Complete NCLEX Study Materials
1. A home care nurse finds a client in the bedroom, unconscious, with a pill bottle in hand. The pill bottle had contained the selective serotonin reuptake inhibitor, sertraline (Zoloft). The nurse immediately assesses the client's:
c) blood pressure
d) urinary output
2. A client began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. The client turns on the nurse call light and describes difficulty breathing, itching, and a tight sensation in the chest. Which of the following is the first action of the nurse?
a) call the physician
b) stop the infusion
c) check the client's temperature
d) recheck the unit of blood for compatibility
3. A nurse is caring for a client with preeclampsia. The nurse develops a plan of care knowing that if the client progresses from preeclampsia to eclampsia, the nurse's first action is to:
a) administer oxygen by face mask
b) clear and maintain an open airway
c) assess the maternal blood pressure and fetal heart tones
d) administer an intravenous infusion of magnesium sulfate
4. A nurse in the emergency department admits a client who is bleeding freely from a scalp laceration obtained during a fall from a stepladder when the client was doing outdoor home repair. The nurse takes which of the following actions first in the care of this wound?
a) prepares for suturing the area
b) administers prophylactic antibiotic
c) cleanses the wound with sterile normal saline
d) asks the client about timing of the last tetanus vaccination
5. A client was admitted to the nursing unit with a closed head injury 6 hours ago. During initial assessment, the nurse finds that the client has vomited, is confused, and complains of dizziness and headache. Which of the following is the most important nursing action?
a) notify the physician
b) administer an antiemetic
c) reorient the client to surroundings
d) change the client's gowns and bed linens
NCLEX Review on Delegation and Prioritization Questions:
Answers and Rationale
1) B- In an emergency situation, the nurse should determine breathlessness first, then pulselessness. Blood pressure would be assessed after these assessments were determined. Urinary output is also important but is not the priority at this time.
2) B- The symptoms reported by the client indicate that the client is experiencing a transfusion reaction. The first action of the nurse when a transfusion reaction is observed is to discontinue the transfusion. The IV line is kept open with normal saline and the physician is notified. The nurse then checks the client's vital signs, temperature, pulse, and respirations and then rechecks the unit of blood as appropriate for infusion into the client. Depending on agency protocol, the nurse may also obtain a urinalysis, draw a sample of blood, and return the unit of blood and tubing to the blood bank. The nurse also institutes supportive care for the client, which may include administration of antihistamines, crystalloids, epinephrine, or vasopressors as prescribed.
3) B- It is important as a first action to keep an open airway and prevent injuries to the client. Options A, C, and D are all procedures that should be done but are not the first action.
4) C- The initial nursing action is to cleanse the wound thoroughly with sterile normal saline. This action removes dirt or foreign matter in the wound and allows visualization of the size of the wound. Direct pressure is also applied as needed to control bleeding. If suturing is necessary, the surrounding hair may be shaved. Prophylactic antibiotics are often prescribed. The date of the client's last tetanus shot is determined, and prophylaxis is given if needed.
5) A- The client with a closed head injury is at risk of developing increased intracranial pressure (ICP). Increased ICP is evidenced by signs and symptoms such as headache, dizziness, confusion, weakness, and vomiting. Because of the implications of the client's manifestations, the most important nursing action is to notify the physician. Other nursing actions that are appropriate include physical care of the client and reorientation to surroundings.
After you reviewed your answers through its rationale, you can now proceed to the next set of questions:
NCLEX Review on Delegation and Prioritization Questions (6-10)
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