has questions about the plan of care.

A nurse on a medical-surgical unit receives the change-of-shift report.Which of the following clients should the nurse assess first?

A nurse on a medical-surgical unit receives the change-of-shift report.
Which of the following clients should the nurse assess first?