Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX Examination, Exams of Nursing

Download Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX Examination and more Exams Nursing in PDF only on Docsity! Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 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? 1. Check the medication administration records (MARs) for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the nurses responsible for the care of this client. - correct answer ✅✅1. 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. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 2. Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? 1. " Where is the pain located, and does it radiate to other parts of your body?" 2. " How would you describe the pain, and how is it affecting you?" 3. " What do you believe about pain medication and drug addiction?" 4. " How is the pain affecting your activity level and your ability to function?" 5. " What information do you need about pain, healing, and addiction?" - correct answer ✅✅2. Ans: 3 Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension. Focus: Prioritization 3. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 5. 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? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for correctly charting the dose and time and discuss the deficits in charting. - correct answer ✅✅5. 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 Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 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. 1. You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weighings - correct answer ✅✅1. 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. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 2. A 56-year-old patient comes to the walk-in clinic reporting scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history of colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis? 1. Diarrhea/ Constipation related to altered bowel patterns 2. Deficient Knowledge related to the disease process and diagnostic procedure 3. Risk for Deficient Fluid Volume related to rectal bleeding and diarrhea 4. Anxiety related to unknown outcomes and perceived threats to body integrity - correct answer ✅✅2. Ans: 4 The patient's physical condition is currently stable, but emotional needs are affecting his or her ability to receive the information required to make an informed decision. The other diagnoses are relevant, but if the patient leaves the clinic the interventions may be delayed or ignored. Focus: Prioritization 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. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 2. A patient who needs enemas and antibiotics to control GI bacteria 3. A patient who needs preoperative teaching for bowel resection surgery 4. A patient who needs central line insertion for chemotherapy - correct answer ✅✅5. 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. 1. 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? 1. Start oxygen at 4 L/ min using a nasal cannula. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 2. Obtain IV access with a large-bore IV catheter. 3. Give epinephrine (Adrenalin) 0.3 mL intramuscularly. 4. Administer 3 mL of nebulized albuterol (Proventil) 0.083%. - correct answer ✅✅1. 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. 2. 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 Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide community. Which nursing action will you delegate to health assistants working for the agency? 1. Supplying injection drug users with sterile injection equipment such as needles and syringes 2. Interviewing patients about behaviors that indicate a need for annual HIV testing 3. Teaching high-risk community members about the use of condoms in preventing HIV infection 4. 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. - correct answer ✅✅2. 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: Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 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. 5. After interviewing an HIV-positive patient who is considering starting highly active antiretroviral therapy (HAART), which patient information concerns you the most? 1. The patient has been HIV positive for 8 years and has never taken any drug therapy for the HIV infection. 2. The patient tells you, "I have never been very consistent about taking medications." 3. The patient is sexually active with multiple partners and says "I always use a condom." 4. The patient has many questions and concerns regarding the effectiveness and safety of the medications. - correct answer ✅✅5. Ans: 2 Drug therapy for HIV infection requires taking medications very consistently. Failure to take the medications daily can lead to mutations and the emergence of more virulent forms of the virus. Although the other data indicate the need for further assessments or interventions, they will Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide not affect the decision to initiate antiretroviral therapy for this patient. 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. 1. 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? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake - correct answer ✅✅1. 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: Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide Practice Excercises for the NCLEX Exam (pp. 171-172). Elsevier Health Sciences. Kindle Edition. 2. The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? 1. Flattened neck veins when the client is in the supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema located in the feet, ankles, and calves 4. Shallow respirations with crackles on auscultation - correct answer ✅✅2. Ans: 1 Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of the nursing diagnosis of Excess Fluid Volume. Focus: Prioritization 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. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide developed prominent U waves. Which laboratory value should you check immediately? 1. Sodium 2. Potassium 3. Magnesium 4. Calcium - correct answer ✅✅5. Ans: 2 Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST- segment depression, inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block. Focus: Prioritization 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. 1. A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? 1. Infuse normal saline at 75 mL/ hr. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 2. Obtain blood, urine, and sputum for cultures. 3. Place the client on airborne and contact precautions. 4. Give methylprednisolone (Solu-Medrol) 1 g IV. - correct answer ✅✅1. Ans: 3 Current Centers for Disease Control and Prevention (CDC) guidelines indicate that rapid implementation of standard, contact, and airborne precautions are needed for any client suspected of having SARS in order to protect other clients and health care workers. If an airborne-agent isolation (negative-pressure) room is not available in the ED, droplet precautions should be initiated until the client can be moved to a negative-pressure room. The other actions should also be taken rapidly but are not as important as preventing transmission of the disease. 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. 2. You are caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza (" bird flu"). Which of these prescribed actions will you implement first? Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 1. Start oxygen using a nonrebreather mask. 2. Infuse 5% dextrose in water at 100 mL/ hr. 3. Administer first dose of oseltamivir (Tamiflu). 4. Obtain blood and sputum specimens for testing. - correct answer ✅✅2. Ans: 1 Because the respiratory manifestations associated with avian influenza are potentially life-threatening, the nurse's initial action should be to start oxygen therapy. The other interventions should be implemented after addressing the client's respiratory problems. 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. 3. 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? 1. Remove N95 respirator. 2. Take off goggles. 3. Remove gloves. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 2. 5-year-old who has a new pruritic rash and a possible chickenpox infection 3. 62-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. 74-year-old who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight - correct answer ✅✅5. Ans: 2 Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the ED. The child with the rash should be quickly isolated from the other ED clients through placement in a negative-pressure room. Droplet and/ or contact precautions should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB. 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. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 1. 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.) 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs - correct answer ✅✅1. 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. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 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. 2. You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/ min by nasal cannula. Which finding concerns you immediately? 1. Fine bibasilar crackles 2. Respiratory rate of 8 breaths/ min 3. The patient sitting up and leaning over the nightstand 4. A large barrel chest - correct answer ✅✅2. Ans: 2 For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory rate. If you do not intervene, the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chronic emphysema. Focus: Prioritization Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 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. 5. You are supervising an RN who floated from the medical-surgical unit to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would you clearly provide to the RN? (Select all that apply.) 1. Position the patient supine and turned on his side. 2. Apply direct lateral pressure to the nose for 5 minutes. 3. Maintain standard body substance precautions. 4. Apply ice or cool compresses to the nose. 5. Instruct the patient not to blow the nose for several hours. - correct answer ✅✅5. Ans: 2, 3, 4, 5 The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed. Focus: Delegation, supervision, assignment Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 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. 1. You are working in the emergency department (ED) when a client arrives reporting substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether you should anticipate implementing the acute coronary syndrome (ACS) standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level - correct answer ✅✅1. Ans: 2 Cardiac troponin levels are elevated 3 hours after the onset of ACS (unstable angina or myocardial infarction [MI]) and are very specific to cardiac muscle injury or infarction. Although levels of creatine kinase MB and myoglobin also increase with MI, the increases occur later and/ or are not as specific to myocardial damage as troponin levels. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction. Focus: Prioritization Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (pp. 177-178). Elsevier Health Sciences. Kindle Edition. 2. You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client finding will require the most immediate action? 1. Blood pressure of 152/ 88 mm Hg 2. Heart rate of 134 beats/ min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 10) - correct answer ✅✅2. Ans: 4 Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 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. 6. While admitting a client, you obtain this information about her cardiovascular risk factors: Her mother and two siblings have had myocardial infarctions (MIs). The client smokes and has a 20 pack-year history of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol (Lopressor) for hypertension, and her blood pressure has been in the range of 130/ 60 to 138/ 85 mm Hg. Which interventions will be important to include in the discharge plan for this client? (Select all that apply.) 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing the stress associated with her cardiovascular risk Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 5. Discussion of the risks associated with having a sedentary lifestyle - correct answer ✅✅6. Ans: 1, 2 The client's major modifiable risk factor is her ongoing smoking. The family history is significant, and she should be aware that this increases her cardiovascular risk. The goal when treating hypertension with medications is reduction of blood pressure to under 140/ 90 mm Hg. There is no indication that stress is a risk factor for this client. The client's work involves moderate physical activity; although leisure exercise may further decrease her cardiac risk, this is not an immediate need for this client. Focus: Prioritization 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. 1. You are reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the physician before surgery? 1. Hematocrit of 33% 2. Hemoglobin level of 10.9 g/ dL Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 3. Platelet count of 426,000/ mm3 4. White blood cell count of 16,000/ mm3 - correct answer ✅✅1. Ans: 4 Centers for Disease Control and Prevention (CDC) guidelines for the prevention of surgical site infections indicate that surgery should be postponed when there is evidence of a pre-existing infection such as an elevation in white blood cell count. The other values are slightly abnormal, but would not be likely to cause postoperative problems for knee arthroscopy. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 180). Elsevier Health Sciences. Kindle Edition. 2. You are providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient who had blood loss during surgery. Which action by the new RN requires that you intervene immediately? 1. Waiting 20 minutes after obtaining the PRBCs before starting the infusion 2. Starting an IV line for the transfusion using a 22-gauge catheter Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 4. 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? 1. Obtaining stool specimens for fecal blood test (Hemoccult) slides 2. Having the patient sign a colonoscopy consent form 3. Giving the prescribed polyethylene glycol electrolyte solution (GoLYTELY) 4. Checking for allergies to contrast dye or shellfish - correct answer ✅✅4. 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. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 5. As charge nurse, you are making the daily assignments on the medical-surgical unit. Which patient is best assigned to a float nurse who has come from the postanesthesia care unit (PACU)? 1. 30-year-old patient with thalassemia major who has an order for subcutaneous infusion of deferoxamine (Desferal) 2. 43-year-old patient with multiple myeloma who requires discharge teaching 3. 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy 4. 65-year-old patient with pernicious anemia who has just been admitted to the unit - correct answer ✅✅5. Ans: 3 A nurse who works in the PACU will be familiar with the monitoring needed for a patient who has just returned from a procedure such as a colonoscopy, which requires conscious sedation. Care of the other patients requires staff with more experience with various types of hematologic disorders and would be better to assign to nursing personnel who regularly work on the medical- surgical unit. Focus: Assignment 6. Ans: 1 Patients with pancytopenia are at higher risk for infection. The patient with digoxin toxicity presents the least risk of infecting the new patient. Viral pneumonia, shingles, and cellulitis are infectious processes. Focus: Prioritization Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 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. 1. What is the priority nursing diagnosis for a client experiencing a migraine headache? 1. Acute Pain related to biologic and chemical factors 2. Anxiety related to change in or threat to health status 3. Hopelessness related to deteriorating physiologic condition 4. Risk for Injury related to side effects of medical therapy - correct answer ✅✅1. Ans: 1 The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of pain, which is often incapacitating. Focus: Prioritization 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. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives - correct answer ✅✅4. 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. 5. A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should you intervene? 1. " You should avoid consumption of all forms of alcohol." 2. " Wear your medical alert bracelet at all times." 3. " Protect your loved one's airway during a seizure." 4. " It's OK to take over-the-counter medications." - correct answer ✅✅5. Ans: 4 A client with a seizure Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families. 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. 1. You are working in an ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased lacrimation for several hours. What should you direct the caller to do first? 1. " Please call your physician" (i.e., refuse to advise). 2. " Apply a cool compress to your eyes." 3. " If you are wearing contact lenses, remove them." 4. " Take an over-the-counter antihistamine." LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 48). Elsevier Health Sciences. Kindle Edition. - correct answer ✅✅1. Ans: 3 If the client is wearing contact lenses, the lenses Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide may be causing the symptoms, and removing them will prevent further eye irritation or damage. Policies on giving telephone advice vary among institutions, and knowledge of your facility policy is essential. The other options may be appropriate, but you should gather additional information before suggesting anything else. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 185). Elsevier Health Sciences. Kindle Edition. 2. At a community health clinic, you are teaching a community group about the prevention of accidental eye injuries. What is the most important thing to stress? 1. Workplace policies for handling chemicals should be followed. 2. Children and parents should be cautious about aggressive play. 3. Protective eyewear should be worn during sports or hazardous work. 4. Emergency eyewash stations should be established in the workplace. - correct answer ✅✅2. Ans: 3 Most Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 3. Have the client gently close the eye and move it around. 4. Have the client look up while you instill the number of prescribed drops. 5. Hold the dropper and stabilize your hand on the client's forehead. 6. Have the client sit down and tilt his or her head slightly backward. _____, _____, _____, _____, _____, _____ - correct answer ✅✅4. Ans: 6, 2, 5, 4, 3, 1 Have the client sit with the head tilted back. Pulling down the lower conjunctival sac creates a small pocket for the drops. Stabilizing the hand prevents accidentally poking the client's eye. Having the client look up prevents the drops from falling on the cornea and stimulating the blink reflex. When the client gently moves the eye, the medication is distributed. Pressing on the lacrimal duct prevents systemic absorption. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 185). Elsevier Health Sciences. Kindle Edition. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 5. Which tasks are appropriate to delegate to an LPN/ LVN who is functioning under the supervision of an RN? (Select all that apply.) 1. Assessing the sexual implications for a client with oculogenital-type Chlamydia trachomatis infection 2. Administering sulfacetamide sodium 10% (Sulf-10 Ophthalmic) to a child with conjunctivitis 3. Reviewing hand-washing and hygiene practices with clients who have eye infections 4. Showing clients how to gently cleanse eyelid margins to remove crusting 5. Assessing nutritional factors for a client with age- related macular degeneration 6. Reviewing the health history of a client to identify risk for ocular manifestations 7. Performing a routine check of a client's visual acuity using the Snellen eye chart - correct answer ✅✅5. Ans: 2, 3, 4, 7 Administering medications, reviewing and demonstrating standard procedures, and performing standardized assessments with predictable outcomes in noncomplex cases are within the scope of the LPN/ LVN. Assessing for systemic manifestations and behaviors, risk factors, and nutritional factors is the responsibility of the RN. Focus: Delegation Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 185). Elsevier Health Sciences. Kindle Edition. 1. You are initiating a nursing care plan for a patient with osteoporosis. All of these nursing interventions apply to the nursing diagnosis Risk for Falls. Which intervention should you delegate to the UAP? 1. Identifying environmental factors that increase risk for falls 2. Monitoring gait, balance, and fatigue level with ambulation 3. Collaborating with the physical therapist (PT) to provide the patient with a walker 4. Assisting the patient with ambulation to the bathroom and in the halls - correct answer ✅✅1. Ans: 4 Assisting with activities of daily living (ADLs) is within the scope of the UAP's practice. The other three interventions require additional educational preparation and are within the scope of practice of licensed nurses. Focus: Delegation, supervision Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 1. Administering 600 mg of ibuprofen (Advil) to the patient 2. Encouraging the patient to perform PT- recommended exercises 3. Applying ice and gentle massage to the patient's lower extremities 4. Reminding the patient to drink milk and eat cottage cheese - correct answer ✅✅4. Ans: 3 Applying heat, not ice, is the appropriate measure to help reduce the patient's pain. Ibuprofen is useful to manage mild to moderate pain. Exercise prescribed by the PT would be nonimpact in nature and provide strengthening for the patient. A diet rich in calcium promotes bone health. 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. 186). Elsevier Health Sciences. Kindle Edition. 5. As charge nurse, you are making assignments for the day shift. Which patient would you assign to the nurse who was floated from the postanesthesia care unit (PACU) for the day? Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 1. 35-year-old with osteomyelitis who needs teaching before hyperbaric oxygen therapy 2. 62-year-old with osteomalacia who is being discharged to a long-term care facility 3. 68-year-old with osteoporosis given a new orthotic device whose knowledge of its use must be assessed 4. 72-year-old with Paget disease who has just returned from surgery for total knee replacement - correct answer ✅✅5. Ans: 4 The PACU nurse is very familiar with the assessment skills necessary to monitor a patient who just underwent surgery. For the other patients, nurses familiar with musculoskeletal system- related nursing care are needed to provide teaching and assessment, and prepare a report to the long-term care facility. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 186). Elsevier Health Sciences. Kindle Edition. 1. When a client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to the UAP? Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 1. Explaining the need for a clear liquid diet 1 to 3 days before the procedure 2. Reinforcing "nothing by mouth" status 8 hours before the procedure 3. Administering laxatives 1 to 3 days before the procedure 4. Administering an enema the night before the procedure - correct answer ✅✅1. Ans: 2 The UAP can reinforce dietary and fluid restrictions after the RN has explained the information to the client. It is also possible that the UAP can administer the enema; however, special training is required, and policies may vary among institutions. Medication administration should be performed by licensed personnel. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition. 2. You would be most concerned about an order for a total parenteral nutrition (TPN) fat emulsion for a client with which condition? 1. Gastrointestinal (GI) obstruction Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 4. Boardlike abdomen with shoulder pain - correct answer ✅✅4. Ans: 4 A boardlike abdomen with shoulder pain is a symptom of a perforation, which is the most lethal complication of peptic ulcer disease. A burning sensation is a typical complaint and can be controlled with medications. Projectile vomiting can signal an obstruction. Coffee-ground emesis is typical of slower bleeding, and the client will require diagnostic testing. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition. 5. You are taking an initial history for a client seeking surgical treatment for obesity. Which finding should be called to the attention of the surgeon before proceeding with additional history taking or physical assessment? 1. Obesity for approximately 5 years 2. History of counseling for body dysmorphic disorder 3. Failure to reduce weight with other forms of therapy 4. Body weight 100% above the ideal for age, gender, and height - correct answer ✅✅5. Ans: 2 Body Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide dysmorphic disorder is a preoccupation with an imagined physical defect. Corrective surgery can exacerbate this disorder when the client continues to feel dissatisfied with the results. The other findings are criterion indicators for this treatment. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 187). Elsevier Health Sciences. Kindle Edition. 1. You are preparing to review a teaching plan for a patient with type 2 diabetes mellitus. To determine the patient's level of compliance with his prescribed diabetic regimen, which value would you be sure to review? 1. Fasting glucose level 2. Oral glucose tolerance test results 3. Glycosylated hemoglobin (HgbA1c) level 4. Fingerstick glucose findings for 24 hours - correct answer ✅✅1. Ans: 3 The higher the blood glucose level is over time, the more glycosylated the hemoglobin becomes. The HgbA1c level is a good indicator of the average blood glucose level over the previous 120 days. Fasting glucose and oral glucose tolerance tests are Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide important diagnostic tools. Fingerstick blood glucose monitoring provides information that allows adjustment of the patient's therapeutic regimen. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 189). Elsevier Health Sciences. Kindle Edition. 2. A patient has newly-diagnosed type 2 diabetes. Which task should you delegate to a UAP? 1. Arranging a consult with the dietitian 2. Assessing the patient's insulin injection technique 3. Teaching the patient to use a glucometer to monitor glucose at home 4. Reminding the patient to check glucose level before each meal - correct answer ✅✅2. Ans: 4 The UAP's role includes reminding patients about interventions that are already part of the plan of care. Arranging for a consult with the dietitian is appropriate for the unit clerk. Teaching and assessing require additional education and should be carried out by licensed nurses. Focus: Delegation, supervision, assignment Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide Practice Excercises for the NCLEX Exam (p. 190). Elsevier Health Sciences. Kindle Edition. 5. The plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to a UAP? 1. Checking to make sure that the patient's bath water is not too hot 2. Discussing community resources for diabetic outpatient care 3. Teaching the patient to perform daily foot inspection 4. Assessing the patient's technique for drawing insulin into a syringe - correct answer ✅✅5. Ans: 1 Checking the bath water temperature is part of assisting with activities of daily living and is within the education and scope of practice of the UAP. Discussing community resources, teaching, and assessing require a higher level of education and are appropriate to the scope of practice of licensed nurses. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 190). Elsevier Health Sciences. Kindle Edition. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 1. A patient is admitted to the medical unit with possible Graves disease (hyperthyroidism). Which assessment finding supports this diagnosis? 1. Periorbital edema 2. Bradycardia 3. Exophthalmos 4. Hoarse voice - correct answer ✅✅1. Ans: 3 Exophthalmos (abnormal protrusion of the eyes) is characteristic of patients with hyperthyroidism due to Graves disease. Periorbital edema, bradycardia, and hoarse voice are all characteristics of patients with hypothyroidism. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 191). Elsevier Health Sciences. Kindle Edition. 2. Which change in vital signs would you instruct the UAP to report immediately for a patient with hyperthyroidism? 1. Rapid heart rate 2. Decreased systolic blood pressure Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 3. Increased respiratory rate 4. Decreased oral temperature - correct answer ✅✅2. Ans: 1 The cardiac problems associated with hyperthyroidism include tachycardia, increased systolic blood pressure, and decreased diastolic blood pressure. Patients with hyperthyroidism also may have increased body temperature related to increased metabolic rate. Respiratory changes are usually not symptomatic of this condition. 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. 191). Elsevier Health Sciences. Kindle Edition. 3. For a patient with hyperthyroidism, which task will you delegate to an experienced UAP? 1. Instructing the patient to report any occurrence of palpitations, dyspnea, vertigo, or chest pain 2. Monitoring the apical pulse, blood pressure, and temperature every 4 hours 3. Drawing blood to measure levels of thyroid-stimulating hormone, triiodothyronine, and thyroxine Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 5. A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should you delegate to a UAP? 1. Reminding the patient to change positions slowly 2. Assessing the patient for muscle weakness 3. Teaching the patient how to collect a 24-hour urine sample 4. Revising the patient's nursing plan of care - correct answer ✅✅5. Ans: 1 Patients with hypofunction of the adrenal gland often have hypotension and should be instructed to change positions slowly. Once a patient has been so instructed, it is appropriate for the UAP to remind the patient of those instructions. Assessing, teaching, and planning nursing care require more education and should be done by licensed nurses. 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. 191). Elsevier Health Sciences. Kindle Edition. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 1. You are caring for a client who has just had a squamous cell carcinoma removed from the face. Which activity can you delegate to an experienced LPN/ LVN? 1. Teaching the client about risk factors for squamous cell carcinoma 2. Showing the client how to care for the surgical site at home 3. Monitoring the surgical site for swelling, bleeding, or pain 4. Discussing the reasons for avoiding aspirin use for a week after surgery - correct answer ✅✅1. Ans: 3 An LPN/ LVN who is experienced in working with postoperative clients will know how to monitor for pain, bleeding, or swelling and will notify the supervising RN. Client teaching requires more education and a broader scope of practice and is appropriate for RN staff members. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 2. You are employed as the charge nurse in a long-term care (LTC) facility that employs RNs, LPNs/ LVNs, and UAPs. When you are planning care for a resident with a stage III sacral pressure ulcer, which nursing intervention is best to delegate to an LPN/ LVN? 1. Choosing the type of dressing to be used on the ulcer 2. Using the Norton scale to assess for pressure ulcer risk factors 3. Assisting the client in changing position at frequent intervals 4. Cleaning and changing the dressing on the ulcer every morning - correct answer ✅✅2. Ans: 4 LPN/ LVN education and scope of practice includes sterile and nonsterile wound care. LPNs/ LVNs do function as wound care nurses in some LTC facilities, but the choice of dressing type and assessment for risk factors are more complex skills that are appropriate to the RN level of practice. Assisting the client to change position is a task included in UAP education and would be more appropriate to delegate to the UAP. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition. 5. You are the nurse manager in the burn unit. Which client is best to assign to an RN who has floated from the oncology unit? 1. 23-year-old who has just been admitted with burns over 30% of the body after a warehouse fire 2. 36-year-old who requires discharge teaching about nutrition and wound care after having skin grafts 3. 45-year-old with infected partial-thickness back and chest burns who has a dressing change scheduled 4. 57-year-old with full-thickness burns on both arms who needs assistance in positioning hand splints - correct answer ✅✅5. Ans: 3 A nurse from the oncology unit would be familiar with dressing changes and sterile technique. The charge RN in the burn unit would work closely with the float RN to provide partners to assist in providing care and to answer any questions. Admission assessment and development of the initial care plan, discharge teaching, and splint positioning in burn clients all require expertise in caring for clients with burns. These clients should be Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide assigned to RNs who regularly work on the burn unit. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition. 1. You are providing nursing care for a 24-year-old female patient admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP? 1. Teaching the patient how to secure a clean-catch urine sample 2. Assessing the patient's urine for color, odor, and sediment 3. Reviewing the nursing care plan and add nursing interventions 4. Providing the patient with a clean-catch urine sample container - correct answer ✅✅1. Ans: 4 Providing the equipment that the patient needs to collect the urine sample is within the scope of practice of a UAP. Teaching, planning, and assessing all require additional education and skill, which is appropriate to the scope of practice of professional nurses. Focus: Delegation, supervision Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition. 2. Which laboratory result is of most concern to you for an adult patient with cystitis? 1. Serum white blood cell (WBC) count of 9000/ mm3 2. Urinalysis results showing 1 or 2 WBCs present 3. Urine bacteria count of 100,000 colonies per milliliter 4. Serum hematocrit of 36% - correct answer ✅✅2. Ans: 3 The presence of 100,000 bacterial colonies per milliliter of urine or the presence of many white blood cells (WBCs) and red blood cells (RBCs) indicates a urinary tract infection. The WBC count is within normal limits and the hematocrit is a little low, which may need follow-up. Neither of these results indicates infection. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 5. A patient is being admitted to rule out interstitial cystitis. What should your plan of care for this patient include? 1. Take daily urine samples for urinalysis. 2. Maintain accurate intake and output records. 3. Obtain an admission urine sample to determine electrolyte levels. 4. Teach the patient about the cystoscopy procedure. - correct answer ✅✅5. Ans: 4 A cystoscopy is needed to accurately diagnose interstitial cystitis. Urinalysis may show WBCs and RBCs, but no bacteria. The patient will probably need a urinalysis upon admission, but daily samples do not need to be obtained. Intake and output may be assessed, but results will not contribute to the diagnosis. Cystitis does not usually affect urine electrolyte levels. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 195). Elsevier Health Sciences. Kindle Edition. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 1. You are assessing a long-term-care client with a history of benign prostatic hyperplasia (BPH). Which information will require the most immediate action? 1. The client states that he always has trouble starting his urinary stream. 2. The chart shows an elevated level of prostate-specific antigen. 3. The bladder is palpable above the symphysis pubis and the client is restless. 4. The client says he has not voided since having a glass of juice 4 hours ago. - correct answer ✅✅1. Ans: 3 A palpable bladder and restlessness are indicators of urinary retention, which would require action (such as insertion of a catheter) to empty the bladder. The other data would be consistent with the client's diagnosis of BPH. More detailed assessment may be indicated, but no immediate action is required. Focus: Prioritization 2. While performing a breast examination on a 22-year- old client, you obtain the following data. Which finding is of most concern? 1. Both breasts have many nodules in the upper outer quadrants. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 2. The client reports bilateral breast tenderness with palpation. 3. The breast on the right side is slightly larger than the left breast. 4. An irregularly shaped, nontender lump is palpable in the left breast. - correct answer ✅✅2. Ans: 4 Irregularly shaped and nontender lumps are consistent with a diagnosis of breast cancer, so this client needs immediate referral for diagnostic tests such as mammography or ultrasound. The other information is not unusual and does not indicate the need for immediate action. Focus: Prioritization 3. After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit (PACU). Which nursing action is best to delegate to an experienced LPN/ LVN? 1. Monitoring the client's dressing for any signs of bleeding 2. Documenting the initial assessment on the client's chart 3. Communicating the client's status report to the charge nurse on the surgical unit Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide that blood clots are obstructing the catheter, which would indicate the need for irrigation of the catheter with 30 to 50 mL of normal saline using a piston syringe. The other data would all be normal after a TURP, but the client may need some teaching about the usual post-TURP symptoms and care. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 197). Elsevier Health Sciences. Kindle Edition. 1. A 30-year-old woman with type 1 diabetes mellitus comes to the clinic for preconception care. What is the priority education for her at this time? 1. Her insulin requirements will likely increase during the second and third trimesters of pregnancy. 2. Infants of diabetic mothers can be macrosomic, which can result in more difficult delivery and higher likelihood of cesarean section. 3. Breast feeding is highly recommended, and insulin use is not a contraindication. 4. Achievement of optimal glycemic control at this time is of utmost importance in preventing congenital anomalies. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide - correct answer ✅✅1. Ans: 4 The incidence of congenital anomalies is three times higher in the offspring of diabetic women. Good glycemic control during preconception and early pregnancy significantly reduces this risk and would be the highest priority message to this patient at this point. The other responses are correct but are not of greatest importance at this time. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition. 2. Which task could be appropriately assigned to the UAP working with you at the obstetric clinic? 1. Checking the blood pressure of a patient who is 36 weeks pregnant and reports a headache 2. Removing the adhesive skin closure strips of a patient who had a cesarean section 2 weeks ago 3. Giving community resource information and emergency numbers to a prenatal patient whom you suspect is experiencing domestic violence Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 4. Dispensing a breast pump with instruction to a lactating patient having trouble with milk supply 4 weeks postpartum - correct answer ✅✅2. Ans: 1 The UAP can check the blood pressure of this patient and report it to the RN. The RN would include this information in her full assessment of the patient, who may be showing signs of preeclampsia. The other tasks listed require nursing assessment, analysis, and planning, and should be performed by the RN. Provision of accurate and supportive education about breastfeeding and breast pumping supports the Perinatal Core Measure of increasing the percentage of women who exclusively breast-feed. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition. 3. You are working in the obstetric triage area, and several patients have just come in. Which patient should you assess first? 1. A 17-year-old gravida 1, para 0 (G1P0) woman at 40 weeks' gestation with contractions every 6 minutes who Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition. 5. Which action would best demonstrate evidence-based nursing practice in the care of a patient who is 1 day postpartum and reporting nipple soreness while breast- feeding? 1. Give the baby a bottle after 5 minutes of nursing to allow soreness to resolve. 2. Assess the mother-baby couplet for nursing position and latch, and correct as indicated. 3. Advise the use of a breast pump until nipple soreness resolves. 4. Advise alternating breast and bottle feedings to avoid excess sucking at the nipple. - correct answer ✅✅5. Ans: 2 It is recommended to avoid artificial nipples and pacifiers while establishing breast feeding unless medically indicated. Improper latch and position are common causes of nipple soreness and can be corrected with assessment and assistance to the mother. This practice supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Focus: Prioritization Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 199). Elsevier Health Sciences. Kindle Edition. 1. In caring for a 3-year-old with pain, which assessment question would be the most useful? 1. " Can you point to the pain with one finger and tell me what that pain feels like inside of you?" 2. " If number 1 were a little pain and number 10 were a big pain, what number would your pain be?" 3. " The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" 4. " One chip is 'a little bit of hurt' and four chips are 'the most hurt.' How many chips would you take for your hurt?" - correct answer ✅✅1. Ans: 3 Pain rating scales using faces (depicting smiling, neutral, frowning, crying, etc.) are appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and the use of advanced vocabulary. Focus: Prioritization Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition. 2. Which pediatric pain patient should be assigned to a newly-graduated RN? 1. Adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient- controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose 2. Child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures 3. Child who is receiving palliative end-of-life care; the child is receiving narcotics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness 4. Child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful - correct answer ✅✅2. Ans: 2 The set of circumstances is least complicated for the child with the Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 1. Remind the child that foods tasted good today and will help the body to get strong. 2. Allow the mother and child time alone to review and control the behavior. 3. Ask the mother to leave until the child can finish eating and then invite her back. 4. Explain to the mother that the behavior could be a normal expression of anger. - correct answer ✅✅4. Ans: 4 Help the mother to understand that the child may be angry about being left in the hospital or about her inability to prevent the illness and protect the child. Reminding the child about the food and the purpose of the food does not address the strong emotions underlying the outburst. Allowing the mother and child time alone is a possibility, but the assumption would be that the mother understands the child's behavior and is prepared to deal with the behavior in a constructive manner. Asking the mother to leave the child suggests that the mother is a source of stress. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 5. An 8-year-old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to the UAP? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting an anesthetic mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Helping the patient to eat a bland, moist, soft diet - correct answer ✅✅5. Ans: 4 Helping the patient to eat is within the scope of responsibilities for a UAP. Assessing ability and willingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. Plain water or saline rinses are preferable if the child cannot gargle or spit out fluids. The RN should assess and administer oral preparations as needed. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 201). Elsevier Health Sciences. Kindle Edition. Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination A+ Guide 1. You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? 1. An advanced practice nurse and an experienced LPN/ LVN 2. An experienced LPN/ LVN and an inexperienced RN 3. An experienced RN and an inexperienced RN 4. An experienced RN and an experienced UAP - correct answer ✅✅1. Ans: 3 Triage requires at least one experienced RN. Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/ LVN is not qualified to perform the initial client assessment or decision making. Pairing an experienced RN with an experienced UAP is the second best option, because the UAP can measure vital signs and assist in transporting. Focus: Assignment LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 204). Elsevier Health Sciences. Kindle Edition.