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
66. A client tells the home care nurse of a personal decision to refuse external cardiac resuscitation measures. Which of the following is the most appropriate initial nursing action?
a) notify the physician of the client's request
b) discuss the client's request with the client's family
c) document the client's request in the home care nursing care plan
d) conduct a client conference with the home care staff to share the client's request
67. A nurse is caring for a client who is going to have an arthrogram using a contrast medium. Which preprocedure assessment would be of highest priority?
a) allergy to iodine or shellfish
b) whether the client wishes to void before the procedure
c) ability of the client to remain still during the procedure
d) whether the client has any remaining questions about the procedure
68. A registered nurse (RN) asks a licensed practical nurse (LPN) to change the colostomy bag on a client. The LPN tells the RN that although attendance at the hospital in-service was completed regarding this procedure, the LPN has never performed a colostomy bag change on a client. The appropriate action by the RN is to:
a) perform the procedure with the LPN
b) request that the LPN observe another LPN perform the procedure
c) ask the LPN to review the materials from the in-service before performing the procedure
d) instruct the LPN to review the procedure in the hospital manual and take the written procedure into the client's room for reference
69. A nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency department. Using principles of triage, the nurse initiates immediate care for a client with which of the following injuries?
a) fractured tibia
b) penetrating abdominal injury
c) bright red bleeding from a neck wound
d) open massive head injury to deep coma
70. A nurse working on an adult nursing unit is told to review the client census to determine which client could be discharged if there are a large number of admissions from a newly declared disaster. The nurse determines that the client with which of the following problems would need to remain hospitalized?
a) laparoscopic cholecystectomy
b) fractured hip, pinned 5 days ago
c) diabetes mellitus with blood glucose at 180 mg/dL
d) ongoing ventricular dysrhythmias while receiving procainamide (Procanbid)
Best NCLEX Reviewer:
Answers and Rationale
66) A
- External cardiac resuscitation is a life-saving treatment that a client may refuse. The most appropriate initial nursing action is to notify the physician, because a written "do not resuscitate" (DNR) order from the physician is needed to ensure that the client's wishes are followed. The DNR order must be reviewed or renewed on a regular basis per agency policy. Although options B, C, an D may be appropriate, remember that obtaining a written physician's DNR order must be completed first. 67) A
- Because of the risk associated with allergy to contrast medium, the nurse places highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test, tells the client about the need to remain still during the procedure, and encourages the client to void before the procedure for comfort.68) A
- The RN must remember that, even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. Only the task, not the ultimate accountability, may be delegated to another. The RN is responsible for ensuring that competent and accurate care is delivered to the client. Requesting that the LPN observe another LPN perform the procedure does not ensure that the procedure will be done correctly. Because colostomy bag change is a new procedure for this LPN, the RN should accompany the LPN, provide guidance, and answer questions following the procedure. Although it is appropriate to review the in-service materials and the hospital procedure manual, it is best for the RN to accompany the LPN to perform the procedure.69) C
- The client with bright red (arterial) bleeding from a neck wound is in "immediate" need of treatment to save the client's life. This client is classified as an emergent client and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of "expectant" would be applied to the client with massive injuries and minimal chance of survival. This client would be color-coded "black" in the triage process. The client who is color-coded "black" is given supportive care and pain management but is given definitive treatment last.70) D
- The client with ongoing ventricular dysrhythmias requires ongoing medical evaluation and treatment because of potentially lethal complications of the problem. Each of the other problems listed may be managed at home with appropriate agency referrals for home care services and support from the family at home.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 71-75
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