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Nursing Prioritization, Delegation, Assignment for NCLEX (Part 1: 25 Questions And Answers)
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Nursing Prioritization, Delegation,Assignment for NCLEX (Part 1: 25 Questions
And Answers)
Nursing Prioritization, Delegation, Assignment
for NCLEX (Part 1: 25 QuestionsAnd Answers)
1. Question 1 of 25
1. Question
A 16-year old patient with cystic fibrosis is admitted with increased
shortness of breath and possible pneumonia. Which nursing activityis most
important to include in the patient’s care?
o A. Perform postural drainage and chest physiotherapy every4 hours.
o B. Allow the patient to decide whether she needs aerosolized
medications.
o C. Place the patient in a private room to decrease the risk offurther
infection.
o D. Plan activities to allow at least 8 hours of uninterrupted sleep.
Correct Answer: A. Perform postural drainage and chest physiotherapy
every 4 hours.
Airway clearance techniques are critical for patients with cystic fibrosis and
should take priority over other activities. The Cystic Fibrosis
Transmembrane Conductance Regulator defect causes mucus to become
dehydrated. Secretions in cystic fibrosis are generally thick, sticky, and
more difficult to clear. Frequent airway clearance is a mainstay in the
treatment of acute exacerbations, as well as an integral part of health
maintenance in cystic fibrosis.
,Nursing Prioritization, Delegation,
Assignment for NCLEX (Part 1: 25 Questions
And Answers)
Option B: Although allowing more independent decision-
making is important for adolescents, the physiologic need for
an improved respiratory function takes precedence at this
time. Collaborate with the client and staff to ensure that the
schedule for therapy is amenable to all and does not interfere
with meals, rest times, or medications.
Option C: A private room may be desirable for the patient but
is not necessary. Ensure that clients with CF are not cohorted.
The cohorting of clients with CF is not recommended based on
published CF Infection Control Consensus Guidelines.
Option D: With increased shortness of breath, it will be more
important that the patient has frequent respiratory treatments
than 8 hours of sleep. Infection, inflammation, and mucous
plugging will cause an increase in the respiratory effort to
compensate for airway obstruction. As moving air into and out
of the lungs becomes more difficult, the breathing pattern
alters to include the use of accessory muscles and retractions.
Question 2 of 25
2. Question
A patient with a pulmonary embolism is receiving anticoagulation with IV heparin. What
instructions would you give the nursing assistant who will help thepatient with activities
of daily living? Select all that apply.
A. Use a lift sheet when moving and positioning the patient inbed.
B. Use an electric razor when shaving the patient each day.
C. Use a soft-bristled toothbrush or tooth sponge for oral care.
D. Use a rectal thermometer to obtain a more accurate bodytemperature.
,Nursing Prioritization, Delegation,
Assignment for NCLEX (Part 1: 25 Questions
And Answers)
E. Be sure the patient's footwear has a firm sole when the patientambulates.
Correct Answers: A, B, C, and E.
All of the other instructions are appropriate to the care of a patient receiving
anticoagulants. Risk for bleeding may arise in any condition that disturbs the“close
circuit” integrity of the circulatory system. Bleeding is the primary complication of
anticoagulant therapy and is a risk of all anticoagulants evenwhen maintained within
the usual therapeutic ranges.
Option A: Educate the at-risk patient about precautionary measuresto
prevent tissue trauma or disruption of the normal clotting mechanisms.
Information about precautionary measures lessens therisk for bleeding.
Option B: Be careful when using sharp objects like scissors and knives. Use
an electric razor for shaving (not razor blades). The patient needs to avoid
situations that may cause tissue trauma andincrease the risk for bleeding.
Option C: Use a soft-bristled toothbrush and nonabrasive toothpaste.
Avoid the use of toothpicks and dental floss. This method providing
oral hygiene reduces trauma to oral mucousmembranes and the risk
for bleeding from the gums.
Option D: 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). These invasive devices or
medications may cause trauma to the mucous membranes that line the
rectum or vagina.
Option E: Educate the patient and family members about signs ofbleeding
that need to be reported to a health care provider. Early evaluation and
treatment of bleeding by a health care provider reduces the risk for
complications from blood loss.
Question 3 of 25
3. Question
, Nursing Prioritization, Delegation,
Assignment for NCLEX (Part 1: 25 Questions
And Answers)
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen bya non-
rebreather mask, but arterial blood gas measurements still show poor
oxygenation. As the nurse responsible for this patient’s care, you would anticipatea
physician order for what action?
A. Perform endotracheal intubation and initiate mechanicalventilation.
B. Immediately begin continuous positive airway pressure (CPAP) viathe
patient's nose and mouth.
C. Administer furosemide (Lasix) 100 mg IV push stat.
D. Call a code for respiratory arrest.
Correct Answer: A. Perform endotracheal intubation and initiate mechanicalventilation
A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation
status does not improve adequately in response to the delivery of oxygen at this high
concentration, refractory hypoxemia is present. Usually, at thisstage, the patient is working
very hard to breathe and may go into respiratory arrest unless healthcare care providers
intervene by providing intubation and mechanical ventilation to decrease the patient’s
work of breathing.
Option B: To maintain oxygenation, ARDSnet recognizes the benefitof PEEP.
The protocol allows for a low or a high PEEP strategy relative to FiO2. Either
strategy tolerates a PEEP of up to 24 cm HO inpatients requiring 100% FiO2.
Interestingly, the mode in which a patient is ventilated affects lung recovery.
Evidence suggests that some ventilatory strategies can exacerbate alveolar
damage and perpetuate lung injury in the context of ARDS.
Option C: The chief treatment strategy is supportive care and focuses on 1)
reducing shunt fraction, 2) increasing oxygen delivery,
3) decreasing oxygen consumption, and 4) avoiding further injury. Patients
are mechanically ventilated, guarded against fluid overload
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