NCLEX Review on Delegation and Prioritization Questions 46-50

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46. A labor and delivery room nurse has just received report on four clients. The nurse should assess which client first?

a) a primiparous client in the active stage of labor
b) a multiparous client who was admitted for induction of labor
c) a client who is not contracting, but has suspected premature rupture
d) a client who has just received an IV loading dose of magnesium sulfate to stop preterm labor

47. A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43-week gestation newborn infant with Apgar scores of 1 and 4. In planning for admission of this infant, the nurse's highest priority should be to:

a) turn on the apnea and cardiorespiratory monitors
b) connect the resuscitation bag to the oxygen outlet
c) set up the intravenous line with 5% dextrose in water
d) set the radiant warmer control temperature at 36.5C (97.6F)



48. A nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, the priority nursing diagnosis would be risk for:

a) infection
b) aspiration
c) activity intolerance
d) altered growth and development

49.  After a tonsillectomy, a child begins to vomit bright red blood. The initial nursing action is to:

a) notify the physician
b) turn the child to the side
c) maintain an NPO status
d) administer the prescribed antiemetic


50. The nurse manager is planning the clinical assignments for the day and avoids assigning which staff member to the client with herpes zoster?

a) the nurse who never had rubeola
b) the nurse who never had mumps
c) the nurse who never had chickenpox
d) the nurse who never had german measles




NCLEX REVIEW ON DELEGATION AND PRIORITIZATION QUESTIONS:
ANSWERS AND RATIONALE

46) D

- Magnesium sulfate is a central nervous system (CNS) depressant and the client could experience adverse effects that includes depressed respiratory rate (below 12 breaths/min), severe hypotension, and absent deep tendon reflexes (DTRs). This client should be seen before the clients in options A, B, and C because these clients conditions represent stable ones.

47) B

- The highest priority on admission to the nursery for a newborn with a low Apgar scores is the airway, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower priority. The newborn infant will be placed on an apnea and cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.

48) A

- Initial care of the newborn with myelomeningocele involves prevention of infection. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents and to prevent tearing or breakdown of the skin integrity at the site. Any opening in the sac greatly increases the risk of infection of the central nervous system. Activity intolerance and risk for aspiration would not be priority problems with this defect. Risk for altered growth and development is a problem for the infant with myelomeningocele, but preventing infection has priority in the preoperative period.

49) B

- After tonsillectomy, if bleeding occurs, the nurse turns the child to the side and then notifies the physician. An NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side.

50) C

- Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella-zoster virus are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster. Options A, B, and D are unrelated to the herpes zoster virus.


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NCLEX Review on Delegation and Prioritization Questions 1-5


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NCLEX Review on Delegation and Prioritization Questions 51-55