Best NCLEX Reviewer about Delegation and Prioritization Questions 71-75

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71. A nurse is called to a client's room by another nurse. When the nurse arrives at the room, she discovers that a fire has occurred in the client's wastebasket. The first nurse removed the client from the room. What is the second nurse's next action?

a) confine the fire
b) evacuate the unit
c) extinguish the fire
d) activate the fire alarm


72. A client with type 2 diabetes mellitus is being discharge from the hospital after an occurrence of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). The nurse develops a discharge teaching plan for the client and identifies which of the following as a priority?

a) exercise routines
b) controlling dietary intake
c) keeping follow-up appointments
d) monitoring for signs of dehydration

73. A client is receiving intralipids (fat emulsion) intravenously at home, and the client's spouse manages the infusion. The health care nurse makes a visit and discusses potential adverse reactions and the side effects of the therapy with the client and the spouse. After the discussion, the nurse expects the spouse to verbalize that, in case of suspected adverse reaction, the priority action is to:

a) stop the infusion
b) contact the nurse
c) take the client's blood pressure
d) contact the local area emergency response team

74. The nurse caring for a client who is dying formulates a nursing diagnosis of Fear and identifies appropriate nursing interventions. From the following list of nursing interventions, which intervention should the nurse implement first?

a) help the client express fears
b) assess the nature of the client's fear
c) help the client identify coping mechanisms that were successful in the past
d) document verbal and nonverbal expressions of fear and other significant data

75. A nurse reviews the preoperative teaching plan for a client scheduled for a radical neck dissection. When implementing the plan, the nurse initially focuses on:

a) the financial status of the client
b) postoperative communication techniques
c) information given to the client by the surgeon
d) the client's support system and coping behaviors





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Answers and Rationale

71) D

- Remember the acronym RACE (i.e., rescue, alarm, confine, extinguish) to set priorities if a fire occurs. In this situation, the client has been rescued from the immediate vicinity of the fire. The next action is to activate the fire alarm.

72) D

- Clients at risk for HHNS should immediately report signs and symptoms of dehydration to health care providers. Dehydration can be severe, and it may progress rapidly. Although options A, B, and C are components of the teaching plan, for the client with HHNS, dehydration is the priority.

73) A

- Fat-emulsion therapy can cause overloading syndrome (i.e., focal seizures, fever, and shock) and adverse effects, including chest pain, chills, and shock. The priority action is to stop the infusion to limit the adverse response. Although options B, C, and D are correct interventions, the priority is to stop the infusion.

74) B

- Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client's fears to know how best to help the client. Next, the nurse would help the client express his or her fears. The client's fear may not be limited to the fear of dying, and the nurse needs this information to help the client. After the nurse is aware of the client's fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would document verbal and nonverbal expressions of fear and any other significant data as a final intervention.

75) D

The first step in client teaching is establishing what the client already knows. This allows the nurse not only to correct any misinformation but also to determine the starting point for teaching and to implement the education at the client's level. Although options A, B, and D may be components of the plan, they are not the initial focus.


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Best NCLEX Reviewer about Delegation and Prioritization Questions 76-80