Best NCLEX Reviewer about Delegation and Prioritization Questions 51-55

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51. A client with a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, the nurse implements which priority intervention?

a) maintains an intravenous access
b) ensures that oxygen is being delivered
c) administers sedation to prevent claustrophobia
d) provides emotional support to the client's family

52. A nurse is caring for a client who had an orthopedic injury of the leg requiring surgery and application of a cast. Postoperatively, which nursing assessment is of highest priority?

a) monitoring of heel breakdown
b) monitoring of bladder distention
c) monitoring of extremity shortening
d) monitoring for loss of blanching ability of toe nailbeds

53. A nurse hears the alarm sound on the telemetry monitor, looks at the monitor, and notes that a client is in ventricular tachycardia. The nurse rushes to the client's room. Upon reaching the client's bedside, the nurse would take which action first?

a) call a code
b) prepare for cardioversion
c) prepare to defibrillate the client
d) check the client's level of consciousness

54. A nurse has just finished assisting the physician in placing a central intravenous (IV) line. Which of the following is a priority nursing intervention after central line insertion?

a) prepare the client for a chest radiograph
b) assess the client's temperature to monitor for infection
c) label the dressing with the date and time of catheter insertion
d) monitor the blood pressure to assess for fluid volume overload

55. A nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse assigns priority to which assessment finding?

a) temperature 99.4F, flat affect
b) fist clenched and pounding table
c) tearful, withdrawn, and isolated
d) blood pressure 160/100 mmHg; pulse 120 bpm, respirations 18 breaths per minute




Best NCLEX Reviewer:
Answers and Rationale

1) B

- Hyperbaric oxygen therapy is a process by which oxygen is administered at greater than atmospheric pressure. When oxygen is inhaled under pressure, the level of tissue oxygen is greatly increased. The high levels of oxygen promote the action of phagocytes and promote healing of the wound. Because the client is placed in a closed chamber, the administration of oxygen is of primary importance. Although options 1, 3, and 4 may be appropriate interventions, option 2 is the priority.

2) D

- With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although bladder distention, extremity lengthening or shortening, or heel breakdown can occur, these complications are not potentially life-threatening complications.

3) D

- Determining unresponsiveness is the first assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for unresponsiveness helps to determine whether the client is affected by the decreased cardiac output. If the client is unconscious, then the ABCDs—airway, breathing, circulation, defibrillation—of cardiopulmonary resuscitation or basic life support are initiated.

4) A

- A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest radiograph is one of the best methods to determine if this complication has occurred and to verify catheter tip placement before initiating intravenous (IV) therapy. A temperature elevation related to central line insertion would not likely occur immediately after placement. Labeling the dressing site is important but is not the priority. Although BP assessment is always important in assessing a client's status after an invasive procedure, fluid volume overload is not a c5oncern until IV fluids are started.

 5) B

- Anxiety can lead to behavior that is harmful to the client and others. If safety is threatened, this is the priority. Tearfulness, withdrawal, isolation, and elevated vital signs are abnormal findings. However, these findings are not life-threatening, although they should be monitored. After the client's mental status is addressed and the client's safety is ensured, the nurse should attend to the elevated vital signs.


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