25Qw/exp Delegation and Prioritization
1. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty
breathing. The nurse performs which intervention as a priority measure to assist the client with
breathing?
a) repositions side to side every 2 hours
b) elevates the head of the bed 60 degrees
c) auscultates the lung field every 4 hours
d) encourages deep breathing exercises every 2 hours - (correct Answer) - 1) B
- The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic
fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The
other options are general measures to promote lung expansion in the client with ascites, but the priority
measure is the one that relieves diaphragmatic pressure.
2. A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the
following studies, if ordered, should the nurse schedule last?
a) ultrasound
b) colonoscopy
c) barium enema
d) computed tomography - (correct Answer) - 2) C
- When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The
presence of barium could cause interference with obtaining clear visualization and accurate results of
the other tests listed, if performed before the client has fully excreted the barium. For this reason,
diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging
studies.
3. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which
nursing diagnosis as the highest priority for this client?
a) diarrhea
b) risk for aspiration
c) risk for deficient flid volume
, d) imbalanced nutrition, less than body requirements - (correct Answer) - 3) B
- Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client
at risk for aspiration. Although options 1, 3, and 4 may be a concern, these are not the priority.
4. A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in
moderate distress. The priority nursing action is to:
a) obtain vital signs
b) ask the client about the precipitating events
c) complete an abdominal physical assessment
d) insert a nasogastric (NG) tube and Hematest the emesis - (correct Answer) - 4) A
- The priority action is to obtain vital signs to determine whether the client is in shock from blood loss
and to obtain a baseline by which to monitor the progress of treatment. The client may not be able to
provide subjective data until the immediate physical needs are met. Insertion of an NG tube may be
prescribed but is not the priority action. A complete abdominal physical assessment needs to be
performed but is not the priority.
5. A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of
depression. Upon the client's arrival, the client's therapist reports to the nurse that the clients
telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts.
Keeping this information in mind, the priority of the nurse is to assess for:
a) interaction with peers
b) the presence of suicidal thoughts
c) the amount of food intake for the past 24 hours
d) information regarding the past medication regimen - (correct Answer) - 5) B
The critical information from the therapist is that the client is having thoughts of self-harm; therefore,
the nurse needs further information about present thoughts of suicide so that the treatment plan may
be as appropriate as possible. The nurse must make sure the client is safe. The items in options A, C, and
D should be assessed; however, evaluation for suicide potential is most important
6. A group of health nurse is caring for a group of homeless people. When planning for the potential
needs of this group, what is the most immediate concern?
a) peer support through structured groups
b) finding affordable housing for the group
1. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty
breathing. The nurse performs which intervention as a priority measure to assist the client with
breathing?
a) repositions side to side every 2 hours
b) elevates the head of the bed 60 degrees
c) auscultates the lung field every 4 hours
d) encourages deep breathing exercises every 2 hours - (correct Answer) - 1) B
- The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic
fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The
other options are general measures to promote lung expansion in the client with ascites, but the priority
measure is the one that relieves diaphragmatic pressure.
2. A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the
following studies, if ordered, should the nurse schedule last?
a) ultrasound
b) colonoscopy
c) barium enema
d) computed tomography - (correct Answer) - 2) C
- When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The
presence of barium could cause interference with obtaining clear visualization and accurate results of
the other tests listed, if performed before the client has fully excreted the barium. For this reason,
diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging
studies.
3. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which
nursing diagnosis as the highest priority for this client?
a) diarrhea
b) risk for aspiration
c) risk for deficient flid volume
, d) imbalanced nutrition, less than body requirements - (correct Answer) - 3) B
- Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client
at risk for aspiration. Although options 1, 3, and 4 may be a concern, these are not the priority.
4. A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in
moderate distress. The priority nursing action is to:
a) obtain vital signs
b) ask the client about the precipitating events
c) complete an abdominal physical assessment
d) insert a nasogastric (NG) tube and Hematest the emesis - (correct Answer) - 4) A
- The priority action is to obtain vital signs to determine whether the client is in shock from blood loss
and to obtain a baseline by which to monitor the progress of treatment. The client may not be able to
provide subjective data until the immediate physical needs are met. Insertion of an NG tube may be
prescribed but is not the priority action. A complete abdominal physical assessment needs to be
performed but is not the priority.
5. A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of
depression. Upon the client's arrival, the client's therapist reports to the nurse that the clients
telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts.
Keeping this information in mind, the priority of the nurse is to assess for:
a) interaction with peers
b) the presence of suicidal thoughts
c) the amount of food intake for the past 24 hours
d) information regarding the past medication regimen - (correct Answer) - 5) B
The critical information from the therapist is that the client is having thoughts of self-harm; therefore,
the nurse needs further information about present thoughts of suicide so that the treatment plan may
be as appropriate as possible. The nurse must make sure the client is safe. The items in options A, C, and
D should be assessed; however, evaluation for suicide potential is most important
6. A group of health nurse is caring for a group of homeless people. When planning for the potential
needs of this group, what is the most immediate concern?
a) peer support through structured groups
b) finding affordable housing for the group
