Nursing Prioritization, Delegation, Assignment NCLEX-RN Practice Exam 2

A nursing assistant reports that another nurse is not assessing a client with abdominal pain. Which of the following actions is best?

A patient on home enoxaparin presents with right leg warmth and swelling. Which should be reported?

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 patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a non-rebreather 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?

A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant?

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?

After a change of shift, you are assigned to care for the following patients. Which patient should you assess first?

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 registered nurse immediately?

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.

Complication to monitor for in a newborn on nasal CPAP for RDS:

Delegation is appropriate when:

Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?

Nurse Janus enters a room and finds a client lying on the floor. Which action should the nurse perform first?

Nurse Paul is developing a care plan for a client after bariatric surgery for morbid obesity. The nurse should include which of the following on the care plan as the priority complication to prevent:

Nurse Pietro receives an 11-month old child with a fracture of the left femur. Which action is important for the nurse to take first?

Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

Paige is a nurse preceptor who is working with a new nurse, Joyce. She notes that Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is most likely due to:

Patient after thoracentesis with 1800 mL removed. Which assessment is important to report?

Precepting RN in ICU for ARDS patient just intubated, which action requires immediate intervention?

Prioritization using ABC approach focuses on: