# 25Qw/exp Delegation and Prioritization - NCLEX Questions

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1. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing?

a) repositions side to side every 2 hours
b) elevates the head of the bed 60 degrees
c) auscultates the lung field every 4 hours
d) encourages deep breathing exercises every 2 hours
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Terms in this set (25)
1. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing?

a) repositions side to side every 2 hours
b) elevates the head of the bed 60 degrees
c) auscultates the lung field every 4 hours
d) encourages deep breathing exercises every 2 hours
1) B
- The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures to promote lung expansion in the client with ascites, but the priority measure is the one that relieves diaphragmatic pressure.
2) C
- When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear visualization and accurate results of the other tests listed, if performed before the client has fully excreted the barium. For this reason, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging studies.
4. A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to:

a) obtain vital signs
c) complete an abdominal physical assessment
d) insert a nasogastric (NG) tube and Hematest the emesis
4) A
- The priority action is to obtain vital signs to determine whether the client is in shock from blood loss and to obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Insertion of an NG tube may be prescribed but is not the priority action. A complete abdominal physical assessment needs to be performed but is not the priority.
5. A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of depression. Upon the client's arrival, the client's therapist reports to the nurse that the clients telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts. Keeping this information in mind, the priority of the nurse is to assess for:

a) interaction with peers
b) the presence of suicidal thoughts
c) the amount of food intake for the past 24 hours
d) information regarding the past medication regimen
5) B
The critical information from the therapist is that the client is having thoughts of self-harm; therefore, the nurse needs further information about present thoughts of suicide so that the treatment plan may be as appropriate as possible. The nurse must make sure the client is safe. The items in options A, C, and D should be assessed; however, evaluation for suicide potential is most important
6. A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern?

a) peer support through structured groups
b) finding affordable housing for the group
c) setting up a 24-hour crisis center and hotline
d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available
7. A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days. When planning forth rescue and relocation of these older residents, what is the first item that the nurse needs to consider?

a) contacting the older resident's families
b) attending to the emotional needs of the older residents
c) arranging for ambulance transportation for the oldest residents
d) attending to the nutritional status and basic needs of the older residents
8) D
- Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary, because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although options A, B, and C are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical.
9. A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on:

a) the comfort level
b) activity tolerance
c) the level of consciousness
d) the hydration and nutrition status
9) D- Many of the diagnostic studies to identify GI disorders require that the GI tract be cleaned (usually with laxatives and enemas) before testing. In addition, the client most often takes nothing by mouth before and during the testing period. Because the studies may be done over a period that exceeds 24 hours, the client may become dehydrated and/or malnourished. Although options A, B, and C may be components of the assessment, option D is the priority.
10. A nurse is assessing a 39 year old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol of level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. The nurse would place priority on which risk factor for coronary heart disease (CHD) in this client?

a) age
b) hypertension
c) hyperlipidemia
d) glucose intolerance
10) B
- Hypertension, cigarette smoking, and hyperlipidemia are major risk factors for CHD. Glucose intolerance, obesity, and response to stress are also contributing factors. An age of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 190 mg/dL and a blood glucose level of 110 mg/dL are within the normal range. The nurse places priority on major risk factors that need modification.