Nursing Prioritization, Delegation And Assignment NCLEX Quiz #2 (10 Questions)

1. The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?

Blood pressure of 152/84 mm Hg

Respiratory rate of 27 breaths/min

Heart rate of 92 beats/min

Oral temperature of 101.2 F (38.4C)

A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection. which may be respiratory in origin. All of the other vital sign values are slightly elevated but are not a cause for immediate concern.

Explanation

A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection. which may be respiratory in origin. All of the other vital sign values are slightly elevated but are not a cause for immediate concern.

2. When a patient with TB is being prepared for discharge. which statement by the patient indicates the need for further teaching?

“Everyone in my family needs to go and see the doctor for TB testing.”

“I will continue to take my isoniazid until I am feeling completely well.”

“I will change my diet to include more foods rich in iron. protein. and vitamin C.”

Patients taking isoniazid must continue the drug for 6 months. The other 3 statements are accurate and indicate understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing. and placing the tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB.

Explanation

Patients taking isoniazid must continue the drug for 6 months. The other 3 statements are accurate and indicate understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing. and placing the tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB.

3. You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient.

Remove the inhaler cap and shake the inhaler

Open your mouth and place the mouthpiece 1 to 2 inches away

Tilt your head back and breathe out fully

Hold your breath for at least 10 seconds

Press down firmly on the canister and breathe deeply through your mouth

Wait at least 1 minute between puffs.

Before each use. the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should tilt the head back and breathe out completely. As the patient begins to breathe in deeply through the mouth. the canister should be pressed down to release one puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait for at least 1 minute between puffs from the inhaler.

Explanation

Before each use. the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should tilt the head back and breathe out completely. As the patient begins to breathe in deeply through the mouth. the canister should be pressed down to release one puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait for at least 1 minute between puffs from the inhaler.

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4. The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem?

Suggest that the patient’s oxygen be humidified

Suggest that a simple face mask be used instead of a nasal cannula.

Suggest that the patient be provided with an extra pillow

Suggest that the patient sit up in a chair at the bedside

When the oxygen flow rate is higher than 4 L/min. the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

Explanation

When the oxygen flow rate is higher than 4 L/min. the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

5. To improve respiratory status. which medication should you be prepared to administer to the newborn infant with RDS?

Theophylline (Theolair. Theochron)

Surfactant (Exosurf)

Dexamethasone (Decadron)

Albuterol (Proventil)

Exosurf neonatal is a form of synthetic surfactant. An infant with RDS may be given two to four doses during the first 24 to 48 hours after birth. It improves respiratory status. and research has show a significant decrease in the incidence of pneumothorax when it is administered.

Explanation

Exosurf neonatal is a form of synthetic surfactant. An infant with RDS may be given two to four doses during the first 24 to 48 hours after birth. It improves respiratory status. and research has show a significant decrease in the incidence of pneumothorax when it is administered.

6. When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago. you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?

Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes

Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs

Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation

The patient’s history and symptoms suggest the development of ARDS. which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min. so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.

Explanation

The patient’s history and symptoms suggest the development of ARDS. which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min. so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.

7. The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?

Observe how well the patient performs pursed-lip breathing

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

Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Planning and consulting require additional education and skills. appropriate to an RN.

Explanation

Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Planning and consulting require additional education and skills. appropriate to an RN.

8. Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?

Evaluating the patient’s complaint of chest pain

Monitoring laboratory values for changes in oxygenation

Assessing for symptoms of respiratory failure

Auscultating the lungs for crackles

An LPN who has been trained to auscultate lungs sounds can gather data by routine assessment and observation. under supervision of an RN. Independently evaluating patients. assessing for symptoms of respiratory failure. and monitoring and interpreting laboratory values require additional education and skill. appropriate to the scope of practice of the RN.

Explanation

An LPN who has been trained to auscultate lungs sounds can gather data by routine assessment and observation. under supervision of an RN. Independently evaluating patients. assessing for symptoms of respiratory failure. and monitoring and interpreting laboratory values require additional education and skill. appropriate to the scope of practice of the RN.

9. You are acting as preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply.

A 38-year old with moderate persistent asthma awaiting discharge

A 63-year old with a tracheostomy needing tracheostomy care every shift.

A 56-year old with lung cancer who has just undergone left lower lobectomy

A 49-year old just admitted with a new diagnosis of esophageal cancer.

The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. The patient with the lobectomy will require the care of a more experienced nurse. who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation. you will want to work with her in providing care for these patients with more complex needs.

Explanation

The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. The patient with the lobectomy will require the care of a more experienced nurse. who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation. you will want to work with her in providing care for these patients with more complex needs.

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10. Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration?

Warfarin (Coumadin) 1.0 mg by mouth (PO)

Morphine sulfate 2 to 4 mg IV

Cephalexin (Keflex) 250 mg PO

Heparin infusion at 900 units/hr

Medication safety guidelines indicate that use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose. such as 10 mg. The order should be clarified before administration. The other orders are appropriate. based on the patient’s diagnosis.

Explanation

Medication safety guidelines indicate that use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose. such as 10 mg. The order should be clarified before administration. The other orders are appropriate. based on the patient’s diagnosis.