1
NCLEX-style Practice Questions -
Prioritization, Delegation, & Assignment
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?
Perform postural drainage and chest physiotherapy every 4
hours.
Allow the patient to decide whether she needs aerosolized
medications.
Place the patient in a private room to decrease the risk of
further infection.
Plan activities to allow at least 8 hours of uninterrupted sleep. -
-Correct Answer --✔️Correct Answer : A.
Explained:
Airway clearance techniques are critical for patients with cystic
fibrosis and should take priority over other activities.
Although allowing more independent decision making is
important for adolescents, the physiologic need for an
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 has frequent respiratory treatments than 8
hours of sleep.
1
, 2
A patient with acute respiratory distress syndrome (ARDS) is receiving
oxygen by a non-rebreather 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?
Perform endotracheal intubation and initiate mechanical
ventilation.
Immediately begin continuous positive airway pressure (CPAP)
via the patient's nose and mouth.
Administer furosemide (Lasix) 100 mg IV push stat.
Call a code for respiratory arrest. - -Correct Answer --✔️Correct
Answer : A.
Explained:
A non-rebreather mask can deliver nearly 100% oxygen. When the
patient's oxygenation status does not improve adequately in response
to the 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?
Assisting the patient to sit up on the side of the bed.
2
NCLEX-style Practice Questions -
Prioritization, Delegation, & Assignment
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?
Perform postural drainage and chest physiotherapy every 4
hours.
Allow the patient to decide whether she needs aerosolized
medications.
Place the patient in a private room to decrease the risk of
further infection.
Plan activities to allow at least 8 hours of uninterrupted sleep. -
-Correct Answer --✔️Correct Answer : A.
Explained:
Airway clearance techniques are critical for patients with cystic
fibrosis and should take priority over other activities.
Although allowing more independent decision making is
important for adolescents, the physiologic need for an
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 has frequent respiratory treatments than 8
hours of sleep.
1
, 2
A patient with acute respiratory distress syndrome (ARDS) is receiving
oxygen by a non-rebreather 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?
Perform endotracheal intubation and initiate mechanical
ventilation.
Immediately begin continuous positive airway pressure (CPAP)
via the patient's nose and mouth.
Administer furosemide (Lasix) 100 mg IV push stat.
Call a code for respiratory arrest. - -Correct Answer --✔️Correct
Answer : A.
Explained:
A non-rebreather mask can deliver nearly 100% oxygen. When the
patient's oxygenation status does not improve adequately in response
to the 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?
Assisting the patient to sit up on the side of the bed.
2
