NCLEX Study Course about Delegation and Prioritization Questions 91-95

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91. A nurse is caring for a client who just returned from the recovery room after a tonsillectomy and adenoidectomy. The client is restless and the pulse rate is elevated. The nurse prepares to continue assessing the client, but the client begins to vomit large amounts of bright red blood. The immediate nursing action is to:

a) notify the surgeon
b) continue with the assessment
c) check the client's temperature
d) obtain a flashlight, gauze, and a curved hemostat

92. A postoperative client suddenly develops chest pain and is experiencing dyspnea and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately plans to:

a) ensure that the intravenous (IV) line is patent
b) prepare the client for a perfusion scan
c) administer nasal oxygen
d) place the client on a cardiac monitor

93. An older client with a history of hyperparathyroidism and severe osteoporosis is newly hospitalized. The nurse reviews the plan of care for the client and selects which nursing diagnosis as the priority?

a) risk for injury
b) impaired urinary elimination
c) risk for constipation
d) ineffective health maintenance

94. A client arrives at the nursing unit following internal maxillary fixation (IMF) surgery. The immediate nursing action is to:

a) administer an anti-emetic to prevent vomiting
b) position the client on the side with the head slightly elevated
c) place wire cutters at the bedside
d) connect the nasogastric tube (NGT) to allow intermittent suction

95. A registered nurse is planning the client assignments for the day. Which of the following is the appropriate assignment for the nursing assistant?

a) a client requiring frequent vital signs following a cardiac catheterization
b) a client who requires frequent ambulation
c) a client requiring wound irrigation
d) a client receiving continuous tube feedings






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Answers and Rationale

91) A

- Hemorrhage is a potential complication following tonsillectomy and adenoidectomy. If the client vomits large amounts of altered blood or bright red blood, or if the pulse rate or temperature rises and the client is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostats, and a waste basin for examination of the surgical site. The nurse would also gather additional assessment data, but the immediate nursing action would be to contact the surgeon.

92) C

- Pulmonary embolism is a life-threatening emergency. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The ECG is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and arterial blood gases may be drawn. However, the immediate nursing action is to administer oxygen.

93) A

- The client with severe osteoporosis as a result of hyperparathyroidism is at great risk for injury as a result of pathological fractures from bone demineralization. The client may or may not have a risk for impaired urinary elimination, depending on other elements in the client history and whether the client is at risk for stone formation from high serum calcium levels. The client may also have a risk for constipation from the disease process, but this would be a lesser priority than client safety. A risk for ineffective health maintenance may be a concern but is not the priority.

94) B

- Immediately after IMF surgery, the client is positioned on his side, with the head slightly elevated. The nurse then connects the NG tube to low intermittent suction. Antiemetic medications are administered to prevent vomiting, but this is not the immediate action. Wire cutters should already have been placed at the bedside.

95) B

- The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The client who has had a cardiac catheterization will require specific monitoring in addition to vital signs. Unlicensed personnel do not perform wound irrigations and tube feedings.


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NCLEX Study Course about Delegation and Prioritization Questions (96-100)