NCLEX Review on Delegation and Prioritization Questions (16-20)

NCLEX Review on Delegation and Prioritization Questions

16. A nurse receives a 10-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first?

a) call for a social worker to meet with the family
b) check the child's blood pressure, then pulse, respiration, and temperature
c) administer pain medication
d) speak with the parents about how the fracture occurred

17. A nurse on the cardiac unit is caring for four clients and is preparing to do initial rounds. Which client should the nurse assess first?

a) a client scheduled for cardiac ultrasound this morning
b) a client with syncope being discharged today
c) a client with chronic bronchitis on nasal oxygen
d) a client with a diabetic foot ulcer that needs a dressing change

18.  A nurse enters a room and finds lying face down on the floor, bleeding from a gash in the head. Which action should the nurse perform first?

a) determine level of consciousness
b) push the call button for help
c) turn the client face up to assess
d) go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician

19. A nurse is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best?

a) ask the other nurse if she needs any help
b) assess the client, and let the other nurse know what should be done
c) ask the client if he is satisfied with his care
d) contact the nursing supervisor to address the situation

20. The nurse is reviewing immunizations with the caregiver of a 72 year old client with a history of cerebral vascular disease. The caregiver learns that which immunization is a priority for the client?

a) hepatitis A vaccine
b) lyme disease vaccine
c) hepatitis B vaccine
d) pneumococccal vaccine





NCLEX Review on Delegation and Prioritization Questions:
ANSWERS AND RATIONALE

16) D

- in case of injury especially among children, it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse.

17) C

- a client with problem of the airway should be attended first. ABC is a priority.

18) A

- assessing level of consciousness is the first action when dealing with a situation where the client might have had a fall or when preparing to do CPR (cardio-pulmonary resuscitation).

19) D

- the RN should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.

20) D

pneumococcal vaccine is a priority immunization for the elderly, especially those with chronic illness. It is administered every 5 years.




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