NCLEX RN prioritization delegation assignment EXAM A+ GRADE ASSURED COMPLETE SOLUTIONS AND VERIFIED ANSWERS LATEST UPDATE!!!!

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Exam Solution zm




NCLEX prioritization delegation jan2023 2026 A+ GRAzm zm zm zm zm zm




DE ASSURED COMPLETE SOLUTIONS AND VERIFIED AN
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SWERS (78ED3) zm




QUESTION 1 zm




1. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites a
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nd difficulty breathing. The nurse performs which intervention as a priority measure t
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o assist the client with breathing?
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a) repositions side to side every 2 hours
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b) elevates the head of the bed 60 degrees
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c) auscultates the lung field every 4 hours
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d) encourages deep breathing exercises every 2 hours
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ANSWER

1) B - zm zm



The client is having difficulty breathing because of upward pressure on the diaphragm from the asc
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itic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphr
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agm. The other options are general measures to promote lung expansion in the client with ascites, b
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ut the priority measure is the one that relieves diaphragmatic pressure.
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QUESTION 2 zm




2. A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system.
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Which of the following studies, if ordered, should the nurse schedule last?
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a) ultrasound
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b) colonoscopy
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c) barium enema
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d) computed tomography
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ANSWER

2) C - zm zm



When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. T
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he presence of barium could cause interference with obtaining clear visualization and accurate result
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s of the other tests listed, if performed before the client has fully excreted the barium. For this reas
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, on, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical
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imaging studies. zm




QUESTION 3 zm




3. A nurse is formulating a plan of care for a client receiving enteral feedings. The nu
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rse identifies which nursing diagnosis as the highest priority for this client?
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a) diarrhea
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b) risk for aspiration
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c) risk for deficient flid volume
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d) imbalanced nutrition, less than body requirements
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ANSWER

3) B - zm zm



Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a
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client at risk for aspiration. Although options 1, 3, and 4 may be a concern, these are not the priorit
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y.



QUESTION 4 zm




4. A client arrives at the emergency department with upper gastrointestinal (GI) bleed
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ing and is in moderate distress. The priority nursing action is to:
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a) obtain vital signs
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b) ask the client about the precipitating events
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c) complete an abdominal physical assessment
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d) insert a nasogastric (NG) tube and Hematest the emesis
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ANSWER

4) A - zm zm



The priority action is to obtain vital signs to determine whether the client is in shock from blood l
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oss and to obtain a baseline by which to monitor the progress of treatment. The client may not be
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able to provide subjective data until the immediate physical needs are met. Insertion of an NG tube
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may be prescribed but is not the priority action. A complete abdominal physical assessment needs t
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o be performed but is not the priority.
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QUESTION 5 zm




6. A group of health nurse is caring for a group of homeless people. When planning fo
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r the potential needs of this group, what is the most immediate concern?
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a) peer support through structured groups
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b) finding affordable housing for the group
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c) setting up a 24-hour crisis center and hotline
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d) meeting the basic needs to ensure that adequate food, shelter, and clothing are ava
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ilable
ANSWER