NCLEX Review on Delegation and Prioritization Questions (36-40)

NCLEX Review on Delegation and Prioritization Questions

36. The nurse is giving a bed bath to an assigned client when a nursing assistant enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The appropriate nursing action is which of the following?

a) finish the bed bath and then administer the pain medication to the other client
b) ask the nursing assistant to find out when the last pain medication was given to the client
c) ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is complete
d) cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client


37. A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to preform the Allen's Test on the client. Arrange in order of priority the steps for performing Allen's test. (Letter A is the first step and letter F is the last step.

a) document the findings
b) explain the procedure to the client
c) release pressure from the ulnar artery
d) apply pressure over the ulnar and radial arteries
e) ask the client to open and close the hand repeatedly
f) assess the color of the extremity distal to the pressure point



38. A nurse is monitoring a client receiving parenteral nutrition. The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. Arrange the actions that the nurse would take in order of priority (Letter A is the first action and letter F is the last action).

a) administer oxygen
b) contact the physician
c) document the occurrence
d) take the client's vital signs
e) clamp the intravenous catheter
f) position the client in left trendelenburg position

39. A client has 1L bag of 5% dextrose in 0.9% sodium chloride hung at 3PM. The nurse making rounds at 3:45PM finds that the client is complaining of pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 ml remaining. The nurse should take which of the following action first?

a) call the physician
b) slow the IV infusion
c) sit the client up in bed
d) remove the IV catheter

40. The nurse determines that he client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next?

a) remove the IV line
b) run normal saline at a keep vein open rate
c) run a solution of 5% dextrose in water
d) obtain a culture of the tip of the catheter device removed from the client




NCLEX Review on Delegation and Prioritization Questions:
ANSWERS AND RATIONALE

36) D

- The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options A and C delay the administration of medication to the client in pain. Option B is not a responsibility of the nursing assistant.

37) F, A, D, B, C, E

- The Allen’s test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client’s ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Finally, the nurse documents the findings.

38) D, C, F, E, A, B

- If air embolism is suspected, the nurse would first clamp the intravenous catheter to prevent the embolism from traveling through the heart to the pulmonary system. The nurse would next place the client in a left side-lying position with the head lower than the feet (to trap air in right side of the heart). The nurse would notify the physician and administer oxygen as prescribed. The nurse would monitor the client closely and take the client’s vital signs. Finally,  the nurse documents the occurrence.

39) B

- The client’s symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client’s breathing, if necessary. The nurse also notifies the physician immediately. The IV catheter is not removed; it may be needed once the complication has been resolved.

40) B

- If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep vein open rate pending further physician orders. This maintains a patent IV access line and aids in maintaining the client’s intravascular volume. The nurse would not discontinue the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.




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