NCLEX Review on Delegation and Prioritization Questions (31-35)

NCLEX Review on Delegation and Prioritization Questions

31. A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients?

a) a client complaining of muscle aches, a headache, and malaise
b) a client who twisted her ankle when she fell while rollerblading
c) a client with a minor laceration on the index finger sustained while cutting an eggplant
d) a client with chest pain who states that he just ate pizza that was made with a very spicy sauce

32. The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?

a) a client requiring colostomy irrigation
b) a client receiving continuous tube feedings
c) a client who requires urine specimen collections
d) a client with difficulty swallowing foods and fluids



33. The RN employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse?

a) the client who requires a bed bath
b) an older client requiring frequent ambulation
c) a client who requires a 24-hour urine collection
d) a client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

34. The RN has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the RN plan to care for first?

a) A client who is ambulatory
b) a client scheduled for physical therapy at 1PM
c) a client with a fever who is diaphoretic and restless
d) a postoperative client who has just received pain and medication

35. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

a) a client scheduled for a chest x-ray
b) a client requiring daily dressing changes
c) a postoperative client preparing for discharge
d) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift




NCLEX Review on Delegation and Prioritization Questions:
ANSWERS AND RATIONALE

31) D

- In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority.

32) C

- The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires urine specimen collections. The nursing assistant is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration.

33)  D

- When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine sample, giving a bed bath, and assisting with frequent ambulation can be provided most appropriately by the nursing assistant. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

34)  C

The RN would plan to care for the client who has a fever and is diaphoretic and restless first because this client’s needs are the priority. Waiting for pain medication to take effect before providing care to the postoperative client is best. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care.

35) D

- Airway is always a highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options A, B, and C have needs that would be identified as intermediate priorities.




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