NURSING PRIORITIZATION, DELEGATION & ASSIGNMENT NCLEX RN TEST EXAM/ BEST FOR REVISION
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Course
Prioritization
Institution
Prioritization
Four victims of an automobile crash are brought by ambulance to the emergency department
(emergency department). The triage nurse determines that the victim who has the highest priority for
treatment is the one with
a. severe bleeding of facial and head lacerations.
b. an open femur fracture ...
NURSING PRIORITIZATION, DELEGATION &
ASSIGNMENT NCLEX RN TEST EXAM/ BEST
FOR REVISION
Four victims of an automobile crash are brought by ambulance to the emergency department
(emergency department). The triage nurse determines that the victim who has the highest priority for
treatment is the one with
a. severe bleeding of facial and head lacerations.
b. an open femur fracture with profuse bleeding.
c. a sucking chest wound.
d. absence of peripheral pulses. - ANSWER Correct Answer: C
Rationale: Most immediate deaths from trauma occur because of problems with ventilation, so the
patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the
airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid
intervention but do not have airway or breathing problems.
Cognitive Level: Application Text Reference: p. 1823
A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal
pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's first action should be to
a. tell the patient that it may be several hours before being seen by the doctor.
b. assess the patient's current vital signs.
c. obtain a clean-catch urine for urinalysis.
d. ask the health care provider to order a nonopioid analgesic medication for the patient. - ANSWER
Correct Answer: B
Rationale: The patient's pain and statement about an elevated temperature indicate that the nurse
should obtain vital signs before deciding how rapidly the patient should be seen by the health care
, provider. A urinalysis may be needed, but vital signs will provide the nurse with more useful data for
triage. The health care provider will not order a medication before assessing the patient.
Cognitive Level: Application Text Reference: pp. 1822-1823
During the primary assessment of a trauma victim, the nurse determines that the patient has a patent
airway. The next assessment by the nurse should be to
a. check the patient's level of consciousness.
b. examine the patient for any external bleeding.
c. observe the patient's respiratory effort.
d. palpate for the presence of peripheral pulses. - ANSWER Correct Answer: C
Rationale: Even with a patent airway, patients can have other problems that compromise ventilation, so
the next action is to assess the patient's breathing. The other actions are also part of the initial survey
but are not accomplished as rapidly as the assessment of breathing.
Cognitive Level: Application Text Reference: p. 1823
During the primary assessment of a patient with multiple trauma, the nurse observes that the patient's
right pedal pulses are absent and the leg is swollen. The nurse's first action should be to
a. initiate isotonic fluid infusion through two large-bore IV lines.
b. send blood to the lab for a complete blood count (CBC).
c. finish the airway, breathing, circulation, disability survey.
d. assess further for a cause of the decreased circulation. - ANSWER Correct Answer: A
Rationale: The assessment data indicate that the patient may have arterial trauma and hemorrhage.
When a possibly life-threatening injury is found during the primary survey, the nurse should immediately
start interventions before proceeding with the survey. Although a CBC is indicated, administration of IV
fluids should be started first. Completion of the primary survey and further assessment should be
completed after the IV fluids are initiated.
Cognitive Level: Application Text Reference: pp. 1822-1824
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