Comprehensive NCLEX-RN Questions & Answer Real Exam V4

Comprehensive NCLEX-RN Questions & Answer Real Exam V4: 1. Question Category: Management of Care Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply. o A. Assist the patient to reposition every 2 hours. o B. Reapply pneumatic compression boots. o C. Remind the patient to perform active ROM. o D. Check extremities for redness and edema. Incorrect Correct Answer: A, B, & C. The experienced nursing assistant would know how to reposition the patient and how to reapply compression boots and would remind the patient to perform activities he has been taught to perform.  Option D: Assessing for redness and swelling (signs of deep venous thrombosis {DVT}) requires additional education and is still appropriate to the professional nurse. 2. 2. Question Category: Management of Care The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient?  A. Position the patient sitting up in bed before you feed her.  B. Check the patient’s gag and swallowing reflexes.  C. Feed the patient quickly because there are three more waiting.  D. Suction the patient’s secretions between bites of food. Incorrect Correct Answer: A. Position the patient sitting up in bed before you feed her. Positioning the patient in a sitting position decreases the risk of aspiration.  Option B: The nursing assistant is not trained to assess gag or swallowing reflexes.  Option C: The patient should not be rushed during feeding.  Option D: A patient who needs to be suctioned between bites of food is not handling secretions and is at risk for aspiration. This patient should be assessed further before feeding