NCLEX Exam: Nursing Prioritization, Delegation and AssignmentMore NCLEX Exam: Nursing Prioritization, Delegation And Assignment 100% Questions With Correct Answers 2023

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? - ANS-Perform postural drainage and chest physiotherapy every 4 hours Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep. A patient with a pulmonary embolus 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. - ANS-While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). All of the other instructions are appropriate for the care of a patient receiving anticoagulants. A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather 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? - ANS-Perform endotracheal intubation and initiate mechanical ventilation A non-rebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing. A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)? - ANS-Assisting the patient to sit up on the side of the bed Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse. 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 (PCT)? - ANS-Remind the patient to sleep on his side instead of his back CONTINUES...