NURS 2539 PRIORITIZATION AND DELEGATION

PRIORITIZATION AND DELEGATION Question 1 What is the priority nursing measure for a client with von Willebrand’s disease who is having epistaxis? You Selected: • Apply pressure to the nose Correct response: • Apply pressure to the nose Explanation: Remediation: Question 2 See full question 1m 12s Which nursing intervention is a priority for a child with hemophilia, who has fallen, and has an acutely bruised leg? You Selected: • Heating pad and administration of factor VIII concentrate Correct response: • Pressure on the site and administration of the required clotting factor Explanation: Remediation: Question 3 See full question 8m 24s The nurse is preparing to administer digoxin to an infant. What is the most important intervention by the nurse? You Selected: • Withhold the dose if the apical pulse rate is less than 90/bpm Correct response: • Withhold the dose if the apical pulse rate is less than 90/bpm Explanation: Remediation: Question 4 See full question 1h 29m 37s A two-year-old child comes to the emergency department with inspiratory stridor and a barking cough. A preliminary diagnosis of croup has been made. What is the nurse’s most important intervention? You Selected: • Provide oxygen by face mask Correct response: • Establish and maintain the airway Explanation: Remediation: Question 5 See full question 16s A three-year-old child is given a preliminary diagnosis of acute epiglottitis. Which initial nursing intervention is most appropriate? You Selected: • Have emergency airway equipment readily available Correct response: • Have emergency airway equipment readily available Explanation: Remediation: Question 6 See full question 17s A client with an uncomplicated, term pregnancy arrives at the labor-and-delivery unit in early labor saying that she thinks her water has broken. What is the nurse’s best action? You Selected: • Ask what time this happened and note the color, amount, and odor of the fluid Correct response: • Ask what time this happened and note the color, amount, and odor of the fluid Explanation: Remediation: Question 7 See full question 27s At the beginning of a shift, the team leader notices that all of the IV antibiotics for a client are still in the medication room. What is the team leader’s first action? You Selected: • Ask the nurse assigned to this client about the medications Correct response: • Ask the nurse assigned to this client about the medications Explanation: Remediation: Question 8 See full question 24s A client with a panic disorder is having difficulty falling asleep. Which nursing intervention should be performed first? You Selected: • Teach the client progressive relaxation Correct response: • Teach the client progressive relaxation Explanation: Remediation: Question 9 See full question 27s The nurse is caring for a three-year-old with acute lymphocytic leukemia and notes that the child has a decreased appetite. What is the priority nursing intervention? You Selected: • Have the dietician meet with the child and family to provide foods he will eat Correct response: • Have the dietician meet with the child and family to provide foods he will eat Explanation: Remediation: Question 10 See full question 18s Two hours after starting total enteral nutrition (TEN) through a nasogastric tube, a client starts to have abdominal distention. Which action should the nurse take first? You Selected: • Stop the feeding Correct response: • Stop the feeding Explanation: Remediation: Question 1 See full question 3m 23s The nurse has just admitted a client with sickle cell crisis. What is the nurse’s priority intervention? You Selected: • Giving antibiotics and analgesics Correct response: • Increasing fluid intake and giving analgesics Explanation: Remediation: Question 2 See full question 7m 15s Which client would be considered to be at the highest risk for respiratory failure? You Selected: • A client with Guillain-Barré syndrome Correct response: • A client with Guillain-Barré syndrome Explanation: Remediation: Question 3 See full question 14h 26m 44s Which nursing intervention is the most appropriate for a client diagnosed with functional neurologic symptom disorder who has experienced pseudoseizures? You Selected: • Promote independence and withdraw attention from the pseudoseizures Correct response: • Promote independence and withdraw attention from the pseudoseizures Explanation: Question 4 See full question 50s What is the priority nursing action for a client with generalized anxiety disorder who is working to develop coping skills? You Selected: • Assist the client to identify coping mechanisms used in the past Correct response: • Assist the client to identify coping mechanisms used in the past Explanation: Question 5 See full question 20s The nurse is caring for three-year-old client who has polycythemia. What is the most important intervention for the nurse to include in this child’s plan of care? You Selected: • Use of a soft toothbrush Correct response: • Encouragement of fluid intake Explanation: Remediation: Question 6 See full question 25s A nurse is caring for a three-year-old child following the removal of a Wilms’ tumor. The mother states that her child is in pain, and requests pain medication. What is the nurse’s priority in regards to this mother’s request? You Selected: • Use the Faces Pain Scale to assess the child’s degree of pain Correct response: • Use the Faces Pain Scale to assess the child’s degree of pain Explanation: Remediation: Question 7 See full question 21s The nurse in the emergency department is caring for a 12-year-old child with full- thickness, circumferential burns to the chest, and has difficulty breathing. What is the priority intervention? You Selected: • Intubation Correct response: • Intubation Explanation: Remediation: Question 8 See full question 21s A nurse, working in the triage area of an emergency department, sees several pediatric clients arrive simultaneously. Which client should be treated first? You Selected: • A two-year-old child with stridorous breath sounds, sitting up and drooling Correct response: • A two-year-old child with stridorous breath sounds, sitting up and drooling Explanation: Remediation: Question 9 See full question 15s The nurse is assessing a laboring client. The client suddenly screams and exclaims, “My baby is coming.” What is the priority action by the nurse? You Selected: • Assess for crowning Correct response: • Assess for crowning Explanation: Remediation: Question 10 See full question 32s A charge nurse is developing the client care assignments for the shift. Which client is mostappropriately assigned to a licensed practical nurse (LPN)? ..............................................CONTINUED.......................................