Delegation NCLEX Questions (11-15)

Welcome to Delegation NCLEX Questions. Enjoy answering and I hope that it can somehow help you in your future examination. 
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11. A nurse on the day shift receives a client assignment for the day. Which assigned client will the nurse assess first?

a) a client who had a pulmonary wedge resection 1 day ago and is attached to a closed chest-tube drainage system
b) a client with ulcerative colitis who is scheduled to be discharged today
c) a client who was admitted during the night because of severe exacerbation of asthma
d) a client scheduled for a kidney, ureter, and bladder (KUB) x-ray to determine the location of a kidney stone

12. A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. A nurse assigned to care for the client would first:

a) ask the client to talk to the people about what she witnessed
b) take the client to a quiet room
c) teach the client how to take deep breaths
d) ask the client to describe the events of the accident

13. A nurse who is caring for a client with a tracheostomy tube notes heavy bleeding form the stoma. The nurse also notes that the tracheostomy tube pulsates with the client's heartbeat and suspects  that the client has developed a trachea-innominate artery fistula. The nurse immediately prepares to take which first action?

a) transport the client to surgery
b) remove the tracheostomy tube
c) apply pressure to the innominate artery at the stoma site
d) initiate an intravenous (IV) line

14. A nurse is caring for a client who had a tracheostomy tube inserted 1 week ago. The client begins to cough vigorously, and accidental decannulation of the tracheostomy tube occurs. The nurse immediately:

a) replaces the tracheostomy tube
b) calls an anesthesiologist
c) calls a respiratory therapist
d) calls a code

15. A nurse is preparing the client assignments for the day. The nurse avoids assigning which client to a registered nurse who just learned that she is pregnant?

a) a client with a colostomy who is on contact precautions
b) a client with a tracheostomy who is receiving mechanical ventilation
c) a client with a solid sealed implanted radiation source
d) a client who requires frequent abdominal wound irrigation

Delegation NCLEX QuestionsAnswers and Rationale

11) C
- The nurse would first assess the client who was admitted during the night because of a severe exacerbation of asthma. This client's problem directly relates to airway, and the nurse would need to determine that the interventions administered on admission and during the night were effective. The nurse would next assess the client who had a pulmonary wedge resection 1 day ago and is attached to a closed chest-tube drainage system. This client's problem also relates to airway; however, there is no indication that this client is experiencing any severe problems. The nurse would next assess the client scheduled for a KUB. The nurse would want to ensure that this client understands the reason for the x-ray. Additionally, the nurse needs to determine if the client is experiencing pain as a result of the kidney stone. The nurse would next assess the client preparing for discharge to determine the need for reinforcement of home care instructions.

12) B
- If a client with severe anxiety is left alone, she may feel abandoned and become overwhelmed. Placing the client in a quiet room is a priority intervention, but the nurse must stay with the client. It is not possible to teach the client deep-breathing or relaxation exercises until the anxiety decreases. The client should not be asked to describe the events of the accident or to talk to the police until the anxiety has decreased.

13) B
- With a trachea–innominate artery fistula, a malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure from the tracheostomy tube causes necrosis and erosion of the innominate artery. This situation is a life-threatening complication. The tracheostomy tube is immediately removed. Direct pressure is then applied to the innominate artery at the stoma site. The client is then prepared for immediate surgical repair. An IV line will need to be initiated, but this is not the immediate action.

14) A
- If decannulation of a tracheostomy tube occurs 72 hours after surgical placement of the tracheostomy, the nurse extends the client's neck and opens the tissues of the stoma to secure an airway. With the obturator inserted into the tracheostomy tube, the nurse quickly and gently replaces the tube and removes the obturator. The nurse checks for airflow through the tube and for bilateral breath sounds. If unable to secure the airway, the nurse notifies a more experienced nurse, respiratory therapist, or physician for assistance and attempts to ventilate the client with a bag-valve mask. If the client is in distress and further attempts to secure the airway fail, the nurse calls the resuscitation team, including an anesthesiologist, for assistance and calls a code if necessary.

15) C
- The solid forms of brachytherapy involve sealed radiation sources implanted within the tumor target tissues. With solid implants the client emits radiation while the implant is in place, although the client's excreta are not radioactive. Pregnant nurses should not care for these clients. There are no contraindications for assigning the clients in options A, B, and D to a pregnant nurse.

After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning: 

Delegation NCLEX Questions (1-5)

Or proceed to the next set of questions: 

Delegation NCLEX Questions (16-20)

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