NCLEX Preparation Course - Critical Thinking ANSWERS (41-50) -->
41. A nurse is planning the assignment for the day shift. The care team consists of an RN, an LPN/LVN, and a nursing assistant. Which of the following clients is most appropriate to assign to the nursing assistant?
a) a 50-year old obese client who needs assistance out of bed with a Hoyer lift
b) a 42-year old client who needs to be straight catheterized (in-and-out catheterization)
c) a 45-year old woman admitted for mastectomy and who is upset and tearful
d) a 62-year old client with an abdominal dressing and Montgomery straps
42. The nurse has delegated care of a client requiring nasopharyngeal suctioning to the LPN/LVN. Which of the following actions if performed by the LPN/LVN would require intervention by the nurse?
a) suction is applied as the catheter is inserted in the nares
b) the suction catheter is coiled as it is picked up from the sterile field
c) sterile gloves are used
d) the catheter is rotated slightly as it is inserted
43. The nurse has delegated care of a client who needs wrapping of an above the knee amputation stump to a LPN/LVN. Which of the following actions by the LPN/LVN would not require intervention by the nurse?
a) the stump is unwrapped for the bath and left unwrapped for 1 hour after
b) the stump is wrapped from proximal to distal
c) a diagonal figure of eight bandaging technique is used
d) care is taken to not flatten the skin at the end of the incision during wrapping
44. The nurse has delegated administration of 10am medications to an LPN/LVN. At 10:15am, the nurse notes none of the medications have been administer yet. Which is the best action for the nurse to take?
a) ask another LPN/LVN assigned to the unit to help administer medications
b) begin administering the medications
c) report he situation to the head nurse
d) ask the LPN/LVN to give the nurse a status report
45. A nurse on a pediatric unit is preparing the assignment for the evening shift. The unit employs unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP?
a) setting up Bryant's traction
b) completing the FACES pain scale for a child with sickle cell crisis
c) obtaining post-operative vital signs on a client status post-tonsillectomy
d) setting up an intravenous therapy pump
46. A new staff nurse is discussing with a nurse preceptor some of the ethical dilemmas related to delegation. Which resource is most appropriate for the nurse preceptor to direct the staff nurse to?
a) the Nursing Department Philosophy Statement
b) the National Council of State Board of Nurses
c) the Hospital Policy and Procedure Manual
d) the American Nurses Association's Code for Nurses
47. A nurse on a surgical unit is working with a team consisting of an LPN/LVN and a nursing assistant. Which of the following activities should be performed by the RN rather than delegated to the LPN/LVN or nursing assistant? Select all that apply
a) completing a pressure ulcer assessment form
b) setting up tracheal suctioning device
c) changing a dressing on an abdominal wound
d) documenting a client's level of pain on a pain scale
e) giving an oral pain medication to a client with prostate cancer
f) evaluating the response of a client to pain medication
48. A nurse is assigned to care for a group of clients. On review of the client's medical records, the nurse determines that which client is at risk for deficient fluid volume
a) a client with a colostomy
b) a client with congestive heart failure
c) a client with decreased kidney function
d) a client receiving frequent wound irrigation
49. A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition?
a) lung congestion
b) decreased hematocrit
c) increased blood pressure
d) decreased central venous pressure (CVP)
50. A nurse is assigned to care for a group of clients. On review of the client's medical records, the nurse determines that which client is at risk for excess fluid volume?
a) the client taking diuretics
b) the client with renal failure
c) the client with ileostomy
d) the client who requires gastrointestinal suctioning
Go to the next page ---> NCLEX Preparation Course - Level of Cognitive Ability (51-60)
Or go back to NCLEX Preparation Course -Critical Thinking Ability 31-40
Related Topics:
NCLEX Preparation Course - Critical Thinking Exercises VI (Questions 41-50)
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