NCLEX Exam: Nursing Prioritization, Delegation and Assignment 5
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first?
Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.
Nurse Pietro receives a 11-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first?
In case of injury, especially among children, it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse.
Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?
A client with airway problems should be attended first.
A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first?
Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.
Nurse Adonai is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best?
The nurse should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.
You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient. A. Remove the inhaler cap and shake the inhaler B. Open your mouth and place the mouthpiece 1 to 2 inches away C. Tilt your head back and breathe out fully D. Hold your breath for at least 10 seconds E. Press down firmly on the canister and breathe deeply through your mouth F. Wait at least 1 minute between puffs.
Before each use, the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should tilt the head back and breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release one puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait for at least 1 minute between puffs from the inhaler.
After getting the change-of-shift report, whose client should the nurse evaluate first?
The client with heart failure who is complaining of shortness of breath should be assessed first after receiving the change-of-shift report.
Heart failure is a serious condition that can lead to fluid accumulation in the lungs, causing respiratory distress and shortness of breath. It is important for the nurse to prioritize this client because their symptoms indicate a potential worsening of their condition and the need for immediate assessment and intervention.
Multiple clients' vital signs are evaluated by the nurse. Which client condition and assessment will worry the nurse the most?
The adult client receiving patient-controlled administration of morphine with a respiratory rate of 9 breaths/minute would cause the nurse the most concern.
A respiratory rate of 9 breaths/minute is significantly lower than the normal range for adults, which is typically between 12 and 20 breaths per minute. This low respiratory rate indicates respiratory depression, which can be a serious adverse effect of opioid medications like morphine.
A patient's blood glucose level must be known by the nurse before a medication can be given. She enquires about the nursing assistant's training in fingersticks. The nursing assistant claims she has performed the task numerous times but has not received formal training. Was the nurse supposed to do?
In this situation, the nurse should not allow the nursing assistant to perform the fingerstick without official training. While the nursing assistant may have some experience in performing fingersticks, it is important to prioritize patient safety and adhere to proper protocols and guidelines.
A nurse's initial interview and evaluation of a patient must include: (Select all that apply.)
Please select 3 correct answers
The following are examples of nursing interventions that follow a doctor's or primary care provider's orders:
Nursing interventions that originate from the physician or primary care provider orders are considered dependent interventions.
Dependent interventions are those that require an order or prescription from a healthcare provider. Nurses follow these orders to carry out specific actions or procedures for patient care. The orders may include medication administration, treatments, diagnostic tests, therapies, or other prescribed interventions.
After a heart catheterization, the nurse is evaluating a client's peripheral circulation. Which discovery is the most important?
The finding that the femoral site is soft and free of hematoma or bleeding is a positive finding and does not require immediate priority. However, the highest priority finding in this situation would be any signs or symptoms of compromised peripheral circulation.
An RN, an LPN, and a nursing assistant are providing treatment for a patient who is experiencing respiratory distress. As directed by the RN, the nursing assistant assesses the patient's pulse oximetry level. The reading for the patient is 88%. If the patient's oxygen level is maintained below 90%, 1-4L of oxygen is ordered. What should the RN do after evaluating a critically ill patient?
In this scenario, the patient is in respiratory distress with a pulse oximetry reading of 88%, indicating a low oxygen level. The nurse's priority is to ensure the patient receives the necessary oxygen therapy to improve oxygenation and respiratory function.
Since the RN is currently assessing a critical patient and is unable to attend to the respiratory distress situation immediately, it would be appropriate for the nurse to delegate the task to the LPN. The LPN can obtain the patient's vital signs, including respiratory rate, heart rate, and blood pressure, to gather further information about the patient's condition. Additionally, the LPN can apply a nasal cannula at 2L/min as ordered to provide supplemental oxygen and help increase the patient's oxygen saturation.
Delegating this task to the LPN allows for timely intervention and ensures that the patient's immediate oxygenation needs are addressed. Once the LPN has initiated the oxygen therapy, the RN can continue assessing the critical patient and then reassess the patient in respiratory distress as soon as possible to determine if any further interventions or adjustments are needed.
Which of the following is an intervention for direct care?
A direct care intervention refers to a hands-on, physical act performed by the nurse to directly meet the healthcare needs of the patient. The administration of an injection involves the nurse physically administering medication to the patient through an injection route, such as intramuscular or subcutaneous. This action directly impacts the patient's health and is considered a direct care intervention.
When the registered nurse makes an autonomous nursing intervention, it means that:
An independent nursing intervention refers to an action that a registered nurse can initiate without requiring an order from a healthcare provider. The nurse uses their own knowledge, judgment, and skills to provide direct care to the patient.
The nurse who works in a neighborhood clinic is going over the patients who will be seen today. Which client deserves a longer slot in the schedule?
A 75-year-old with recent cognitive decline should require more time in the schedule at a community clinic.
Cognitive decline in an older adult can have various underlying causes and may significantly impact their ability to communicate, comprehend instructions, and engage in a healthcare visit effectively. Allocating more time for this client allows the nurse to conduct a comprehensive assessment, address their specific needs, and provide appropriate support and interventions.