NCLEX-PN Delegating/Prioritizing

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NCLEX: Prioritizing

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Q: A nurse is monitoring a client following cardioversion.

Which of the following observations would be of highest priority to the nurse?Answer... Status of airway

Q: A client has just been treated with cardioversion. The

nurse should assess which of the following first?Answer... Status of airway

Q: A nurse is assisting in developing a plan of care for a

pregnant client with acquired immunodeficiency syndrome. The nurse determines that which of the following is a priority nursing diagnosis for this client?Answer.. Risk for infection

Q: A client is at risk for complications of heart failure.

What is the nurse's priority for early detection of the most likely cause of complications with this client?Answer... Evaluating total body fluid

Q: A nurse has delegated care of a client with COPD to a

nursing assistant. The nursing assistant notifies the nurse that the client's vital signs are elevated and the client is complaining of pain and dyspnea. Which of the following is appropriate regarding the nurse's next action?Answer... The nurse checks the client and gathers additional data before calling the physician.

Q: A nurse is assigned to care for four clients. When

planning client rounds, which client would the nurse collect data from first?Answer... A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift.

Q: A pregnant client tells the nurse that she felt wetness

on her peripad and that she found some clear fluid. The nurse immediately inspects the perineum and notes the presence of a prolapsed cord. The nurse's initial action is

to:

Answer... Place the client in trendelenburg's position and gently push the presenting part upward.

Q: A client returns from the recovery room following an

abdominal surgical procedure. Following the arrival of the client to the nursing unit, the initial nursing action is to

assess the:

Answer... Vital signs

Q: A 5 year old child has been transferred to the pediatric

unit after a cardiac catherterization. Which of the following interventions has the highest priority in the care of this child immediately following the procedure?Answer... Assess for any bleeding on the dressing Q; An experienced postpartum nurse has received report on four clients. Which client should the nurse most appropriately assign to another LPN?Answer... A client recovering from a scheduled cesarean delivery

Q: A woman is brought to the emergency department in a

severe state of anxiety after witnessing a devastating car accident that killed two people. A nurse assigned to care for the client would first?Answer... Take the client to a quiet room.

Q: A nurse is assigned to assist with caring for a client

who is at risk for eclampsia. If the client progresses from preclampsia to eclampsia, the nurse's first action should be?Answer... Clear and maintain an open airway.

Q: A client with a Sengstaken-Blakemore tube in place to

treat esophageal varices suddenly becomes restless, the heart rate and blood pressure increase, and the client is having difficulty breathing. The immediate nursing action

would be to:

Answer... Cut the tube and pull it out

Q: A nurse is assisting in planning the client assignments.

Which of the following is the least appropriate assignment for the nursing assistant?Answer... Assisting a profoundly developmentally disabled child eat lunch.

Q: A nurse is caring for a client immediately following a

total abdominal hysterectomy. The nurse anticipates that which of the following will be the priority in the first 24 hours following surgery?Answer... Pain

Q: An experienced postpartum nurse has received report

on four clients. Which client should the nurse most appropriately assign to another LPN?Answer... A client recovering from a scheduled cesarean delivery.

Q: A nurse is assigned to care for four clients. When

planning client rounds, which client would the nurse collect data from first?Answer... A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift.

Q: A nurse caring for a client at home arrives at the

client's home and finds the client in the bedroom, unconscious, with a pill bottle in hand. The pill bottle contains the selective serotonin re-uptake inhibitor, sertraline (Zoloft). Which of the following would the nurse check first?Answer.... respirations

Q: A nurse is planning the client assignments for the shift.

Which of the following clients would the nurse appropriately assign to the nursing assistant?Answer...A client requiring frequent ambulation with a walker

Q: A nurse is assigned to care for a client who has

experienced uterine rupture. The nurse plans care knowing that which of the following is the priority concern in caring for the client?Answer...Impaired gas exchange Question... A nurse is assigned to care for a client who is in early labor. When collecting data from the client, it is most important for the nurse to first determine which of the following?Answer... baseline fetal heart rate Question... A nurse is getting a postoperative client out of bed for the first time since surgery. the nurse raises the head of the bed, and the client complains of dizziness.Which of the following actions should the nurse take first?Answer... lower the head of the bed slowly until the dizziness is relieved.Question... A nurse is assisting in preparing a client for a cardiac catheterization. the nurse understands that it is important to check the client for a history of?Answer... Allergy to shellfish Question... A client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breach presentation.The nurse assists with planning care for the client and identifies which of the following as the lowest priority for the care of this client?Answer... measuring the fundal height.Question... A nurse is assisting in planning care for a client with a diagnosis of placenta previa. the nurse identifies which of the following as the priority goal for the client?Answer... Client exhibits no signs of fetal distress Question... A nurse in the newborn nursery received a telephone call to prepare for the admission of an infant born at 43 weeks' gestation with Apgar scores of 1 and 4.When planning for the admission of this infant, the nurse's

highest priority should be to:

Answer... connect the resuscitation bag to the oxygen outlet Question.... A client arrives to the surgical nursing unit

after surgery. The initial nursing action is to check the:

Answer... patency of the airway

Question... A nurse in charge of a rehabilitation center is planning the client assignments for the day. Which of the following clients would the nurse assign to the nursing assistant?Answer... A client on a 24 hour urine collection who is on strict bed rest.Question... the nurse on the day shift is assigned to care for the following six clients. List in order the priority how the nurse would plan to check the assigned clients.Answer... #1 is client of mechanical ventilator, #2 is pre breakfast insulin, # 3 is procedure scheduled at 9 am, # 4 is the 10 a.m. medications, # 5 is the discharge and #6 is the client scheduled for physical therapy in the afternoon.Question... A client has sustained full thickness circumferential burns of the trunk. Which of the following should be the priority concern of the nurse?Answer... client's ability to adequately ventilate.Question... A nurse discovers an unresponsive newborn infant. List in order of priority the nursing actions that should be taken to initiate CPR.Answer... # 1 is to assess responsiveness, # 2 is to yell for help, # 3 is to position infant with open airway, # 4 is to assess for evidence of breathing, # 5 is to check for pulse and # 6 is to begin chest compressions.Question... A nurse is monitoring a client following cardioversion. Which of the following observations would be of highest priority to the nurse?Answer... Status of airway Question... A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first/ Answer... A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift.Question... A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. the next nursing action is which of the following?Answer... open the airway Question... A child with a diagnosis of pertussis is being admitted to the pediatric unit. As soon as the child arrives

to the unit, the nurse would first:

Answer... place the child on a pulse oximeter Question... After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4 day period with fever, an itchy rash, reddish brown papule; and complaints of nausea, vomiting and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which of the following is the nurse's priority for client care?Answer... institute contact precautions Question... A nurse who is employed in a long term care facility is planning the clinical assignments for the day. The nurse avoids assigning which staff member to the client with a diagnosis of herpes zoster?Answer... an experienced nursing assistant who has never had chickenpox.