NCLEX Prioritization Questions 76-80

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76. A nurse in a rehabilitation center is planning the client assignments for the day. Which client would the nurse assign to the nursing assistant?
a) a client on strict bedrest for whom a 24-hour urine specimen is being collected
b) a client scheduled for transfer to the hospital for coronary artery bypass surgery
c) a client scheduled for transfer to the hospital for an invasive diagnostic procedure
d) a client who is going through rehabilitation after undergoing a below-the-knee amputation (BKA)

77. A client has received electroconvulsive therapy (ECT). In the post-treatment area and upon the client's awakening, the nurse will perform which intervention first?

a) assist the client from the stretcher to a wheelchair
b) orient the client and monitor the client's vital signs
c) offer the client frequent reassurance and repeat orientation statements
d) check for a gag reflex and then encourage the client to eat breakfast and resume activity

78. A nurse has assisted the physician in placing a central (subclavian) catheter. Following the procedure, the nurse takes which priority action?

a) ensures that a chest radiograph is done
b) obtains a temperature reading to monitor for infection
c) labels the dressing with the date and time of catheter insertion
d) monitor the blood pressure (BP) to check for fluid volume overload

79. A nurse is caring  for a hospitalized client with a diagnosis of abruptio placentae. The nurse develops a nursing care plan and suggests measures to be implemented in the event of the development of shock. The nurse documents that the initial nursing action in the event of shock is which of the following?

a) turn the client onto her side
b) check the client's blood pressure
c) monitor urinary output
d) check the client's heart rate

80. A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse reviews the plan of care and notes documentation of four nursing diagnoses. Which would the nurse select as the priority?

a) activity intolerance
b) ineffective coping
c) imbalanced nutrition: less than body requirements
d) deficient fluid volume





NCLEX Prioritization Questions
Answers and Rationale

76) A

- The nurse must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency. A client who had a BKA, a client scheduled to be transferred to the hospital for coronary artery bypass surgery, and a client scheduled for an invasive diagnostic procedure will require strategies to meet both physiological and psychosocial needs. The nursing assistant has been trained to care for a client on bedrest and to maintain 24-hour urine collections. The nurse would provide instructions to the nursing assistant regarding the tasks, but the tasks required for this client are within the role description of a nursing assistant.

77) B

- The nurse would first monitor vital signs, orient the client, and review with the client that he or she just received an ECT treatment. The posttreatment area should include accessibility to the anesthesia staff, oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment. The nursing interventions outlined in options A, C, and D will follow accordingly.

78) A

- A major risk associated with central catheter insertion is the possibility of a pneumothorax developing from an accidental puncture of the lung. Obtaining a chest radiograph and checking the results is the best method to determine if this complication has occurred and to verify catheter tip placement before initiating intravenous (IV) therapy. While a client may develop an infection at the central catheter site, a temperature elevation would not likely occur immediately after placement. While BP assessment is always important in checking a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started. Labeling the dressing site is important, but it is not a priority action in this situation.

79) A

- With a client in shock, the goal is to increase perfusion to the placenta. The priority nursing action would be to turn the client onto her side. This would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. Options B, C, and D are also interventions that would be implemented following this initial action.

80) D

- For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and for the fetus, such as an interruption of blood flow to the respiratory system and placenta. Deficient fluid volume would be the priority nursing diagnosis followed by Imbalanced nutrition. Activity intolerance and Ineffective coping may compete regarding the third and fourth priorities depending on the specific client symptoms at the time of care.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Prioritization Questions 1-5


Or proceed to the next set of questions:

NCLEX Prioritization Questions 81-85