NCLEX Delegation Questions

NCLEX ® Delegation Questions ScienceMedicineNursing Daniel_Griffiths2 Save Delegation NCLEX Questions for Nu...17 terms kfs1611Preview Prioritization NCLEX questions 28 terms madisoncastello Preview 25Qw/exp Delegation and Prioritiza...25 terms Preview NCLEX 110 term kan 1. You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication.What is your initial action?

• Check the medication administration records (MARs) for the past several days.
• Ask the nurse educator to provide in-service training about pain management.
• Perform a complete pain assessment on the client and take a pain history.
• Have a conference with the nurses responsible for the care of this client.
• Ans: 4 As charge nurse, you must assess the performance and attitude of the staff in relation to this client. After data are gathered from the

nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem. Focus: Supervision, prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

• As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly

charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first?

• Make a note in the nurse's file and continue to observe clinical performance.
• Refer the new nurse to the in-service education department.
• Quiz the nurse about knowledge of pain management and pharmacology.
• Give praise for correctly charting the dose and time and discuss the deficits in charting.
• Ans: 4 In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking

the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists.

Focus: Supervision, delegation

LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

• You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP?
• Assisting the patient with oral hygiene
• Observing the patient's response to feedings
• Facilitating expression of grief or anxiety
• Initiating daily weighings
• Ans: 1 Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the nurse to observe response to treatments and to help

the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but should not be expected to know when to initiate that

measurement. Focus: Delegation

LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 168). Elsevier Health Sciences. Kindle Edition.

• When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most

appropriate to assign to an LPN/ LVN under the supervision of a team leader RN? 1. A patient with severe anemia secondary to GI bleeding 2. A patient who needs enemas and antibiotics to control GI bacteria

• A patient who needs preoperative teaching for bowel resection surgery
• A patient who needs central line insertion for chemotherapy
• Ans: 2 Administering enemas and antibiotics is within the scope of practice of LPNs/ LVNs. Although some states an facilities may allow the

LPN/ LVN to administer blood, in general, administering blood, providing preoperative teaching, and assisting with central line insertion are the

responsibilities of the RN. Focus: Assignment

LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 168). Elsevier Health Sciences. Kindle Edition.

• A few minutes after you have given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient

reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should you take first?

• Start oxygen at 4 L/ min using a nasal cannula.
• Obtain IV access with a large-bore IV catheter.
• Give epinephrine (Adrenalin) 0.3 mL intramuscularly.
• Administer 3 mL of nebulized albuterol (Proventil) 0.083%.
• Ans: 3 Epinephrine is the initial drug of choice for treatment of anaphylaxis. Giving epinephrine rapidly at the onset of an anaphylactic reaction

may prevent or reverse cardiovascular collapse as well as airway narrowing caused by bronchospasm and inflammation. Oxygen use is also appropriate, but oxygen would be administered using a nonrebreather mask in order to achieve a fraction of inspired oxygen closer to 100%.Albuterol may also be administered to decrease airway narrowing but would not be the first therapy used for anaphylaxis. IV access will take longer to establish and should not be the first intervention. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 170). Elsevier Health Sciences. Kindle Edition.

• As the nurse manager in a public health department, you are implementing a plan to reduce the incidence of infection with human

immunodeficiency virus (HIV) in the community. Which nursing action will you delegate to health assistants working for the agency?

• Supplying injection drug users with sterile injection equipment such as needles and syringes
• Interviewing patients about behaviors that indicate a need for annual HIV testing
• Teaching high-risk community members about the use of condoms in preventing HIV infection
• Assessing the community to determine which population groups to target for education

LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 18). Elsevier Health Sciences. Kindle Edition.

• Ans: 1 Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with health assistant

education. Assessing for high-risk behaviors, education, and community assessment are RN-level skills. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 171). Elsevier Health Sciences. Kindle Edition.

• You are working with a student nurse to care for an HIV-positive patient with severe esophagitis caused by Candida albicans. Which action by

the student indicates that you need to intervene most quickly?

• Putting on a mask and gown before entering the patient's room
• Giving the patient a glass of water after administering the ordered oral nystatin (Mycostatin) suspension
• Suggesting that the patient should order chile con carne or chicken soup for the next meal
• Placing a "No Visitors" sign on the door of the patient's room
• Ans: 2 Nystatin should be in contact with the oral and esophageal tissues as long as possible for maximum effect. The other actions are also

inappropriate and should be discussed with the student but do not require action as quickly. HIV-positive patients do not require droplet/ contact precautions or visitor restrictions to prevent opportunistic infections. Hot or spicy foods are not usually well tolerated by patients with

oral or esophageal fungal infections. Focus: Prioritization

LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 171). Elsevier Health Sciences. Kindle Edition.

• You are evaluating an HIV-positive patient who is receiving IV pentamidine (Pentam) as a treatment for Pneumocystis jiroveci (PCP)

pneumonia. Which information is most important to communicate to the physician?

• The patient is reporting pain at the site of the infusion. 2. The patient is not taking in an adequate amount of oral fluids.
• Blood pressure is 104/ 76 mm Hg after pentamidine administration.
• Blood glucose level is 55 mg/ dL after medication administration.
• Ans: 4 Pentamidine can cause fatal hypoglycemia, so the low blood glucose level indicates a need for a change in therapy. The low blood

pressure suggests that the pentamidine infusion rate may need to be slowed. The other responses indicate a need for independent nursing actions (such as establishing a new IV site and encouraging oral intake) but are not associated with pentamidine infusion. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 171). Elsevier Health Sciences. Kindle Edition.

• The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be

delegated to a UAP?

• Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals
• Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake
• Ans: 2 UAPs can reinforce additional fluid intake once it is part of the care plan. Administering IV fluids, developing plans, and teaching families

require additional education and skills that are within the scope of practice of an RN. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (pp. 171-172). Elsevier Health Sciences. Kindle Edition.

• The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of

practice for an LPN/ LVN being supervised by a nurse? (Select all that apply.)

• Reminding the client to avoid commercial mouthwashes
• Encouraging mouth rinsing with warm saline
• Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake
• Seeking a dietary consult to increase fluids on meal trays
• Ans: 1, 2, 3, 4 The LPN/ LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary

as to whether LPNs/ LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 172). Elsevier Health Sciences. Kindle Edition.

• You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order

will you perform the following actions?

• Remove N95 respirator.
• Take off goggles.
• Remove gloves.
• Take off gown.
• Perform hand hygiene. _____, _____, _____, _____,
• Ans: 3, 2, 4, 1, 5 This sequence will prevent contact of the contaminated gloves and gown with areas (such as your hair) that cannot be easily

cleaned after client contact and stop transmission of microorganisms to you and your other clients. The correct method for donning and removal of personal protective equipment (PPE) has been standardized by agencies such as the CDC and the Occupational Safety and Health

Administration. Focus: Prioritization

LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 173). Elsevier Health Sciences. Kindle Edition.