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WorksheetsNCLEX - Prioritiz and Delegration Day1 (Part 2)
Total questions: 10
Worksheet time: 10mins
Name
Class
Date
1.
An emergency department nurse is assigned to triage. Which client should the nurse assess first?
a)
Five-year-old with a superficial leg laceration
b)
Lethargic 3-month-old with diarrhea for the past 12 hours
c)
Seven-year-old with an elevated temperature of 101 F (38.3 C) and hematuria
d)
Seventeen-year-old with severe, acute abdominal pain
e)
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2.
The nurse is reviewing laboratory test results for assigned clients. Which of the following test results would require immediate follow-up?
a)
A decreased blood glucose level for a client with radiation enteritis who is receiving total parenteral nutrition
b)
A decreased CD4+ cell count for a client with oral candidiasis and HIV who is receiving oral fluconazole
c)
An elevated hemoglobin A1c for a client with pneumonia and type 2 diabetes mellitus who is receiving IV levofloxacin
d)
An elevated WBC count for a client with primary adrenal insufficiency who is receiving oral methylprednisolone
e)
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3.
The nurse in a pulmonary clinic triages telephone messages left by several clients. Which client should the nurse call back first?
a)
Client with a history of asthma who reports scoring a peak flow of 45% of personal best
b)
Client with a pneumothorax who reports scant, clear drainage from the Heimlich valve
c)
Client with active tuberculosis reporting dark red-orange urine after starting rifampin
d)
Client with chronic obstructive pulmonary disease with an oxygen saturation of 90%
e)
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4.
The nurse is caring for assigned clients. The nurse should first assess the client with
a)
chronic obstructive pulmonary disease who is maintaining a tripod position to facilitate breathing
b)
acute streptococcal pharyngitis who began receiving antibiotic therapy 12 hours ago
c)
amyotrophic lateral sclerosis who is experiencing increased dysphagia
d)
urolithiasis who is reporting wave-like flank pain and nausea
e)
-
5.
The nurse performs admission assessments on 4 clients. Which client assessment information is most concerning and needs priority care?
a)
17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 C), headache with photophobia, and stiff neck
b)
36-year-old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F (39.6 C), and foul smelling drainage from self-injection sites
c)
45-year-old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F (38.3 C) and a serum glucose of 295 mg/dL (16.4 mmol/L)
d)
76-year-old with chronic bronchitis who has a fever of 101 F (38.3 C) and a productive cough of thick green mucus
e)
-
6.
An 87-year-old client is admitted with a UTI, agitation, and confusion. What is the most important nursing action?
a)
Encouraging frequent fluid intake
b)
Keeping the bed elevated and side rails raised
c)
Providing one-on-one supervision
d)
Turning the lights off in the client's room
e)
-
7.
After a family therapy session, a client is punching the wall. Which defense mechanism is being used?
a)
Projection
b)
Displacement
c)
Rationalization
d)
Reaction formation
e)
-
8.
A client asks, "Am I going to die?" before hearing biopsy results. The nurse has not received permission to disclose. What is the appropriate response?
a)
You seem upset. Tell me how you're feeling.
b)
Watch TV, it might help you relax.
c)
I'm sure it will all work out.
d)
The biopsy shows cancer, but it's treatable.
e)
-
9.
Nurse hears staff ask client, "Why did you get angry when your spouse ignored you?" What should the nurse do?
a)
No intervention
b)
Encourage open-ended clarification
c)
Ask about hallucinations instead
d)
Intervene due to use of a "why" question
e)
-
10.
A client with schizophrenia says, "There is a bad person in my room." What should the nurse say?
a)
Your illness is making you hallucinate.
b)
I know you're frightened, but I don't see anyone.
c)
Don't worry. The meds will make it go away.
d)
Let's play a board game in the dayroom.
e)
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