Best NCLEX Reviewer about Delegation and Prioritization Questions 61-65

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61. A client received a thermal burn caused by the inhalation of steam. The client's mouth is edematous and the nurse notes blisters in the client's mouth. The nurse first assesses which priority item(s)?

a) neurological status
b) level of consciousness
c) temperature via the rectal route
d) respiratory status and lung sounds

62. A registered nurse (RN) is planning the assignments for the day and is leading a team composed of a licensed practical nurse (LPN) and a nursing assistant (NA). The nurse assigns which client to the LPN

a) client with dementia
b) a 1-day postoperative mastectomy client
c) a client who requires some assistance with bathing
d) a client who requires some assistance with ambulation

63. A client requests pain medication and the nurse administers a ventrogluteal intramuscular injection. After administration of the injection, the nurse does which of the following first?

a) washes the hands
b) removes the gloves
c) applies gentle pressure to the injection site
d) places the syringe in the secure, puncture-resistant needle box container

64. A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate for the nursing assistant?

a) collecting a urine specimen from a client
b) obtaining frequent oral temperatures on a client
c) accompanying a man being discharged
d) assisting a postcardiac catheterization client who needs to lie flat to eat lunch

65. A nurse is planning the client assignments for the shift. Which client would the nurse assign to the nursing assistant?

a) a client requiring dressing changes
b) a client requiring frequent ambulation
c) a client on a bowel management program requiring rectal suppositories and a daily enema
d) a client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures





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Answers and Rationale

61) D

- Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and generally appear erythematous and edematous with mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after burn injury. Assessment of respiratory status is the priority. Although the nurse would check the client's temperature and the client's neurological status, respiratory status is the priority.

62) B

- Assignment of tasks needs to be implemented based on the job description of the LPN and NA, the level of education and clinical competence, and state law. The 1-day postoperative mastectomy client will need care that requires the skill of a licensed nurse. The nursing assistant has the skills to care for a client with dementia, a client who requires some assistance with bathing, and a client who requires some assistance with ambulation.

63) C

- Following administration of an intramuscular injection, the nurse would apply gentle pressure to the site to assist in medication absorption and prevent bleeding. Then, the nurse assists the client to a comfortable position. The uncapped needle and syringe are discarded in a secure, puncture-resistant container, gloves are removed, and the hands are washed. Of the options provided, the nurse would perform option C first.

64) D

- Work that is delegated to others must be consistent with the individual's level of expertise and licensure, if any. Based on the options provided, the least appropriate activity for a nursing assistant would be assisting the postcardiac catheterization client. Because this client needs to eat while lying flat, the client is at risk for aspiration. The remaining three options do not include situations that indicate that these activities carry foreseeable risk.

65) B

- Assignment of tasks to the nursing assistant needs to be made based on job description, level of clinical competence, and state law. Options A, C, and D involve care that requires the skill of a licensed nurse. The client described in option 2 has needs that can be met by a nursing assistant.


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Best NCLEX Reviewer about Delegation and Prioritization Questions 66-70