Welcome to the Best NCLEX Reviewer about Delegation and Prioritization. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :
Complete NCLEX Study Materials
56. A client is being brought into the emergency department after suffering a head injury. The first action by the nurse is to determine the client's:
a) level of consciousness
b) pulse and blood pressure
c) respiratory rate and depth
d) ability to move extremities
57. A nurse is caring for a client scheduled for an arthroscopy. The nurse develops a postoperative plan of care and includes which priority nursing action in the plan?
a) monitor intake and output
b) assess the tissue at the surgical site
c) monitor the area for numbness or tingling
d) assess the complete blood cell count results
58. A nurse is performing an assessment on a client who has a suspected spinal cord injury. Which of the following is the priority nursing assessment?
a) pain level
b) mobility level
c) respiratory status
d) pupillary response
59. A 52-year old male client is seen in the physician's office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet, 8 inches, and his weight is 220 pounds. Vital signs are: temperature 98F orally, pulse 86 beats per minute, and respirations 18 breaths per minute. The blood pressure (BP) is 184/100 mmHg. Random blood sugar glucose is 122 mg?dL. Which of the following questions should the nurse ask the client first?
a) do you exercise regularly?
b) are you considering trying to lose weight?
c) is there a history of diabetes mellitus in your family?
d) when was the last time you had your blood pressure checked?
60. A client admitted to the nursing unit from the emergency department has a spinal cord injury at the level of the fourth cervical vertebra (C-4). Which assessment should the nurse perform first when admitting the client to the nursing unit?
a) listen to breath sounds
b) observe for dyskinesias
c) take the client's temperature
d) assess extremity muscle strength
Best NCLEX Reviewer:
Answers and Rationale
56) C
- The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated (option B), followed by evaluation of the neurological status (options A and D).57) C
- The priority nursing action is to monitor the affected area for numbness or tingling. Options A, B, and D are also a component of postoperative care, but, from the options presented, are not the priority.58) C
- All of these assessments would be performed on a client with a suspected spinal cord injury. However, respiratory status is the priority.59) D
- The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the client's major modifiable risk factors.60) A
- Because compromise of respiration is a leading cause of death in cervical spinal cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is assured. Dyskinesias occur in cerebellar disorders, so they are not as important in spinal cord-injured clients, unless head injury accompanies the spinal cord injury.After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:
Best NCLEX Reviewer about Delegation and Prioritization Questions 1-5
Or proceed to the next set of questions:
Best NCLEX Reviewer about Delegation and Prioritization Questions 61-65
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