Welcome to NCLEX RN Questions 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
101. A registered nurse (RN) is implementing a team nursing approach. The RN has a licensed practical nurse (LPN) and a nursing assistant on the team and is planning the client assignments for the day. The RN appropriately assigns which of the following clients to the LPN?
a) a client who needs assistance with grooming
b) a client who needs frequent ambulation
c) a client who needs to be suctioned as needed (PRN)
d) a client who needs assistance with hygiene measures
102. A nurse is planning client assignments. Which of the following is the least appropriate assignment for the nursing assistant?
a) assisting a profoundly developmentally disabled child to eat lunch
b) obtaining frequent oral temperatures on a client
c) accompanying a 51-year old man, being discharged to home following a bowel resection
d) collecting a urine specimen from a 70-year old woman admitted 3 days ago
103. A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?
a) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift
b) a postoperative client preparing fro discharge
c) a client scheduled for a chest x-ray
d) a client requiring daily dressing changes
104. A nurse is planning the client assignments for the shift. Which of the following clients would the nurse appropriately assign to the nursing assistant?
a) a client requiring twice -daily dry dressing changes
b) a client requiring frequent ambulation with a walker
c) a client on a bowel management program requiring rectal suppositories and a daily enema
d) a client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures
105. A client with a spinal cord injury develops a severe, pounding headache. The client is diaphoretic, hypertensive, and bradycardic and complains of nausea and nasal congestion. The nurse determines that the client is experiencing autonomic hyperreflexia (autonomic dysreflexia). Which action would the nurse take first?
a) notify the physician
b) document the findings
c) perform a rectal examination
d) place the client in a sitting position
NCLEX RN:
Answers and Rationale
101) C
- When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. Option C can be assigned to the LPN because this staff member can perform certain invasive procedures. Noninvasive interventions can be assigned to a nursing assistant. These include the tasks identified in options A, B, and D.102) A
- 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 least appropriate assignment for a nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating and therefore a higher potential for complications such as choking and aspiration. The remaining three options include no data indicating that these tasks carry any unforeseen risk.103) A
- Airway is always a high priority, so the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options B, C, and D would be an intermediate priority.104) B
- Assignment of tasks needs to be implemented on the basis of the job description of the nursing assistant, the level of clinical competence, and state law. Options A, C, and D involve care that requires the skill of a licensed nurse. Although a nursing assistant may be trained to administer an enema (depending on state practice acts and agency policy), a rectal suppository needs to be administered by a licensed nurse. Option B is the most appropriate assignment for the nursing assistant.105) D
- Autonomic hyperreflexia is an acute emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A number of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction), or stimulation of the skin. When autonomic hyperreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse would then perform a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately via a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or broken skin. The physician is notified, and the nurse documents the occurrence and the actions taken.After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:
NCLEX RN Questions about Delegation and Prioritization Questions 1-5
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