NCLEX Exam: Nursing Prioritization, Delegation and Assignment
A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care?
Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.
A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply.
Please select 4 correct answers
While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action?
A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s work of breathing.
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)?
Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse.
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)?
The nursing assistant can remind patients about actions that have already been taught by the nurse and are part of the patient’s plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN.
After change of shift, you are assigned to care for the following patients. Which patient should you assess first?
The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient’s needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.
After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately?
Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body’s normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.
An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply.
Please select 2 correct answers
The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient’s abilities require additional education and skills. These actions are within the scope of practice of the professional RN.
The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit?
Many surgical patients are taught about coughing, deep breathing, and use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.
The ventilator of a patient sounds the high-pressure alarm. The oxygen saturation meter in the patient's room indicates 87% when you walk in to evaluate the ARDS patient, who is also having trouble sitting up. Which move ought to you make next?
You can give the patient 100% FiO2 by manually ventilating them while you try to figure out what's causing the high-pressure alarm. Safe ventilation parameters for each patient and their conditions should be taken into account while using proper ventilation strategies with the BVM.
A patient who is getting oxygen through a nasal cannula at a flow rate of 6 L/min complains of nasal passage irritation, the nursing assistant informs you. What course of action might you recommend to enhance the patient's comfort in light of this issue?
The mucous membranes may dry out if the oxygen flow rate exceeds 4 L/min. The best course of action is to upgrade the oxygen delivery system with humidification. For patients who need high-flow oxygen systems for longer than 24 hours or who complain of upper airway irritation owing to dryness, it is permissible to utilize humidified oxygen. It can also be beneficial to apply a water-soluble jelly to the nares to lessen mucosal irritation. None of the alternative solutions will address the issue.
Which comment made by a TB patient during the discharge process suggests the need for additional instruction?
Patients must take isoniazid for a minimum of six months. The other three assertions are true and demonstrate knowledge about TB. The preferred drug is isoniazid. Usually, it is taken along with pyridoxine, or vitamin B6 (to prevent nerve damage). For people who test positive for Mantoux or Quantiferon, isoniazid should be continued for 6 or 9 months.
Which medication should you be prepared to provide to the newborn baby who has respiratory distress syndrome (RDS) in order to improve respiratory status?
A type of artificial surfactant is called exosurf neonatal. Two to four doses may be administered to a newborn with RDS within the first 24 to 48 hours of birth. It promotes respiratory health, and studies have shown that giving it reduces the risk of pneumothorax significantly.
The client's potassium level is 6.7 mEq/L, and the clinical teacher instructed the student nurse to administer care. Which intervention is properly assigned to the nursing student?
Supervision and delegation. Potassium levels should be between 3.5 and 5 mEq/L. The client has a high potassium level. With the help of kayexalate, potassium is expelled from the body through the digestive tract. The appropriate person must be given the appropriate tasks and responsibilities under the appropriate conditions. Following that, the nurse who assigned the tasks and jobs must interact with and supervise the person performing them.
Ineffective Breathing Pattern is the nursing diagnostic for the COPD patient. Which task should you assign to the seasoned LPN working under your direction?
Experienced LPNs/LVNs can collect information on how well patients perform interventions that have already been taught by observing patients. The legal ability for the licensed practical or vocational nurse to gather data, plan, implement, and evaluate care while working under the direct supervision and direction of the registered nurse would most likely be included in the scope of practice for this nurse.
A 22-year-old patient who underwent emergency surgery and many transfusions three days prior is examined, and you discover that the patient appears agitated and is breathing laboriously at a rate of 38 breaths per minute. 90% oxygen saturation is achieved with a 6 L/min nasal cannula oxygen supply. Which course of action is best?
The patient's medical history and current symptoms point to the possibility of developing ARDS, which calls for intubation and mechanical ventilation. Until signs of improvement are seen, patients are mechanically ventilated, protected from fluid excess with diuretics, and given nutritional support.