NCLEX Prioritization Questions (86-90)

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86. A nurse employes 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 who had a below-the-knee amputation
b) a client on a 24-hour urine collection who is on strict bedrest
c) a client scheduled to be transferred to the hospital for coronary artery bypass surgery
d) a client scheduled for transfer to the hospital for an invasive diagnostic procedure

87. The parents of an 18-month-old child arrive at the emergency department with the child. The child is unconscious. The physical examination reveals bruises on the child's upper arms that resemble grip marks, and the nurse suspects child abuse. The first priority of the nurse is to:

a) contact the appropriate state officials to report the abuse case
b) establish a trusting relationship with the parents
c) secure a safe environment for the child
d) stabilize the child's physical condition

88. A nurse is planning care for a client with an obsessive-compulsive disorder. The nurse would assign the highest priority to which of the following nursing interventions?

a) educate the client about self-control techniques
b) establish a trusting nurse-client relationship
c) monitor the client for abnormal behavior
d) encourage participation in daily self-care and unit activities

89. A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility following delegation of the tasks is to:

a) allow each staff member to make judgements when performing the tasks
b) follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task
c) document that the task was complemented
d) assign the tasks that were not completed to the next nursing shift

90. A client who has had abdominal surgery calls the nurse and reports that she felt that "something gave way" in the abdominal incision. The nurse checks the abdominal incision and notes the presence of wound dehiscence. The nurse should take which action first?

a) contact the physician
b) document the findings
c) place the client inlow-fowler's position and instruct the client to lie quietly
d) cover the abdominal wound with a sterile dressing moistened with sterile saline solution



NCLEX Prioritization Questions
Answers and Rationale

86) B

- The nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of nursing practice acts and the job descriptions of the employing agency. A client who had a below-the-knee amputation, a client scheduled to be transferred to the hospital for coronary artery bypass surgery, and a client scheduled for an invasive diagnostic procedure will have physiological as well as psychosocial needs. The nursing assistant is trained to care for a client on bedrest and on a urine collection.

87) D

- In all child abuse cases, the primary concern is the health and safety of the child. Although all of the options are correct, this child is experiencing a medical crisis (unconsciousness); therefore, the first priority is to stabilize the child's condition. Because the child's future health and safety depend on the family, it is critical that the nurse establish a trusting relationship with the parents and collaborate on developing goals that are mutually acceptable. Cases of suspected abuse are reported.

88) B

A trusting nurse-client relationship is the foundation for giving effective nursing care to the client with a mental health disorder. The nursing interventions identified in each of the other options may be appropriate but are not of the highest priority.

89) B

- The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse would document that the task was completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

90) C

- Wound dehiscence is the disruption of the surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in low-Fowler's position and instructs the client to lie quietly. These actions will minimize protrusion of the underlying body tissues. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline. The physician is then notified, and the nurse documents the occurrence and the nursing actions implemented.



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NCLEX Prioritization Questions 1-5


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NCLEX Prioritization Questions 91-95