NCLEX Delegation Questions

NCLEX ® Delegation Questions Aubreyy44 Save Delegation Questions 16 terms AnadimirraPreview Prioritization, Delegation, and Assig...106 terms habshicoPreview Delegation practice questions

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Bec 1. 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.

• 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.

• An experienced LPN/ LVN, 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/ LVN? (Select all that apply.)

• Auscultating breath sounds
• Administering medications via metered-dose inhaler (MDI)
• Completing in-depth admission assessment
• Checking oxygen saturation using pulse oximetry
• Developing the nursing care plan
• Evaluating the patient's technique for using MDIs
• Ans: 1, 2, 4 The experienced LPN/ LVN 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/ LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN.LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 175). Elsevier Health Sciences. Kindle Edition.

• The UAP tells you that a patient who is receiving oxygen at a flow rate of 6 L/ min by nasal cannula is reporting nasal passage discomfort.

What intervention should you suggest to improve the patient's comfort for this problem?

• Humidify the patient's oxygen.
• Use a simple face mask instead of a nasal cannula.
• Provide the patient with an extra pillow.
• Have the patient sit up in a chair at the bedside.
• Ans: 1 When the oxygen flow rate is higher than 4 L/ min, the mucous membranes can be dried out. The best treatment is to add humidification

to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options

will treat the problem. Focus: Prioritization

LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 175). Elsevier Health Sciences. Kindle Edition.

• You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to

intervene?

• Suctioning the tracheostomy tube before performing tracheostomy care
• Removing old dressings and cleaning off excess secretions
• Removing the inner cannula and cleaning using standard precautions
• Replacing the inner cannula and cleaning the stoma site
• Ans: 3 When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing

hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate. 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. 175). Elsevier Health Sciences. Kindle Edition.

• The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are

appropriate to delegate to an experienced LPN/ LVN who is working with you in the ED? (Select all that apply.)

• Attaching cardiac monitor leads
• Giving heparin 5000 units IV push
• Administering morphine sulfate 4 mg IV
• Obtaining a 12-lead electrocardiogram (ECG)
• Asking the client about pertinent medical history
• Having the client chew and swallow aspirin 162 mg
• Ans: 1, 4, 6 Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/

LVNs. An experienced ED LPN/ LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/ LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 178). Elsevier Health Sciences. Kindle Edition.

• These activities are included in the care plan for a 78-year-old patient admitted to the hospital with anemia caused by possible

gastrointestinal bleeding. Which activity can you delegate to an experienced UAP?

• Obtaining stool specimens for fecal blood test (Hemoccult) slides
• Having the patient sign a colonoscopy consent form
• Giving the prescribed polyethylene glycol electrolyte solution (GoLYTELY)
• Checking for allergies to contrast dye or shellfish
• Ans: 1 An experienced UAP will have been taught how to obtain a stool specimen for the Hemoccult slide test, because this is a common

screening test for hospitalized patients. Having the patient sign an informed consent form should be done by the physician who will be performing the colonoscopy. Administering medications and checking for allergies are within the scope of practice of licensed nursing staff.

Focus: Delegation

LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 181). Elsevier Health Sciences. Kindle Edition.

• After a client has a seizure, which action can you delegate to the UAP?
• Documenting the seizure
• Performing neurologic checks
• Taking the client's vital signs
• Restraining the client for protection
• Ans: 3 Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and

document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary. 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. 182). Elsevier Health Sciences. Kindle Edition.

• You are preparing to admit a client with a seizure disorder. Which actions can you delegate to an LPN/ LVN? 1. Completing the admission

assessment

• Setting up oxygen and suction equipment
• Placing a padded tongue blade at the bedside
• Padding the side rails before the client arrives
• Ans: 2 The LPN/ LVN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment.

Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins. 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. 182). Elsevier Health Sciences. Kindle Edition.