NCLEX Exam: Nursing Prioritization, Delegation and Assignment 1 — Questions and Answers
Question 1: A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care?
- Perform postural drainage and chest physiotherapy every 4 hours (Correct answer)
- Allow the patient to decide whether she needs aerosolized medications
- Place the patient in a private room to decrease the risk of further infection
- Plan activities to allow at least 8 hours of uninterrupted sleep
Correct answer: Perform postural drainage and chest physiotherapy every 4 hours
Cystic fibrosis causes the production of thick, sticky mucus that obstructs airways, making patients highly susceptible to respiratory infections like pneumonia and increased shortness of breath. Postural drainage and chest physiotherapy are critical interventions for mobilizing these secretions, improving airway clearance, and preventing further lung complications. Regular performance of these activities is vital for maintaining respiratory function and reducing infection risk.
Question 2: A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply.
- Use a lift sheet when moving and positioning the patient in bed (Correct answer)
- Use an electric razor when shaving the patient each day (Correct answer)
- Use a soft-bristled toothbrush or tooth sponge for oral care (Correct answer)
- Use a rectal thermometer to obtain a more accurate body temperature
- Be sure the patient’s footwear has a firm sole when the patient ambulates (Correct answer)
Correct answer: Use a lift sheet when moving and positioning the patient in bed
Patients receiving IV heparin are at an increased risk of bleeding and bruising due to the anticoagulant's effects. Therefore, instructions to the nursing assistant must focus on minimizing trauma and preventing injury. Using a lift sheet, electric razor, and soft-bristled toothbrush reduces the risk of skin tears, cuts, and gum bleeding, while firm-soled footwear helps prevent falls that could lead to significant injury.
Question 3: A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action?
- Perform endotracheal intubation and initiate mechanical ventilation (Correct answer)
- Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth
- Administer furosemide (Lasix) 100 mg IV push stat
- Call a code for respiratory arrest
Correct answer: Perform endotracheal intubation and initiate mechanical ventilation
Acute Respiratory Distress Syndrome (ARDS) causes severe hypoxemia that often does not respond to conventional oxygen therapy. When a patient's oxygenation remains poor despite a nonrebreather mask, it indicates a critical need for more aggressive respiratory support. Endotracheal intubation and mechanical ventilation allow for precise control of oxygen delivery, positive end-expiratory pressure (PEEP), and respiratory rate, which are essential to improve gas exchange and prevent further lung injury in ARDS.
Question 4: A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)?
- Assisting the patient to sit up on the side of the bed (Correct answer)
- Instructing the patient to cough effectively
- Teaching the patient to use incentive spirometry
- Auscultation of breath sounds every 4 hours
Correct answer: Assisting the patient to sit up on the side of the bed
Assisting a patient to sit up on the side of the bed is a basic activity of daily living (ADL) that falls within the scope of practice for a nursing assistant. This position can help improve breathing for a patient with COPD by allowing for better lung expansion. Other options involve assessment, teaching, or advanced skills that require the knowledge and judgment of a licensed nurse.
Question 5: A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)?
- Discuss weight-loss strategies such as diet and exercise with the patient
- Teach the patient how to set up the BiPAP machine before sleeping
- Remind the patient to sleep on his side instead of his back (Correct answer)
- Administer modafinil (Provigil) to promote daytime wakefulness
Correct answer: Remind the patient to sleep on his side instead of his back
Reminding a patient to sleep on their side to alleviate sleep apnea symptoms is a routine task that reinforces established care plans and falls within the scope of a nursing assistant's responsibilities. This action does not require independent assessment, teaching of new information, or medication administration, which are typically outside the nursing assistant's scope of practice.
Question 6: After change of shift, you are assigned to care for the following patients. Which patient should you assess first?
- A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab
- A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
- A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
- A 50-year old with asthma who complains of shortness of breath after using a bronchodilator (Correct answer)
Correct answer: A 50-year old with asthma who complains of shortness of breath after using a bronchodilator
This patient presents with an acute change in respiratory status and a potential lack of response to a prescribed rescue medication (bronchodilator). Shortness of breath, especially after medication, indicates a worsening condition and potential airway compromise, which is a life-threatening priority. The other patients have stable or less immediately critical conditions, making the asthma patient the highest priority for immediate assessment and intervention.
Question 7: After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately?
- Heart rate of 98 beats/min
- Respiratory rate of 24 breaths/min
- Blood pressure of 168/90 mm Hg
- Tympanic temperature of 101.4 F (38.6 C) (Correct answer)
Correct answer: Tympanic temperature of 101.4 F (38.6 C)
A tympanic temperature of 101.4 F (38.6 C) indicates a fever, which is a significant finding in an intubated patient. Intubated patients are at high risk for ventilator-associated pneumonia and other infections, so a fever requires immediate assessment by the RN to determine the cause and initiate appropriate interventions. The other vital signs, while important, are not immediately indicative of a life-threatening or rapidly worsening condition requiring urgent notification.
Question 8: An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply.
- Auscultate breath sounds (Correct answer)
- Administer medications via metered-dose inhaler (MDI) (Correct answer)
- Complete in-depth admission assessment
- Initiate the nursing care plan
- Evaluate the patient’s technique for using MDI’s
Correct answer: Auscultate breath sounds
An experienced LPN's scope of practice includes performing focused assessments, such as auscultating breath sounds, and administering medications, including those via metered-dose inhaler (MDI). However, initiating comprehensive admission assessments, developing nursing care plans, or independently evaluating the effectiveness of patient education (like MDI technique) typically falls under the RN's scope, as these require higher-level critical thinking and independent judgment.
Question 9: The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit?
- A 58-year old on airborne precautions for tuberculosis (TB)
- A 68-year old just returned from bronchoscopy and biopsy
- A 72-year old who needs teaching about the use of incentive spirometry (Correct answer)
- A 69-year old with COPD who is ventilator dependent
Correct answer: A 72-year old who needs teaching about the use of incentive spirometry
Teaching about incentive spirometry is a common nursing intervention that, while requiring instruction, is generally considered a stable and predictable task. It does not involve complex assessments, unstable conditions, or specialized equipment like a ventilator. This makes it an appropriate assignment for a new nurse floating from a different unit, as it allows them to perform a standard nursing duty without being overwhelmed by high-acuity or unfamiliar patient needs.
Question 10: The ventilator of a patient sounds the high-pressure alarm. The oxygen saturation meter in the patient's room indicates 87% when you walk in to evaluate the ARDS patient, who is also having trouble sitting up. Which move ought to you make next?
- Reassure the patient that the ventilator will do the work of breathing for him
- Manually ventilate the patient while assessing possible reasons for the high-pressure alarm (Correct answer)
- Insert an oral airway to prevent the patient from biting on the endotracheal tube
- Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning
Correct answer: Manually ventilate the patient while assessing possible reasons for the high-pressure alarm
A high-pressure alarm on a ventilator, combined with a low oxygen saturation (87%) and patient distress, indicates an acute respiratory emergency. The immediate priority is to ensure adequate oxygenation and ventilation. Manually ventilating the patient with a bag-valve mask allows the nurse to bypass the malfunctioning ventilator, provide immediate respiratory support, and simultaneously assess for the cause of the alarm (e.g., kinked tubing, secretions, pneumothorax) without delay.
Question 11: A patient who is getting oxygen through a nasal cannula at a flow rate of 6 L/min complains of nasal passage irritation, the nursing assistant informs you. What course of action might you recommend to enhance the patient's comfort in light of this issue?
- Suggest that the patient sit up in a chair at the bedside
- Suggest that the patient's oxygen be humidified (Correct answer)
- Suggest that a simple face mask be used instead of a nasal cannula
- Suggest that the patient be provided with an extra pillow
Correct answer: Suggest that the patient's oxygen be humidified
High-flow oxygen delivered via nasal cannula, especially at 6 L/min, can be very drying to the nasal mucosa, leading to irritation, dryness, and even epistaxis. Humidifying the oxygen adds moisture, which helps to soothe and protect the nasal passages, significantly improving patient comfort. This is a standard intervention for preventing and alleviating nasal irritation from oxygen therapy.
Question 12: Which comment made by a TB patient during the discharge process suggests the need for additional instruction?
- "I will continue to take my isoniazid until I am feeling completely well" (Correct answer)
- "Everyone in my family needs to go and see the doctor for TB testing"
- "I will change my diet include more foods rich in iron, protein, and vitamin C"
- "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag"
Correct answer: "I will continue to take my isoniazid until I am feeling completely well"
Tuberculosis treatment, especially with drugs like isoniazid, requires a prolonged course (typically 6-9 months) to ensure complete eradication of the bacteria and prevent drug resistance. Stopping medication prematurely, even if the patient feels well, can lead to a relapse of the infection and the development of drug-resistant TB. This statement indicates a critical misunderstanding of the treatment regimen and the importance of adherence.
Question 13: Which medication should you be prepared to provide to the newborn baby who has respiratory distress syndrome (RDS) in order to improve respiratory status?
- Surfactant (Exosurf) (Correct answer)
- Theophylline (Theolair, Theochron)
- Albuterol (Proventil)
- Dexamethasone (Decadron)
Correct answer: Surfactant (Exosurf)
Neonatal Respiratory Distress Syndrome (RDS) is primarily caused by a deficiency of pulmonary surfactant in the immature lungs of premature infants. Surfactant reduces surface tension in the alveoli, preventing their collapse and facilitating gas exchange. Administering exogenous surfactant directly into the lungs is a critical and highly effective intervention to improve lung compliance and respiratory function in newborns with RDS.
Question 14: The client's potassium level is 6.7 mEq/L, and the clinical teacher instructed the student nurse to administer care. Which intervention is properly assigned to the nursing student?
- Give potassium 10 mEq orally
- Assess the electrocardiogram (ECG) strip for tall T waves
- Give sodium polystyrene sulfonate (Kayexalate) 15 g orally (Correct answer)
- Give spironolactone (Aldactone) 25 mg orally
Correct answer: Give sodium polystyrene sulfonate (Kayexalate) 15 g orally
Administering oral medications like sodium polystyrene sulfonate (Kayexalate) is a common task that, under direct supervision, can be assigned to a nursing student. Kayexalate is used to lower potassium levels by binding to potassium in the gut. While the potassium level is high and requires careful monitoring, the administration of a routine oral medication is within the scope of a student nurse under the guidance of a clinical teacher.
Question 15: Ineffective Breathing Pattern is the nursing diagnostic for the COPD patient. Which task should you assign to the seasoned LPN working under your direction?
- Plan a nursing care regimen that gradually increases activity intolerance
- Assist the patient with basic activities of daily living
- Consult with the physical therapy department about reconditioning exercises
- Observe how well the patient performs pursed-lip breathing (Correct answer)
Correct answer: Observe how well the patient performs pursed-lip breathing
Observing a patient's technique for a learned skill like pursed-lip breathing is an assessment task that falls within the scope of an experienced LPN. This involves evaluating the patient's performance against established criteria and reporting findings to the RN. Planning complex care regimens, assisting with basic ADLs (which could be delegated to a PCT), or consulting with other departments are typically RN responsibilities.
Question 16: A 22-year-old patient who underwent emergency surgery and many transfusions three days prior is examined, and you discover that the patient appears agitated and is breathing laboriously at a rate of 38 breaths per minute. 90% oxygen saturation is achieved with a 6 L/min nasal cannula oxygen supply. Which course of action is best?
- Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation.
- Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status. (Correct answer)
- Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs.
- Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes.
Correct answer: Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status.
The patient's agitation, labored breathing (tachypnea at 38 breaths/min), and persistent hypoxemia (90% SpO2 on 6 L/min nasal cannula) indicate significant respiratory distress and potential acute lung injury. The immediate priority is to improve oxygenation by switching to a nonrebreather mask, which delivers the highest concentration of oxygen. Simultaneously, notifying the physician is crucial for further assessment, diagnostic testing, and initiation of advanced interventions.
NCLEX Exam: Nursing Prioritization, Delegation and Assignment 1
A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia.
Which nursing activity is most important to include in the patient’s care?