Delegation and Prioritization

Question 1

1. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing?

a) repositions side to side every 2 hours
b) elevates the head of the bed 60 degrees
c) auscultates the lung field every 4 hours
d) encourages deep breathing exercises every 2 hours

Answer 1

1) B
- The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures to promote lung expansion in the client with ascites, but the priority measure is the one that relieves diaphragmatic pressure.

Question 2

2. A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last?

a) ultrasound
b) colonoscopy
c) barium enema
d) computed tomography

Answer 2

2) C
- When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear visualization and accurate results of the other tests listed, if performed before the client has fully excreted the barium. For this reason, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging studies.

Question 3

3. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client?

a) diarrhea
b) risk for aspiration
c) risk for deficient flid volume
d) imbalanced nutrition, less than body requirements

Answer 3

3) B
- Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Although options 1, 3, and 4 may be a concern, these are not the priority.

Question 4

4. A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to:

a) obtain vital signs
b) ask the client about the precipitating events
c) complete an abdominal physical assessment
d) insert a nasogastric (NG) tube and Hematest the emesis

Answer 4

4) A
- The priority action is to obtain vital signs to determine whether the client is in shock from blood loss and to obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Insertion of an NG tube may be prescribed but is not the priority action. A complete abdominal physical assessment needs to be performed but is not the priority.

Question 5

5. A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of depression. Upon the client’s arrival, the client’s therapist reports to the nurse that the clients telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts. Keeping this information in mind, the priority of the nurse is to assess for:

a) interaction with peers
b) the presence of suicidal thoughts
c) the amount of food intake for the past 24 hours
d) information regarding the past medication regimen

Answer 5

5) B
The critical information from the therapist is that the client is having thoughts of self-harm; therefore, the nurse needs further information about present thoughts of suicide so that the treatment plan may be as appropriate as possible. The nurse must make sure the client is safe. The items in options A, C, and D should be assessed; however, evaluation for suicide potential is most important

Question 6

6. A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern?

a) peer support through structured groups
b) finding affordable housing for the group
c) setting up a 24-hour crisis center and hotline
d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available

Answer 6

6) D
- The question asks about the immediate concern. The ABCs of community health are always attending to people’s basic needs of food, shelter, and clothing. Options A, B, and C are other activities that may be completed at a later time.

Question 7

7. A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days. When planning forth rescue and relocation of these older residents, what is the first item that the nurse needs to consider?

a) contacting the older resident’s families
b) attending to the emotional needs of the older residents
c) arranging for ambulance transportation for the oldest residents
d) attending to the nutritional status and basic needs of the older residents

Answer 7

7) D
- The question asks about the first thing that the nurse needs to consider. The ABCs of community health are always attending to people’s basic needs of food, shelter, and clothing. Options A, B, and C are other activities that may or may not be needed at a later date.

Question 8

8. A client is scheduled for an arteriogram using a radiopaque dye. The nurse assesses which most critical item before the procedure?

a) vital signs
b) intake and output
c) height and weight
d) allergy to iodine or shellfish

Answer 8

8) D
- Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary, because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although options A, B, and C are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical.

Question 9

9. A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on:

a) the comfort level
b) activity tolerance
c) the level of consciousness
d) the hydration and nutrition status

Answer 9

9) D- Many of the diagnostic studies to identify GI disorders require that the GI tract be cleaned (usually with laxatives and enemas) before testing. In addition, the client most often takes nothing by mouth before and during the testing period. Because the studies may be done over a period that exceeds 24 hours, the client may become dehydrated and/or malnourished. Although options A, B, and C may be components of the assessment, option D is the priority.

Question 10

10. A nurse is assessing a 39 year old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol of level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. The nurse would place priority on which risk factor for coronary heart disease (CHD) in this client?

a) age
b) hypertension
c) hyperlipidemia
d) glucose intolerance

Answer 10

10) B
- Hypertension, cigarette smoking, and hyperlipidemia are major risk factors for CHD. Glucose intolerance, obesity, and response to stress are also contributing factors. An age of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 190 mg/dL and a blood glucose level of 110 mg/dL are within the normal range. The nurse places priority on major risk factors that need modification.

Question 11

11. A labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which priority action would the nurse implement to assist in preventing a sickle cell crisis from occurring during labor?

a) continually reassure and coach the client
b) administer the prescribed oxygen throughout labor
c) maintain strict asepsis throughout the labor process
d) increase the intravenous (IV) fluids if the client complains of feeling thirsty

Answer 11

11) B
- During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and is at high risk for sickle cell crisis. An intervention to prevent sickle cell crisis during labor includes administering oxygen. Options A and C are appropriate interventions during labor but are not specific to sickle cell anemia. Intravenous fluids may need to be increased, but a physician’s order is needed to do so.

Question 12

12. A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. The initial nursing action would be to:

a) check the fetal heart rate
b) check the maternal blood pressure
c) maintain an open airway
d) administer oxygen to the mother by face mask

Answer 12

12) C
- The initial nursing action when a client progresses to an eclamptic state (has a seizure) is to maintain an open airway. Options A, B, and D are procedures that may be implemented but option 3 identifies the initial action.

Question 13

13. A nurse is caring for a client who has wrist restraints applied. Which nursing intervention would receive highest priority regarding the wrist restraints?

a) providing range-of-motion exercises to the wrists
b) removing the restraints periodically per agency guidelines
c) applying lotion to the skin under the restraints
d) assessing color, sensation, and pulses distal to the restraint

Answer 13

13) D
- Assessing color, sensation, and pulses distal to the restraint determines the presence of neurovascular compromise that is associated with the use of restraints. All of the other interventions should be implemented, but option 4 is the priority.

Question 14

14. A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client’s blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next?

a) the RN need not to carry out further assessment because the LPN is very experienced and trustworthy
b) the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively
c) the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic
d) the RN assesses the client, checks the client’s surgical notes, and gathers addition data before calling the surgeon

Answer 14

14) D
- The RN must not depend exclusively on the judgment of an LPN because the RN is responsible for supervising those to whom client care has been delegated. The client has recently had surgery, and there is the potential for complications, which may be signaled by alterations in vital signs and respiratory status. An analgesic may be needed, but in order to make that determination, the RN must have more information. A call to the surgeon may be warranted, but the RN has insufficient data at this time. In order to provide the client with the degree of care required, the nurse must assess the client, gather additional information, and analyze that information before notifying the surgeon.

Question 15

15. A primigravida is admitted to the labor unit. During the assessment of the client, her membranes rupture spontaneously. The priority nursing action is which of the following?

a) monitor the contraction pattern
b) assess the fetal heart rate
c) note the amount, color, and odor of the amniotic fluid
d) check maternal vital signs

Answer 15

15) B
- When the membranes rupture in the birth setting, the nurse immediately checks the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options A, C, and D may be a component of care but are not the priority action.

Question 16

16. A nurse is assigned to provide care to a client in labor and will care for the client throughout labor and into the postpartum period. The nurse assists in developing a plan of care and determines that the priority assessment in the fourth stage of labor is which of the following?

a) assessing the uterine fundus and lochia
b) checking the mother’s temperature
c) encouraging food and fluid intake
d) providing privacy for the parents and their newborn infant

Answer 16

16) A
- The fourth stage of labor is the stage of physical recovery for the mother and newborn infant. It lasts from the delivery of the placenta through the first 1 to 4 hours after birth. A potential complication following delivery is hemorrhage. The most significant source of bleeding is the site where the placenta is implanted. It is critical that the uterus remain contracted and that vaginal blood flow is monitored every 15 minutes for the first 1 to 2 hours. Although options B, C, and D are also interventions during this stage, they are not the priority.

Question 17

17. A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. The nurse should take which initial action?

a) examine and treat the wound sites
b) obtain and record a detailed history
c) encourage and assist the client to ventilate feelings
d) administer an anti-anxiety agent

Answer 17

17) A
- The client has a physiological injury, and the nurse would initially examine and treat the wound sites because of bleeding. Although options B,C, and D may be appropriate at some point, the initial action would need to be to treat the wounds.

Question 18

18. A nurse has just administered a dose of hydralazine hydrochloride (Apresoline) intravenously to a client. Based on the action of this medication, the nurse would initially assess the client’s:

a) cardiac rhythm
b) oxygen saturation
c) blood pressure
d) respiratory rate

Answer 18

18) C
Hydralazine is a powerful vasodilator that exerts it action on the smooth muscle walls of arterioles. After an intravenous dose is administered, the nurse should check the client’s blood pressure every 5 minutes until stable and every 15 minutes thereafter (or per agency procedure). Although options A, B, and D are a component of the assessment, based on the action of the medication the nurse would initially check the client’s blood pressure

Question 19

19. A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client’s vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check:

a) lung sounds
b) vital signs
c) the chest tube connections
d) the amount of drainage

Answer 19

19) C
- Constant bubbling in the water seal chamber indicates an air leak. This is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires physician intervention. Although the items in options A, B, and D need to be assessed, they should be performed after initial attempts to locate and correct the air leak.

Question 20

20. A client with mania will be placed in seclusion after overturning two tables and throwing a chair against the wall. Before placing the client in seclusion, the nurse would first:

a) inspect the client for injuries resulting from the incident and initiate appropriate treatment
b) document the behavior leading to seclusion
c) document the time and the client is placed in seclusion
d) make sure that there is a written order by the physician allowing for the seclusion

Answer 20

20) A
- The primary concern of the nurse should be to ascertain that the client is injury free or to attend to any injuries that may have resulted. Options B, C, and D are all important tasks for the nurse, but they do not refer to assessment of the client and would not be the nurse’s first action.

Question 21

21. A nurse in a postanesthesia care unit (PACU) receives a client transferred from the operating room. The PACU nurse assesses the client for which of the following first?

a) active bowel sounds
b) adequate urine output
c) orientation to the surroundings
d) a patent airway

Answer 21

21) D
- After a transfer from the operating room, the PACU nurse performs an assessment of the client. The ABCs’airway, breathing, and circulation’must be assessed first. Urine output and orientation to the surroundings might also be assessed, but these are not the first actions. The client might not have active bowel sounds at this time because of the effects of anesthesia.

Question 22

22. A nurse manager is planning the client assignments for the day. Which of the following clients would the nurse assign to the nursing assistant?

a) a 2-day postoperative client who had a below-the-knee amputation
b) a client on a 24-hour urine collection who is on strict bedrest
c) a cleint scheduled to be discharged after coronary artery bypass surgery
d) a client scheduled for a cardiac catheterization

Answer 22

22) B
- The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of nurse practice acts and the job description of the employing agency. A 2-day postoperative client who had a below-the-knee amputation will require both physiological and psychosocial care. A client scheduled to be discharged after coronary artery bypass surgery will require reinforcement of home care management. A client scheduled for a cardiac catheterization requires physiological needs and frequent nursing assessments. The nursing assistant has been trained to care for a client on bedrest and on urine collections. The nurse manager would provide instructions to the nursing assistant regarding the tasks, but the tasks required for this client are within the role description of a nursing assistant.

Question 23

23. A registered nurse (RN) must determine how best to assign coworkers (another RN and one licensed practical nurse LPN) to provide care to a group of clients. Which of the following is the appropriate assignment?

a) the RN is assigned to care for an unemployed 26-year old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS), who has four school-age children
b) the LPN is assigned to care for a 41-year old male, postresection of an acoustic neuroma 2 days ago, transferred from the intensive care unit (ICU) this morning
c) the LPN is assigned to provide discharge teaching about medications and maintenance of nephrostomy tube to a 35-year old man
d) the RN is assigned to care for a 65-year old woman hospitalized because of chest pain, being discharged today to home with no medication

Answer 23

23) A
- In order to determine what can and cannot be delegated to a co-worker, several factors need to be considered. The nurse must carefully consider what level of care each client requires immediately and potentially in the future, what competencies are possessed by co-workers, and what legal limitations there are on the practice of those co-workers. In option 2, the client has undergone a serious neurosurgical procedure that can impair swallowing and gag reflexes, and there is significant risk of increased intracranial pressure in the first few days postoperatively. This and the fact that the client has been transferred from the ICU this morning make this an inappropriate assignment for an LPN. The LPN is also not able to provide discharge teaching on medications and treatments to a client. Teaching is a professional responsibility, which the RN cannot delegate to anyone except another RN, making option 3 incorrect. Although under some circumstances the RN might care for a client being discharged following chest pain, the question tells you that there is an LPN available. The RN would be best used to care for the client with more critical or complicated needs. Option 4 is therefore incorrect. The woman newly diagnosed with AIDS, who is unemployed and with small children, is likely to be in need of the skills of an RN in terms of both physiological and psychosocial needs, making option 1 an appropriate assignment.

Question 24

24. A nurse manager of a medical-surgical unit returns to work after being on vacation for a week. It is the beginning of the shift, and the nurse manager is faced with several activities that need attention. Which activity will the nurse manager attend to first?

a) a crash cart needs checking
b) client assignments for the day
c) a phone message that indicates that the charge nurse of the next shift is ill and will not be reporting to work
d) a stack of mail from the education department and administrative services

Answer 24

24) B
- The nurse manager needs to attend to the client assignments first. Client care is the priority. In addition, the nursing staff needs assignments so that they can begin client assessments and begin delivering client care. The nurse manager should next check the crash cart (which is normally done every shift) to ensure that needed equipment is available in the event of an emergency. The nurse manager could also delegate this task to another registered nurse while client assignments are being planned. The nurse manager would next begin the problem-solving process related to finding a charge nurse for the next shift. Because this activity directly affects client care, this would be done before reading the stack of mail.

Question 25

25. A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim will the nurse attend to first? a) an alert victim who has numerous bruises on the arms and legs b) a victim with a partial amputation of a leg who is bleeding profusely c) a hysterical victim who received a head injury d) a victim who sustained multiple serious injuries and is deceased

Answer 25

25) B - The nurse determines which victim will be attended to first on the basis of the acuity level of the victims involved in the disaster. The priority victim is the one who must be treated immediately or life, limb, or vision will be threatened. This victim is categorized as emergent (option 2). The victim who requires treatment, but life, limb, or vision is not threatened if care can be provided within 1 to 2 hours is considered urgent and is the second priority (option 3). The victim who requires evaluation and possible treatment but for whom time is not a critical factor is categorized as nonurgent and is the third priority (option 1).