NCLEX Review on Delegation and Prioritization Questions (1-5)

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1. A nurse from medical-surgical unit is asked to work on the orthopedic unit. The medical-surgical nurse has no orthopedic nursing experience. Which client should be assigned to the medical-surgical nurse?a) a client with a cast for a fractured femur and who has numbness and discoloration of the toesb) a client with balanced skeletal traction and who needs assistance with morning carec) a client who had an above-the-knee amputation yesterday and has a temperature of 101.4Fd) a client who had a total hip replacement 2 days ago and needs blood glucose monitoring

2. The nurse plans care for a client undergoing a colposcopy. Which of the following actions should the nurse take first?a) discuss the client's fear regarding potential cervical cancerb) assist with silver nitrate application to the cervix to control bleedingc) provide instructions regarding douching and sexual relationsd) administer pain medication

3. A nurse is caring for four clients and is preparing to do her initial rounds. Which client should the nurse assess first?a) a client with diabetes being discharged todayb) a client with tracheostomy and copious secretionsc) a client scheduled for physical therapy this morningd) a client with a pressure ulcer that needs dressing change

4. A nurse enters a room and finds a client lying on the floor. Which action should the nurse perform first?a) call for help to get the client back in bedb) establish whether the client is responsivec) assist the client back to bedd) ask the client what happened

5. A nurse preceptor is working with a new nurse and notes that the new nurse is reluctant to delegate tasks to members of the care team. The nurse preceptor recognizes that this reluctance most likely is due to:a) role modeling behaviors of the preceptorb) the philosophy of the new nurse's school of nursingc) the orientation provided to the new nursed) lack of trust in the team members

6. A nurse is working in an emergency department and receives a client after a radiologic incident. Which task is a priority for the nurse to do first?a) decontaminate the client's clothingb) decontaminate an open wound on the client's thighc) decontaminate the examination room the client is placed ind) save the client's vomitus for analysis by the radiation safety staff

7. The nurse plans care for a client in the post-anesthesia care unit. Which assessment should the nurse make first?a) respiratory statusb) level of consciousnessc) level of paind) reflexes and movement of extremities

8. A nurse in the clinic is reviewing the diet of a 28-year old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. Which is a priority for the nurse to counsel the client to avoid in her diet?a) fiberb) broccolic) yogurtd) simple carbohydrates

9. A nurse is developing the care plan for a client after bariatric surgery for morbid obesity. The nurse includes which of the following on the care plan as the priority complication to prevent?a) painb) wound infectionc) depressiond) thrombophlebitis

10. A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the client is pale and diaphoretic with blood pressure 94/60, respiration 32. The client is anxious, fearing death. Which action should the nurse take first?a) administer pain medicationb) administer IV fluidsc) administer dopamined) administer oxygen per nasal cannula

11. A nurse in a long term facility is planning care for an elderly client with confusion. Which action should the nurse take first?a) sit the client in a geriatric chair with an activityb) apply a vest restraint when the client is in a chairc) apply bilateral wrist restraints when the client is in bedd) have a staff member sit with the client at all times

12. The nurse is providing care in the emergency department to the client with chest pain. Which action is most important for the nurse to do first?a) perform venipuncture and start an IV lineb) administer oxygen via nasal cannulac) administer morphine sulfate intravenouslyd) start lidocaine (xylocaine) infusion

13. A nurse arrives on the scene of a multi-motor vehicle accident. The nurse determines that which of the following clients should be seen first?a) A 48 year old male who is pale, diaphoretic and reporting chest pain and shortness of breathb) a 16 year old male with ecchymosis, pain, and swelling of the right armc) a 42 year old female who has a laceration on the forehead and is reporting neck and shoulder paind) an 8 year old child who is crying hysterically and reports abdominal pain

14. A child reports to the camp nurse's office after stepping on a bee. The child has pain, erythema, and edema of the lower aspect of the left foot. As the nurse is observing the foot, the child says, "I feel like my throat is getting tight." The first action the nurse should take is:a) assess the child's airway and breathingb) call 911 and request an ambulancec) administer subcutaneous epinephrined) remove the stinger from the foot

15. A nurse is working on a poison control hot-line and gets a call from a mother who reports her child has apparently taken part of a bottle of adult acetaminophen capsules. The priority action for the nurse to take first is:a) tell the mother to position the child lying down on her sideb) tell the mother to dial 911 and request an ambulancec) have the mother give the child a glass of milkd) instruct the mother on how to administer syrup of ipecac

16. A nurse receives a 10-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first?a) call for a social worker to meet with the familyb) check the child's blood pressure, then pulse, respiration, and temperaturec) administer pain medicationd) speak with the parents about how the fracture occurred

17. A nurse on the cardiac unit is caring for four clients and is preparing to do initial rounds. Which client should the nurse assess first?a) a client scheduled for cardiac ultrasound this morningb) a client with syncope being discharged todayc) a client with chronic bronchitis on nasal oxygend) a client with a diabetic foot ulcer that needs a dressing change

18.  A nurse enters a room and finds lying face down on the floor, bleeding from a gash in the head. Which action should the nurse perform first?a) determine level of consciousnessb) push the call button for helpc) turn the client face up to assessd) go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician

19. A nurse is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best?a) ask the other nurse if she needs any helpb) assess the client, and let the other nurse know what should be donec) ask the client if he is satisfied with his cared) contact the nursing supervisor to address the situation

20. The nurse is reviewing immunizations with the caregiver of a 72 year old client with a history of cerebral vascular disease. The caregiver learns that which immunization is a priority for the client?a) hepatitis A vaccineb) lyme disease vaccinec) hepatitis B vaccined) pneumococccal vaccine

21. A nurse delegates administration of an enema to a nursing assistant. The nurse should intervene if the nursing assistant:a) advances the catheter 4 inches into the anal canalb) hangs the enema bag 12 to 18 inches above the anusc) lubricates 4 to 5 inches of the catheter tipd) positions the client on the right side with head slightly elevated

22. A nurse is reviewing with a nursing assistant the care assignment for a client. Which of the following statements if made by the nurse regarding care of a client with crutches is most appropriate?a) the client needs to ambulate with crutches and a two-point gaitb) ambulate the client without weight bearing every 4 hours the length of the hall and backc) ask the client if she understands how to use a two-point gait, if not, please explain it to the clientd) make sure the client does not bend the elbows when using the crutches

23. The home care nurse has four phone calls to answer. Which phone call should the home care nurse respond to first?a) a client who received chemotherapy yesterday and is reporting nausea and vomitingb) a client who was discharged two days ago with a urinary catheter after a transurethral prostactemomy and is reporting pink-tinged urinec) a client with schizophrenia who says that the police has surrounded the housed) the wife of a client with chronic heart disease who reports her husband is coughing frothy, white secretions and became confused during the night

24. A nurse arrives on the scene of an apartment fire. Which of the following clients does the nurse attend to first?a) a 3-year old child who cannot find her parents and is reporting a headacheb) a 48-year old male who has burns on both hands and reports severe painc) an 18-year old male who jumped from a second story window and is reporting severe arm paind) a 28-year old woman who has burns on the face and neck and reports difficulty swallowing

25. A female college student reports to the student health center very distressed after waking up in a male student's restroom and not remembering what happened to the night before. The first action the nurse should take is:a) obtain a rape kitb) ask the client if she thinks she was rapedc) place the client in an examining room and leave her while she puts on a gownd) provide a quiet, private area to use for initial assessment of the client

26. A nurse recently started working in a hospital that employs unlicensed assistant personnel (UAP). Which of the following are essential to effective delegation?a) give the UAP written instructions for assignmentsb) make frequent walking rounds to assess clientsc) delegate tasks based on the experience of the UAPd) take frequent mini-reports from the UAPe) have the UAP repeat instructionsf) explain unexpected outcomes of delegated tasks to the UAP  

27. A nurse is teaching a class regarding lead poisoning in children to student nurses. The nursing students learn to target which priority group of children for screening?a) those with sickle cell anemiab) those who live in homes built in the 1960'sc) those who live in low-income familiesd) adolescents living in the inner city

28. A nurse is attending an In-service training class on delegation. The nurse learns that proper delegation can involve which of the following? Select all that applya) giving authorityb) delegating nursing processc) delegating tasksd) delegating accountabilitye) delegating responsibilityf) giving orders

29. When developing the plan of care for a client with suicidal ideation, which of the following would the nurse anticipate as the priority?a)Self-esteemb)Sleepc)Hygiened)Safety

30. A client in early labor is receiving oxytocin. When observing late decelerations in the fetal heart rate, the nurse should first:a) Administer oxygenb) Place her on her left sidec) Check the blood pressured) Discontinue the oxytocin infusion

31. A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients?a) a client complaining of muscle aches, a headache, and malaiseb) a client who twisted her ankle when she fell while rollerbladingc) a client with a minor laceration on the index finger sustained while cutting an eggplantd) a client with chest pain who states that he just ate pizza that was made with a very spicy sauce

32. The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?a) a client requiring colostomy irrigationb) a client receiving continuous tube feedingsc) a client who requires urine specimen collectionsd) a client with difficulty swallowing foods and fluids

33. The 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 (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse?a) the client who requires a bed bathb) an older client requiring frequent ambulationc) a client who requires a 24-hour urine collectiond) a client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

34. The RN has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the RN plan to care for first?a) A client who is ambulatoryb) a client scheduled for physical therapy at 1PMc) a client with a fever who is diaphoretic and restlessd) a postoperative client who has just received pain and medication

35. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?a) a client scheduled for a chest x-rayb) a client requiring daily dressing changesc) a postoperative client preparing for discharged) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift

36. The nurse is giving a bed bath to an assigned client when a nursing assistant enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The appropriate nursing action is which of the following?a) finish the bed bath and then administer the pain medication to the other clientb) ask the nursing assistant to find out when the last pain medication was given to the clientc) ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is completed) cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client

37. A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to preform the Allen's Test on the client. Arrange in order of priority the steps for performing Allen's test. (Letter A is the first step and letter F is the last step.a) document the findingsb) explain the procedure to the clientc) release pressure from the ulnar arteryd) apply pressure over the ulnar and radial arteriese) ask the client to open and close the hand repeatedlyf) assess the color of the extremity distal to the pressure point

38. A nurse is monitoring a client receiving parenteral nutrition. The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. Arrange the actions that the nurse would take in order of priority (Letter A is the first action and letter F is the last action).a) administer oxygenb) contact the physicianc) document the occurrenced) take the client's vital signse) clamp the intravenous catheterf) position the client in left trendelenburg position39. A client has 1L bag of 5% dextrose in 0.9% sodium chloride hung at 3PM. The nurse making rounds at 3:45PM finds that the client is complaining of pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 ml remaining. The nurse should take which of the following action first?a) call the physicianb) slow the IV infusionc) sit the client up in bedd) remove the IV catheter

40. The nurse determines that he client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next?a) remove the IV lineb) run normal saline at a keep vein open ratec) run a solution of 5% dextrose in waterd) obtain a culture of the tip of the catheter device removed from the client

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42. A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following?a) open the airwayb) give the client oxygenc) start chest compressionsd) ventilate with a mouth-to-mask device

43. A nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange in order of priority the steps of adult CPR. (Letter A is the first step and letter F is the last step.)a) initiate breathingb) open the client's airwayc) determine breathlessnessd) perform chest compressionse) check for a pulse at the carotid arteryf) determine unconsciousness by shaking the client and asking "Are you OK?"

44. A nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to do which of the following first on arrival of the client?a) assess the patency of the airwayb) check tubes or drains for patencyc) check the dressing to assess for bleedingd) assess the vital signs to compare with preoperative measurements.

45. A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses for preeclampsia to eclampsia, the nurse's first action should be to: a) administer oxygen by face maskb) clear and maintain an open airwayc) administer magnesium sulfate intravenouslyd) assess the blood pressure and fetal heart rate

46. A labor and delivery room nurse has just received report on four clients. The nurse should assess which client first?

a) a primiparous client in the active stage of laborb) a multiparous client who was admitted for induction of laborc) a client who is not contracting, but has suspected premature ruptured) a client who has just received an IV loading dose of magnesium sulfate to stop preterm labor

47. A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43-week gestation newborn infant with Apgar scores of 1 and 4. In planning for admission of this infant, the nurse's highest priority should be to:a) turn on the apnea and cardiorespiratory monitorsb) connect the resuscitation bag to the oxygen outletc) set up the intravenous line with 5% dextrose in waterd) set the radiant warmer control temperature at 36.5C (97.6F)

48. A nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, the priority nursing diagnosis would be risk for:a) infectionb) aspirationc) activity intoleranced) altered growth and development

49.  After a tonsillectomy, a child begins to vomit bright red blood. The initial nursing action is to:a) notify the physicianb) turn the child to the sidec) maintain an NPO statusd) administer the prescribed antiemetic

50. The nurse manager is planning the clinical assignments for the day and avoids assigning which staff member to the client with herpes zoster?a) the nurse who never had rubeolab) the nurse who never had mumpsc) the nurse who never had chickenpoxd) the nurse who never had german measles

51. A client with a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, the nurse implements which priority intervention?a) maintains an intravenous accessb) ensures that oxygen is being deliveredc) administers sedation to prevent claustrophobiad) provides emotional support to the client's family

52. A nurse is caring for a client who had an orthopedic injury of the leg requiring surgery and application of a cast. Postoperatively, which nursing assessment is of highest priority?a) monitoring of heel breakdownb) monitoring of bladder distentionc) monitoring of extremity shorteningd) monitoring for loss of blanching ability of toe nailbeds

53. A nurse hears the alarm sound on the telemetry monitor, looks at the monitor, and notes that a client is in ventricular tachycardia. The nurse rushes to the client's room. Upon reaching the client's bedside, the nurse would take which action first?a) call a codeb) prepare for cardioversionc) prepare to defibrillate the clientd) check the client's level of consciousness

54. A nurse has just finished assisting the physician in placing a central intravenous (IV) line. Which of the following is a priority nursing intervention after central line insertion?a) prepare the client for a chest radiographb) assess the client's temperature to monitor for infectionc) label the dressing with the date and time of catheter insertiond) monitor the blood pressure to assess for fluid volume overload

55. A nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse assigns priority to which assessment finding? a) temperature 99.4F, flat affectb) fist clenched and pounding tablec) tearful, withdrawn, and isolatedd) blood pressure 160/100 mmHg; pulse 120 bpm, respirations 18 breaths per minute

56. A client is being brought into the emergency department after suffering a head injury. The first action by the nurse is to determine the client's: a) level of consciousnessb) pulse and blood pressurec) respiratory rate and depthd) ability to move extremities

57. A nurse is caring for a client scheduled for an arthroscopy. The nurse develops a postoperative plan of care and includes which priority nursing action in the plan?a) monitor intake and outputb) assess the tissue at the surgical sitec) monitor the area for numbness or tinglingd) assess the complete blood cell count results

58. A nurse is performing an assessment  on a client who has a suspected spinal cord injury. Which of the following is the priority nursing assessment?a) pain levelb) mobility levelc) respiratory statusd) pupillary response

59. A 52-year old male client is seen in the physician's office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet, 8 inches, and his weight is 220 pounds. Vital signs are: temperature 98F orally, pulse 86 beats per minute, and respirations 18 breaths per minute. The blood pressure (BP) is 184/100 mmHg. Random blood sugar glucose is 122 mg?dL. Which of the following questions should the nurse ask the client first?a) do you exercise regularly?b) are you considering trying to lose weight?c) is there a history of diabetes mellitus in your family?d) when was the last time you had your blood pressure checked?

60. A client admitted to the nursing unit from the emergency department has a spinal cord injury at the level of the fourth cervical vertebra (C-4). Which assessment should the nurse perform first when admitting the client to the nursing unit?a) listen to breath soundsb) observe for dyskinesiasc) take the client's temperatured) assess extremity muscle strength

61. A client received a thermal burn caused by the inhalation of steam. The client's mouth is edematous and the nurse notes blisters in the client's mouth. The nurse first assesses which priority item(s)?a) neurological statusb) level of consciousnessc) temperature via the rectal routed) respiratory status and lung sounds

62. A registered nurse (RN) is planning the assignments for the day and is leading a team composed of a licensed practical nurse (LPN) and a nursing assistant (NA). The nurse assigns which client to the LPNa) client with dementiab) a 1-day postoperative mastectomy clientc) a client who requires some assistance with bathingd) a client who requires some assistance with ambulation

63. A client requests pain medication and the nurse administers a ventrogluteal intramuscular injection. After administration of the injection, the nurse does which of the following first?a) washes the handsb) removes the glovesc) applies gentle pressure to the injection sited) places the syringe in the secure, puncture-resistant needle box container

64. A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate for the nursing assistant?a) collecting a urine specimen from a clientb) obtaining frequent oral temperatures on a clientc) accompanying a man being dischargedd) assisting a postcardiac catheterization client who needs to lie flat to eat lunch

65. A nurse is planning the client assignments for the shift. Which client would the nurse assign to the nursing assistant?a) a client requiring dressing changesb) a client requiring frequent ambulationc) a client on a bowel management program requiring rectal suppositories and a daily enemad) a client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

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 familyc) document the client's request in the home care nursing care pland) conduct a client conference with the home care staff to share the client's request67. 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 shellfishb) whether the client wishes to void before the procedurec) ability of the client to remain still during the procedured) 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 LPNb) request that the LPN observe another LPN perform the procedurec) ask the LPN to review the materials from the in-service before performing the procedured) 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 tibiab) penetrating abdominal injuryc) bright red bleeding from a neck woundd) 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 cholecystectomyb) fractured hip, pinned 5 days agoc) diabetes mellitus with blood glucose at 180 mg/dLd) ongoing ventricular dysrhythmias while receiving procainamide (Procanbid)

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 fireb) evacuate the unitc) extinguish the fired) 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 routinesb) controlling dietary intakec) keeping follow-up appointmentsd) 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 infusionb) contact the nursec) take the client's blood pressured) 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 fearsb) assess the nature of the client's fearc) 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 clientb) postoperative communication techniquesc) information given to the client by the surgeond) the client's support system and coping behaviors

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 collectedb) a client scheduled for transfer to the hospital for coronary artery bypass surgeryc) a client scheduled for transfer to the hospital for an invasive diagnostic procedured) 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 wheelchairb) orient the client and monitor the client's vital signsc) offer the client frequent reassurance and repeat orientation statementsd) 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 doneb) obtains a temperature reading to monitor for infectionc) labels the dressing with the date and time of catheter insertiond) 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 sideb) check the client's blood pressurec) monitor urinary outputd) 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 intoleranceb) ineffective copingc) imbalanced nutrition: less than body requirementsd) deficient fluid volume

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 clothingb) give the clothing to the family member or significant otherc) place the clothing in a paper bagd) 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 responseb) respiratory statusc) mobilityd) 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 taskb) waiting for the team member to report the results of the completed taskc) completing the task for the team memberd) 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 siteb) temperaturec) potassium leveld) 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-groupb) safety with activitiesc) familiarity with all activities and providing orientation throughout the activitiesd) activities that provide verbal stimulation

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 amputationb) a client on a 24-hour urine collection who is on strict bedrestc) a client scheduled to be transferred to the hospital for coronary artery bypass surgeryd) 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 caseb) establish a trusting relationship with the parentsc) secure a safe environment for the childd) 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 techniquesb) establish a trusting nurse-client relationshipc) monitor the client for abnormal behaviord) 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 tasksb) follow up with each staff member regarding the performance of the task and the outcomes related to implementing the taskc) document that the task was complementedd) 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 physicianb) document the findingsc) place the client inlow-fowler's position and instruct the client to lie quietlyd) cover the abdominal wound with a sterile dressing moistened with sterile saline solution

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 surgeonb) continue with the assessmentc) check the client's temperatured) 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 patentb) prepare the client for a perfusion scanc) administer nasal oxygend) 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 injuryb) impaired urinary eliminationc) risk for constipationd) 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 vomitingb) position the client on the side with the head slightly elevatedc) place wire cutters at the bedsided) 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 catheterizationb) a client who requires frequent ambulationc) a client requiring wound irrigationd) a client receiving continuous tube feedings

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 showerb) a client requiring a bed bath and frequent ambulation with a walkerc) a client who requires frequent temperatures takend) 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 medicationb) a client scheduled for a chest x-ray at 11:00 AMc) 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 gastroenteritisb) a client in skeletal tractionc) a client attached to a ventilatord) 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 AMb) client newly diagnosed with diabetes mellitus who is scheduled for discharge to homec) client with pulmonary edema who was treated with furosemide (Lasix) at 5:00 AMd) 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 hoursb) a client who needs to be catheterized every 12 hoursc) a client who needs to be suctioned as needed (PRN)d) a client who needs a dressing change performed every 4 hours

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 groomingb) a client who needs frequent ambulationc) 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 lunchb) obtaining frequent oral temperatures on a clientc) accompanying a 51-year old man, being discharged to home following a bowel resectiond) 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 shiftb) a postoperative client preparing fro dischargec) a client scheduled for a chest x-rayd) 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 changesb) a client requiring frequent ambulation with a walkerc) a client on a bowel management program requiring rectal suppositories and a daily enemad) 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 physicianb) document the findingsc) perform a rectal examinationd) place the client in a sitting position