,COMPREHENSIVE NCLEX RN PRIORITIZATION DELEGATION
QUESTIONS AND ANSWERS GRADED A+
QUESTIONS AND ANSWERS GRADED A+
2. A nurse is scheduling a client for diagnostic studies of gastrointestinal
(GI) system. Which of the following studies, if ordered, should the nurse
schedule last?
a) ultrasound
b) colonoscopy
c) barium enema
d) computed tomography. Answer: 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.
● 3. A nurse is formulating a plan of care for a client receiving enteral
feedings. The nurse identifies which nursing diagnosis as the highest
priority for this client?
a) diarrhea
b) risk for aspiration
c) risk for deficient flid volume
d) imbalanced nutrition, less than body requirements. Answer: 3) B
, - Any condition in which gastrointestinal motility is slowed or
esophageal reflux is possible places a client at risk for aspiration.
Although options 1, 3, and 4 may be a concern, these are not the priority.
● 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
b) ask the client about the precipitating events
c) complete an abdominal physical assessment
d) insert a nasogastric (NG) tube and Hematest the emesis. Answer: 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:
QUESTIONS AND ANSWERS GRADED A+
QUESTIONS AND ANSWERS GRADED A+
2. A nurse is scheduling a client for diagnostic studies of gastrointestinal
(GI) system. Which of the following studies, if ordered, should the nurse
schedule last?
a) ultrasound
b) colonoscopy
c) barium enema
d) computed tomography. Answer: 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.
● 3. A nurse is formulating a plan of care for a client receiving enteral
feedings. The nurse identifies which nursing diagnosis as the highest
priority for this client?
a) diarrhea
b) risk for aspiration
c) risk for deficient flid volume
d) imbalanced nutrition, less than body requirements. Answer: 3) B
, - Any condition in which gastrointestinal motility is slowed or
esophageal reflux is possible places a client at risk for aspiration.
Although options 1, 3, and 4 may be a concern, these are not the priority.
● 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
b) ask the client about the precipitating events
c) complete an abdominal physical assessment
d) insert a nasogastric (NG) tube and Hematest the emesis. Answer: 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:
