NURSING PRIORITIZATION, DELEGATION &
ASSIGNMENT NCLEX RN TEST EXAM 50 Q&A’S WITH
RATIONALES GUARANTEED PASS | RATED A+
1. A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and
...
NURSING PRIORITIZATION, DELEGATION &
ASSIGNMENT NCLEX RN TEST EXAM 50 Q&A’S WITH
RATIONALES GUARANTEED PASS | RATED A+
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?
o A. Perform postural drainage and chest physiotherapy every 4 hours.
o B. Allow the patient to decide whether she needs aerosolized medications.
o C. Place the patient in a private room to decrease the risk of further infection.
o D. Plan activities to allow at least 8 hours of uninterrupted sleep.
Correct Answer: A. Perform postural drainage and chest physiotherapy every 4 hours.
Airway clearance techniques are critical for patients with cystic fibrosis and should take priority
over other activities. The Cystic Fibrosis Transmembrane Conductance Regulator defect causes
mucus to become dehydrated. Secretions in cystic fibrosis are generally thick, sticky, and more
difficult to clear. Frequent airway clearance is a mainstay in the treatment of acute exacerbations,
as well as an integral part of health maintenance in cystic fibrosis.
Option B: Although allowing more independent decision-making is important for
adolescents, the physiologic need for an improved respiratory function takes
precedence at this time. Collaborate with the client and staff to ensure that the
schedule for therapy is amenable to all and does not interfere with meals, rest
times, or medications.
Option C: A private room may be desirable for the patient but is not necessary.
Ensure that clients with CF are not cohorted. The cohorting of clients with CF is
not recommended based on published CF Infection Control Consensus
Guidelines.
Option D: With increased shortness of breath, it will be more important that the
patient has frequent respiratory treatments than 8 hours of sleep. Infection,
inflammation, and mucous plugging will cause an increase in the respiratory
effort to compensate for airway obstruction. As moving air into and out of the
lungs becomes more difficult, the breathing pattern alters to include the use of
accessory muscles and retractions.
2. A patient with a pulmonary embolism 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.
A. Use a lift sheet when moving and positioning the patient in bed.
B. Use an electric razor when shaving the patient each day.
C. Use a soft-bristled toothbrush or tooth sponge for oral care.
D. Use a rectal thermometer to obtain a more accurate body temperature.
E. Be sure the patient's footwear has a firm sole when the patient
ambulates.
Correct Answers: A, B, C, and E.
All of the other instructions are appropriate to the care of a patient receiving anticoagulants. Risk
for bleeding may arise in any condition that disturbs the “close circuit” integrity of the
circulatory system. Bleeding is the primary complication of anticoagulant therapy and is a risk of
all anticoagulants even when maintained within the usual therapeutic ranges.
Option A: Educate the at-risk patient about precautionary measures to prevent
tissue trauma or disruption of the normal clotting mechanisms. Information about
precautionary measures lessens the risk for bleeding.
Option B: Be careful when using sharp objects like scissors and knives. Use an
electric razor for shaving (not razor blades). The patient needs to avoid situations
that may cause tissue trauma and increase the risk for bleeding.
Option C: Use a soft-bristled toothbrush and nonabrasive toothpaste. Avoid the
use of toothpicks and dental floss. This method providing oral hygiene reduces
trauma to oral mucous membranes and the risk for bleeding from the gums.
Option D: While a patient is receiving anticoagulation therapy, it is important to
avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal
thermometers and enemas). These invasive devices or medications may cause
trauma to the mucous membranes that line the rectum or vagina.
Option E: Educate the patient and family members about signs of bleeding that
need to be reported to a health care provider. Early evaluation and treatment of
bleeding by a health care provider reduces the risk for complications from blood
loss.
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?
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