NCLEX Review on Delegation and Prioritization Questions (21-25)

NCLEX Review on Delegation and Prioritization Questions

21. A nurse delegates administration of an enema to a nursing assistant. The nurse should intervene if the nursing assistant:

a) advances the catheter 4 inches into the anal canal
b) hangs the enema bag 12 to 18 inches above the anus
c) lubricates 4 to 5 inches of the catheter tip
d) positions the client on the right side with head slightly elevated

22. A nurse is reviewing with a nursing assistant the care assignment for a client. Which of the following statements if made by the nurse regarding care of a client with crutches is most appropriate?

a) the client needs to ambulate with crutches and a two-point gait
b) ambulate the client without weight bearing every 4 hours the length of the hall and back
c) ask the client if she understands how to use a two-point gait, if not, please explain it to the client
d) make sure the client does not bend the elbows when using the crutches

23. The home care nurse has four phone calls to answer. Which phone call should the home care nurse respond to first?

a) a client who received chemotherapy yesterday and is reporting nausea and vomiting
b) a client who was discharged two days ago with a urinary catheter after a transurethral prostactemomy and is reporting pink-tinged urine
c) a client with schizophrenia who says that the police has surrounded the house
d) the wife of a client with chronic heart disease who reports her husband is coughing frothy, white secretions and became confused during the night

24. A nurse arrives on the scene of an apartment fire. Which of the following clients does the nurse attend to first?

a) a 3-year old child who cannot find her parents and is reporting a headache
b) a 48-year old male who has burns on both hands and reports severe pain
c) an 18-year old male who jumped from a second story window and is reporting severe arm pain
d) a 28-year old woman who has burns on the face and neck and reports difficulty swallowing

25. A female college student reports to the student health center very distressed after waking up in a male student's restroom and not remembering what happened to the night before. The first action the nurse should take is:

a) obtain a rape kit
b) ask the client if she thinks she was raped
c) place the client in an examining room and leave her while she puts on a gown
d) provide a quiet, private area to use for initial assessment of the client




NCLEX Review on Delegation and Prioritization Questions:
ANSWERS AND RATIONALE

21) D

- the appropriate position of the client during enema administration is left lateral position to facilitate flow of solution by gravity. Therefore, the action of the CNA in choices no. 4 needs to be corrected.

22) B

- when delegating task, the nurse should provide complete, concrete and specific directions.

23) D

- the situation indicates development of pulmonary edema in the client with chronic heart disease. This serious complication is a priority.

24) D

- burns on the face and neck involves obstruction of airway due to smoke inhalation. Airway is a priority.

25) D

- this situation indicates possible rape of the client. Providing psychosocial support and ensuring privacy for initial assessment of the client is most appropriate initial action.





Related Topics:

•   NCLEX Review on Delegation and Prioritization Questions (26-30)
• Or go back to NCLEX Review on Delegation and Prioritization Questions (1-5) to start the test in the beginning