NCLEX Study Course about Delegation and Prioritization Questions 96-100

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96. A registered nurse (RN) employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical nurse (LPN) and three nursing assistants on a nursing team. Which of the following clients would the nurse appropriately assign to the LPN?

a) a client with a right leg amputation who requires assistance with a shower
b) a client requiring a bed bath and frequent ambulation with a walker
c) a client who requires frequent temperatures taken
d) a client with a decubitus ulcer that requires a wound irrigation and dressing change

97. A registered nurse (RN) has received the assignment for the day shift. After making initial rounds and checking all the assigned clients, which client will the RN plan to care for first?

a) a postoperative client with chest tubes who has just received pain medication
b) a client scheduled for a chest x-ray at 11:00 AM
c) a client who is scheduled for surgery at 1:00 PM
d) a client who is self-care

98. A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?

a) a client admitted on the previous shift with a diagnosis of gastroenteritis
b) a client in skeletal traction
c) a client attached to a ventilator
d) a postoperative client preparing for discharge

99. A nurse on the day shift is assigned to care for four clients. Following report from the night shift, which client will the nurse plan to asses first?

a) client scheduled for a cardiac catheterization at 10:00 AM
b) client newly diagnosed with diabetes mellitus who is scheduled for discharge to home
c) client with pulmonary edema who was treated with furosemide (Lasix) at 5:00 AM
d) client scheduled to have an electrocardiogram (ECG) at 9:00 AM

100. A registered nurse (RN) is planning the client assignments for the day. The RN assigns which of the following clients to the nursing assistant?

a) a client who needs range-of-motion exercises every 4 hours
b) a client who needs to be catheterized every 12 hours
c) a client who needs to be suctioned as needed (PRN)
d) a client who needs a dressing change performed every 4 hours





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Answers and Rationale

96) D

- When delegating nursing assignments, the nurse needs to consider the skills and educational levels of the nursing staff. The nursing assistant can most appropriately give a shower, give a bed bath, ambulate a client with a walker, and take an oral temperature. The LPN can administer the rectal suppository to the client requiring the enema. The LPN is skilled in wound irrigations and dressing changes, and this client would most appropriately be assigned to this staff member.

97) C

- The RN would plan to care for the client who is scheduled for surgery at 1:00 PM first. There are several items that need to be addressed preoperatively, including client preparation (physically and emotionally) and physician orders that need to be carried out. This preparation takes time. Additionally, often the operating room makes late changes in the schedule, depending on room and physician availability, and requests an earlier surgical time. Therefore, it is best to ensure that this client is prepared. It is best to wait for pain medication to take effect before providing care to the postoperative client. The client who is self-care and the client scheduled for an x-ray later in the morning do not have priority needs related to care.

98) C

- Airway is always a high priority, and the nurse would assess the client attached to a ventilator first. The clients described in options A, B, and D have needs that would be identified as intermediate priorities.

99) C

- Airway is always a high priority, and the nurse would assess the client with pulmonary edema who was treated with furosemide at 5:00 am first. The nurse would next assess the client scheduled for the cardiac catheterization, followed by the client scheduled for discharge and the client scheduled for an ECG.

100) A

- When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the tasks is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. Noninvasive interventions can be assigned to a nursing assistant. Options B, C, and D can be assigned to a licensed practical nurse or another RN because these staff members can perform certain invasive procedures.



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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 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 81-85

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81. An emergency department nurse prepares a client who sustained a gunshot wound for surgery. The nurse removes the client's clothing and places a gown on the client to prepare the client for the surgical procedure. Which of the following indicates the appropriate nursing action regarding the client's clothing, which is stained with blood?

a) discard clothing
b) give the clothing to the family member or significant other
c) place the clothing in a paper bag
d) place the clothing in a plastic bag and in a locked cabinet

82. A nurse is assessing a client who has a suspected spinal cord injury. Which of the following is the priority assessment?

a) pupillary response
b) respiratory status
c) mobility
d) pain

83. When delegating a task to a team member, the nurse as the team leader gives authority over the task by:

a) offering suggestions on how to complete the task
b) waiting for the team member to report the results of the completed task
c) completing the task for the team member
d) checking to be sure the task is complete

84. A nurse is assigned to care for a client with coronary artery disease (CAD) who is scheduled fro a cardiac catheterization. Following the catheterization, the priority nursing action is to assess the:

a) catheter insertion site
b) temperature
c) potassium level
d) urine output

85. A nurse in a day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and plans activities that will meet the child's needs. The priority consideration in planning activities for the child is to ensure:

a) social interactions with other children in the same age-group
b) safety with activities
c) familiarity with all activities and providing orientation throughout the activities
d) activities that provide verbal stimulation





NCLEX Prioritization Questions
Answers and Rationale

81) C

- All evidence discovered during an examination is recorded. Documentation of evidence includes the bodily location from which the sample was obtained and when or to whom it was delivered. Evidence should be maintained in its original condition. Clothing is stored in a paper bag instead of plastic to prevent decomposition. If clothing needs to be cut off the client, special attention is taken not to destroy evidence inadvertently.

82) B

- All of the assessments in the options would be performed on a suspected spinal cord injury client; however, respiratory status is the priority.

83) B

Authority for task completion is given to the team member by not directing or participating, and allowing the team member to complete the task under her own responsibility. The team member then reports the results to the team leader. Options A, C, and D involve the team leader in task completion.

84) A

- During the post–cardiac catheterization period, priorities of nursing care include frequent monitoring of the blood pressure and pulse. The catheter insertion site is checked frequently for signs of bleeding and swelling. Distal pulses also are assessed. Potassium level, temperature, and urine output should also be monitored but are not the priority of the items identified in the options.

85) B

- Safety with all activities is a priority in planning activities with the child. The child with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensory perceptual deficits. Although social interactions, verbal communications, and providing familiarity with activities and orientation are also appropriate interventions, the priority is safety.


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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.


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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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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 66-70

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66. A client tells the home care nurse of a personal decision to refuse external cardiac resuscitation measures. Which of the following is the most appropriate initial nursing action?

a) notify the physician of the client's request
b) discuss the client's request with the client's family
c) document the client's request in the home care nursing care plan
d) conduct a client conference with the home care staff to share the client's request

67. A nurse is caring for a client who is going to have an arthrogram using a contrast medium. Which preprocedure assessment would be of highest priority?

a) allergy to iodine or shellfish
b) whether the client wishes to void before the procedure
c) ability of the client to remain still during the procedure
d) whether the client has any remaining questions about the procedure

68. A registered nurse (RN) asks a licensed practical nurse (LPN) to change the colostomy bag on a client. The LPN tells the RN that although attendance at the hospital in-service was completed regarding this procedure, the LPN has never performed a colostomy bag change on a client. The appropriate action by the RN is to:

a) perform the procedure with the LPN
b) request that the LPN observe another LPN perform the procedure
c) ask the LPN to review the materials from the in-service before performing the procedure
d) instruct the LPN to review the procedure in the hospital manual and take the written procedure into the client's room for reference

69. A nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency department. Using principles of triage, the nurse initiates immediate care for a client with which of the following injuries?

a) fractured tibia
b) penetrating abdominal injury
c) bright red bleeding from a neck wound
d) open massive head injury to deep coma

70. A nurse working on an adult nursing unit is told to review the client census to determine  which client could be discharged if there are a large number of admissions from a newly declared disaster. The nurse determines that the client with which of the following problems would need to remain hospitalized?

a) laparoscopic cholecystectomy
b) fractured hip, pinned 5 days ago
c) diabetes mellitus with blood glucose at 180 mg/dL
d) ongoing ventricular dysrhythmias while receiving procainamide (Procanbid)





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66) A

- External cardiac resuscitation is a life-saving treatment that a client may refuse. The most appropriate initial nursing action is to notify the physician, because a written "do not resuscitate" (DNR) order from the physician is needed to ensure that the client's wishes are followed. The DNR order must be reviewed or renewed on a regular basis per agency policy. Although options B, C, an D may be appropriate, remember that obtaining a written physician's DNR order must be completed first.

67) A

- Because of the risk associated with allergy to contrast medium, the nurse places highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test, tells the client about the need to remain still during the procedure, and encourages the client to void before the procedure for comfort.

68) A

- The RN must remember that, even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. Only the task, not the ultimate accountability, may be delegated to another. The RN is responsible for ensuring that competent and accurate care is delivered to the client. Requesting that the LPN observe another LPN perform the procedure does not ensure that the procedure will be done correctly. Because colostomy bag change is a new procedure for this LPN, the RN should accompany the LPN, provide guidance, and answer questions following the procedure. Although it is appropriate to review the in-service materials and the hospital procedure manual, it is best for the RN to accompany the LPN to perform the procedure.

69) C

- The client with bright red (arterial) bleeding from a neck wound is in "immediate" need of treatment to save the client's life. This client is classified as an emergent client and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of "expectant" would be applied to the client with massive injuries and minimal chance of survival. This client would be color-coded "black" in the triage process. The client who is color-coded "black" is given supportive care and pain management but is given definitive treatment last.

70) D

- The client with ongoing ventricular dysrhythmias requires ongoing medical evaluation and treatment because of potentially lethal complications of the problem. Each of the other problems listed may be managed at home with appropriate agency referrals for home care services and support from the family at home.



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