NCLEX Review on Delegation and Prioritization Questions (11-15)

NCLEX Review on Delegation and Prioritization Questions

11. A nurse in a long term facility is planning care for an elderly client with confusion. Which action should the nurse take first?

a) sit the client in a geriatric chair with an activity
b) apply a vest restraint when the client is in a chair
c) apply bilateral wrist restraints when the client is in bed
d) have a staff member sit with the client at all times

12. The nurse is providing care in the emergency department to the client with chest pain. Which action is most important for the nurse to do first?

a) perform venipuncture and start an IV line
b) administer oxygen via nasal cannula
c) administer morphine sulfate intravenously
d) start lidocaine (xylocaine) infusion

13. A nurse arrives on the scene of a multi-motor vehicle accident. The nurse determines that which of the following clients should be seen first?

a) A 48 year old male who is pale, diaphoretic and reporting chest pain and shortness of breath
b) a 16 year old male with ecchymosis, pain, and swelling of the right arm
c) a 42 year old female who has a laceration on the forehead and is reporting neck and shoulder pain
d) an 8 year old child who is crying hysterically and reports abdominal pain


14. A child reports to the camp nurse's office after stepping on a bee. The child has pain, erythema, and edema of the lower aspect of the left foot. As the nurse is observing the foot, the child says, "I feel like my throat is getting tight." The first action the nurse should take is:

a) assess the child's airway and breathing
b) call 911 and request an ambulance
c) administer subcutaneous epinephrine
d) remove the stinger from the foot

15. A nurse is working on a poison control hot-line and gets a call from a mother who reports her child has apparently taken part of a bottle of adult acetaminophen capsules. The priority action for the nurse to take first is:

a) tell the mother to position the child lying down on her side
b) tell the mother to dial 911 and request an ambulance
c) have the mother give the child a glass of milk
d) instruct the mother on how to administer syrup of ipecac





NCLEX Review on Delegation and Prioritization Questions:
ANSWERS AND RATIONALE

11) A

promotion of safety and providing diversional activities are priority nursing care for confused elderly clients. Application of restraints should be the last resort. Having a staff member sit with the client at all times is not necessary, unless the client is at risk to injury.

12) B

- administration of oxygen is a priority nursing action in a client with chest pain. The primary reason for chest pain is inadequate myocardial oxygenation.

13) A

- the client with problem of the airway and who has unstable condition should be given highest priority. Priority ABC.

14) A

- the situation indicates that the child is having anaphylactic reaction. The first action by the nurse is to assess airway and breathing. Priority assessment is ABC.

15) D

- acetaminophen is non-corrosive. Therefore, inducing vomiting by administering syrup of ipecac is appropriate management in case of acetaminophen overdose or poisoning.




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