NCLEX Review on Delegation and Prioritization Questions (41-45)

NCLEX Review on Delegation and Prioritization Questions


42. A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following?

a) open the airway
b) give the client oxygen
c) start chest compressions
d) ventilate with a mouth-to-mask device



43. A nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange in order of priority the steps of adult CPR. (Letter A is the first step and letter F is the last step.)

a) initiate breathing
b) open the client's airway
c) determine breathlessness
d) perform chest compressions
e) check for a pulse at the carotid artery
f) determine unconsciousness by shaking the client and asking "Are you OK?"

44. A nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to do which of the following first on arrival of the client?

a) assess the patency of the airway
b) check tubes or drains for patency
c) check the dressing to assess for bleeding
d) assess the vital signs to compare with preoperative measurements.

45. A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses for preeclampsia to eclampsia, the nurse's first action should be to:

a) administer oxygen by face mask
b) clear and maintain an open airway
c) administer magnesium sulfate intravenously
d) assess the blood pressure and fetal heart rate





NCLEX Review on Delegation and Prioritization Questions
ANSWERS AND RATIONALE

42)  A

- The next nursing action would be to open the airway. Ventilation cannot be initiated unless the airway is opened. Chest compressions are started after opening the airway and initiating ventilation. Oxygen may be helpful at some point, but the airway is opened first.

43)  D, B, C, F, E, A

- The sequence for basic CPR for health care providers is as follows. After determining unconsciousness, the airway is opened and breathlessness is determined. Next, the health care provider delivers effective breaths that produce a visible rise in the chest, followed by assessing the carotid artery for presence of a pulse. In the absence of any pulse, chest compressions are provided at an adequate rate and depth that will allow adequate chest recoil, with minimal interruptions in chest compressions.

44)  A

- The first action of the nurse is to assess the patency of the airway and respiratory function. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. If the airway is not patent, the nurse must take immediate measures for the survival of the client. Options B, C, and D are all nursing actions that should be performed after a patent airway has been established.

45)  B

- The immediate care during a seizure (eclampsia) is to ensure a patent airway. Options A, C, and D are actions that follow or are implemented after the seizure has ceased.



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