prioritization-delegation-and-assignment-practice-exercises-for-the-nclex-examination-4th-edition

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Answer KeyIllustration CreditsChapter 1Chapter 2Chapter 7Chapter 10Chapter 11Chapter 12Chapter 13Chapter 14Chapter 15Chapter 19Chapter 21Case Study 5Case Study 13Case Study 1410
Copyright3251 Riverport LaneSt. Louis, Missouri 63043PRIORITIZATION, DELEGATION, AND ASSIGNMENT: PRACTICEEXERCISES FOR THE NCLEX® EXAMINATION, FOURTH EDITIONISBN: 978-0-323-49828-9Copyright © 2019, Elsevier Inc. All rights reserved.Previous editions copyrighted 2014, 2011, and 2006.No part of this publication may be reproduced or transmitted in any form or byany means, electronic or mechanical, including photocopying, recording, or anyinformation storage and retrieval system, without permission in writing fromthe publisher. Details on how to seek permission, further information about thePublisher’s permissions policies and our arrangements with organizations suchas the Copyright Clearance Center and the Copyright Licensing Agency, can befound at our website: www.elsevier.com/permissions.This book and the individual contributions contained in it are protected undercopyright by the Publisher (other than as may be noted herein).NoticesPractitioners and researchers must always rely on their own experience andknowledge in evaluating and using any information, methods, compounds orexperiments described herein. Because of rapid advances in the medicalsciences, in particular, independent verification of diagnoses and drug dosagesshould be made. To the fullest extent of the law, no responsibility is assumed byElsevier, authors, editors or contributors for any injury and/or damage topersons or property as a matter of products liability, negligence or otherwise, orfrom any use or operation of any methods, products, instructions, or ideascontained in the material herein.Library of Congress Cataloging-in-Publication Data11
Page 2 and 3: Prioritization, Delegation, andAssi
Page 4 and 5: Table of ContentsCover imageTitle p
Page 6 and 7: Chapter 10: Visual and Auditory Pro
Page 8 and 9: QuestionsAnswer KeyCase study 5: Di
Page 12 and 13: Names: LaCharity, Linda A., author.
Page 14 and 15: Department of Nursing The Universit
Page 16 and 17: To faculty and other usersPatient c
Page 18 and 19: AcknowledgmentsWe would like to tha
Page 20 and 21: IntroductionRuth Hansten, PhD, MBA,
Page 22 and 23: not so apparent. Patients in all ca
Page 24 and 25: 2. The second level is immediately
Page 26 and 27: SupervisionWhenever a nurse delegat
Page 28 and 29: or evaluated activities of assistiv
Page 30 and 31: Delegation and assignment: the five
Page 32 and 33: leadership and direction would that
Page 34 and 35: for surgery and procedures and befo
Page 36 and 37: Errors can result in uncompensated
Page 38 and 39: Principles for implementation ofpri
Page 40 and 41: 2008;34(10):17-25.Kozlowski S., Ilg
Page 42 and 43: Recommended resourcesAlfaro-Lefevre
Page 44 and 45: C H A P T E R 144
Page 46 and 47: Questions1. Which postoperative cli
Page 48 and 49: measures. What action should the ch
Page 50 and 51: 50
Page 52 and 53: 4. Seek family assistance in resolv
Page 54 and 55: 29. The nurse is caring for a clien
Page 56 and 57: provider.3. Withhold the pain medic
Page 58 and 59: unconfirmed.4. Ask the HCP to valid
Page 60 and 61:
Activity level and function address
Page 62 and 63:
who present with first-time onset o
Page 64 and 65:
30. Ans: 2, 5, 6 The client who is
Page 66 and 67:
42. Ans: 3 If the social worker can
Page 68 and 69:
Cancer68
Page 70 and 71:
night shift nurse?1. “How many ti
Page 72 and 73:
2. Nausea3. Paresthesia4. Anorexia1
Page 74 and 75:
24. For a patient with osteogenic s
Page 76 and 77:
assisting patients in cessation of
Page 78 and 79:
years, biennial or annual mammograp
Page 80 and 81:
9. Ans: 2, 3, 5, 6 Mouthwash should
Page 82 and 83:
23.oxygenation and perfusion. Pulse
Page 84 and 85:
29. Ans: 2 Hyponatremia is a concer
Page 86 and 87:
Focus: Prioritization.86
Page 88 and 89:
Immunologic Problems88
Page 90 and 91:
of prednisone due3. A patient with
Page 92 and 93:
4. Newly graduated RN who needs exp
Page 94 and 95:
1. The patient is currently taking
Page 96 and 97:
Answer Key1. Ans: 1 Because antihis
Page 98 and 99:
to the unit would not have experien
Page 100 and 101:
are given with other medications. M
Page 102 and 103:
Fluid, Electrolyte, and Acid-BaseBa
Page 104 and 105:
6. The health care provider has wri
Page 106 and 107:
4. Serum magnesium level of 0.8 mEq
Page 108 and 109:
2. Potassium level3. Chloride level
Page 110 and 111:
Answer Key1. Ans: 3 An adult should
Page 112 and 113:
muscle weakness. Although the other
Page 114 and 115:
acidosis. Older adults may be takin
Page 116 and 117:
Safety and Infection Control116
Page 118 and 119:
4. Take off gown.5. Perform hand hy
Page 120 and 121:
2. Communicating with other departm
Page 122 and 123:
2. Appropriate antibiotics have bee
Page 124 and 125:
3. Labetalol 20 mg IV over a 2-min
Page 126 and 127:
airborne or contact precautions. Fo
Page 128 and 129:
hand hygiene readily available for
Page 130 and 131:
cholinergic crisis, a possible effe
Page 132 and 133:
Respiratory Problems132
Page 134 and 135:
3. Completing in-depth admission as
Page 136 and 137:
1. Avoid potential environmental as
Page 138 and 139:
1. Encourage the patient to eat foo
Page 140 and 141:
4. Observing whether the patient's
Page 142 and 143:
4. The student nurses uses a twirli
Page 144 and 145:
6. Ans: 1 When the oxygen flow rate
Page 146 and 147:
changed daily but may be reinforced
Page 148 and 149:
32. Ans: 4 Infections are always a
Page 150 and 151:
C H A P T E R 7150
Page 152 and 153:
Questions1. The clinic nurse is eva
Page 154 and 155:
apply.1. Referral to community prog
Page 156 and 157:
4. Persisting chest pain at a level
Page 158 and 159:
Which action will the nurse take fi
Page 160 and 161:
4. Assisting the client in cleaning
Page 162 and 163:
38. The clinic nurse obtains this i
Page 164 and 165:
Answer Key1. Ans: 1 Dark or tarry s
Page 166 and 167:
13. Ans: 2 Because combination angi
Page 168 and 169:
contractions in the setting of myoc
Page 170 and 171:
information are activities that can
Page 172 and 173:
Hematologic Problems172
Page 174 and 175:
6. The nurse is reviewing the compl
Page 176 and 177:
16. A patient with iron deficiency
Page 178 and 179:
4. Educating the patient about ways
Page 180 and 181:
Answer Key1. Ans: 2 Guidelines for
Page 182 and 183:
prescribed actions also should be i
Page 184 and 185:
infection when a patient has a low
Page 186 and 187:
Neurologic Problems186
Page 188 and 189:
1. Documenting the seizure2. Perfor
Page 190 and 191:
5. Developing the nursing plan of c
Page 192 and 193:
1. Position the client sitting up i
Page 194 and 195:
most appropriate for this client?1.
Page 196 and 197:
Answer Key1. Ans: 3 A change in lev
Page 198 and 199:
14. Ans: 1, 2, 4, 5 All of the stra
Page 200 and 201:
report feeling chilled, but warming
Page 202 and 203:
additional educational preparation
Page 204 and 205:
Visual and Auditory Problems204
Page 206 and 207:
3. Client who requests a home healt
Page 208 and 209:
2. Instill a mydriatic agent, such
Page 210 and 211:
24. The nurse is caring for several
Page 212 and 213:
3. Rest eyes as much as possible an
Page 214 and 215:
the eye. The man needs to have emer
Page 216 and 217:
to the client's report of roaring s
Page 218 and 219:
29. Ans: 1 Topical phenylephrine us
Page 220 and 221:
Musculoskeletal Problems220
Page 222 and 223:
2. Remove throw rugs and other obst
Page 224 and 225:
5. Check the neurovascular status o
Page 226 and 227:
instruct the UAP to respond?1. “Y
Page 228 and 229:
1. A2. B3. C4. D228
Page 230 and 231:
Focus: Assignment, Supervision; Tes
Page 232 and 233:
21. Ans: 1 Moving directly from a l
Page 234 and 235:
C H A P T E R 1 2234
Page 236 and 237:
Questions1. The charge nurse is rev
Page 238 and 239:
had fundoplication to reinforce the
Page 240 and 241:
The unit has several clients with h
Page 242 and 243:
31. The nurse is caring for a clien
Page 244 and 245:
nurse do first?1. Explain that the
Page 246 and 247:
Answer Key1. Ans: 4 Laxatives shoul
Page 248 and 249:
therapist should be contacted to se
Page 250 and 251:
displacement, and the correct posit
Page 252 and 253:
The client is likely to report pain
Page 254 and 255:
Diabetes Mellitus254
Page 256 and 257:
bath.”6. An LPN/LVN is assigned t
Page 258 and 259:
fruity odor to his breath. The char
Page 260 and 261:
hours.”2. “Test your urine for
Page 262 and 263:
262
Page 264 and 265:
Answer Key1. Ans: 1 The older patie
Page 266 and 267:
job includes calling and paging phy
Page 268 and 269:
abdomen) to prevent day-to-day chan
Page 270 and 271:
Other Endocrine Problems270
Page 272 and 273:
4. Teaching the patient about side
Page 274 and 275:
3. Potassium level4. White blood ce
Page 276 and 277:
3. Check vital signs every 2 hours.
Page 278 and 279:
1. Bilateral exophthalmos2. Large v
Page 280 and 281:
frequently have dependent edema. Fo
Page 282 and 283:
increased blood glucose level, decr
Page 284 and 285:
C H A P T E R 1 5284
Page 286 and 287:
Questions1. Which actions will the
Page 288 and 289:
a long-term care facility, which fi
Page 290 and 291:
back, and groin. Which question sho
Page 292 and 293:
3. The client has not eaten anythin
Page 294 and 295:
Answer Key1. Ans: 2, 3, 5, 6 Curren
Page 296 and 297:
appropriate, but therapy will chang
Page 298 and 299:
Prioritization.29. Ans: 2 Dairy pro
Page 300 and 301:
Renal and Urinary Problems300
Page 302 and 303:
should the nurse delegate to an exp
Page 304 and 305:
mouth.”3. “If necessary, your H
Page 306 and 307:
1. Incontinence-associated dermatit
Page 308 and 309:
3. Assist the patient with morning
Page 310 and 311:
the scope of practice of profession
Page 312 and 313:
23. Ans: 1 The underlying pathophys
Page 314 and 315:
check BP in the arm opposite to the
Page 316 and 317:
Reproductive Problems316
Page 318 and 319:
postanesthesia care unit. Which nur
Page 320 and 321:
2. Irrigate the retention catheter
Page 322 and 323:
4. Because nausea and vomiting may
Page 324 and 325:
4. Providing discharge instructions
Page 326 and 327:
6. Ans: 1 An LPN/LVN working in a p
Page 328 and 329:
anxiety needs further assessment ne
Page 330 and 331:
The other actions also require corr
Page 332 and 333:
C H A P T E R 1 8332
Page 334 and 335:
Questions1. A 30-year-old woman wit
Page 336 and 337:
4. Go up the chain of command and c
Page 338 and 339:
when desired.5. Ask the parents if
Page 340 and 341:
26. A 3-day-old breast-fed infant i
Page 342 and 343:
maternity patients, and breast feed
Page 344 and 345:
4. A patient with contractions ever
Page 346 and 347:
transmission of group B streptococc
Page 348 and 349:
Focus: Assignment.16. Ans: 3 Fundal
Page 350 and 351:
Measure of increasing the percentag
Page 352 and 353:
flu but does not go far enough in f
Page 354 and 355:
C H A P T E R 1 9354
Page 356 and 357:
Questions1. A 3-month-old infant ar
Page 358 and 359:
laboratory result would cause the n
Page 360 and 361:
leukemia. The patient's sibling has
Page 362 and 363:
1. A 2-year-old patient with a vent
Page 364 and 365:
3. Obtain a history for the type of
Page 366 and 367:
4. “This behavior may be associat
Page 368 and 369:
is 24% (0.24 volume fraction), and
Page 370 and 371:
Answer Key1. Ans: 1 The infant's be
Page 372 and 373:
Electroencephalography may be indic
Page 374 and 375:
diuretics. The other children shoul
Page 376 and 377:
36. Ans: 2 Passage of brown stool i
Page 378 and 379:
patients are in common waiting area
Page 380 and 381:
C H A P T E R 2 0380
Page 382 and 383:
Questions1. The nurse is caring for
Page 384 and 385:
4. “Storage position is unimporta
Page 386 and 387:
16. The RN team leader has assigned
Page 388 and 389:
4. Ethambutol26. A patient diagnose
Page 390 and 391:
__________ mL36. During a check-up
Page 392 and 393:
drug is taken too long before the m
Page 394 and 395:
depression to worsen. Decreased hea
Page 396 and 397:
blocker used to treat GERD and PUD,
Page 398 and 399:
Emergencies and Disasters398
Page 400 and 401:
vomiting_____, _____, _____, _____5
Page 402 and 403:
department (ED); however, this is t
Page 404 and 405:
2. Accompanying organ donor special
Page 406 and 407:
are the priority interventions for
Page 408 and 409:
2. A firefighter who is showing com
Page 410 and 411:
Test Taking Tip: Use knowledge of g
Page 412 and 413:
18. Ans: 3 The correct intervention
Page 414 and 415:
30. Ans: 4 At least one representat
Page 416 and 417:
42. Ans: 3 The nurse recognizes tha
Page 418 and 419:
Psychiatric-Mental Health Problems4
Page 420 and 421:
me about what you are feeling and w
Page 422 and 423:
concern?1. His heart rate is increa
Page 424 and 425:
2. Tell her to care for the patient
Page 426 and 427:
2. Restrain the patient's arms and
Page 428 and 429:
4. Gently suggest that the patient
Page 430 and 431:
very simple and direct instructions
Page 432 and 433:
17. Ans: 4 Although the patient is
Page 434 and 435:
ensuring that the patient is not ex
Page 436 and 437:
PA R T 3Prioritization, Delegation,
Page 438 and 439:
Chest Pressure, Indigestion, andNau
Page 440 and 441:
4. Ms. S's cardiac telemetry monito
Page 442 and 443:
hours and recording the vital sign
Page 444 and 445:
Answer Key1. Ans: 1, 2, 4, 5, 6 Ris
Page 446 and 447:
admission, is not a priority at thi
Page 448 and 449:
Dyspnea and Shortness of Breath448
Page 450 and 451:
2. Forward bent posture3. Respirato
Page 452 and 453:
2. Keep accurate records of intake
Page 454 and 455:
Answer Key1. Ans: 1, 2, 3, 5 Baseli
Page 456 and 457:
was productive. The changes in Mr.
Page 458 and 459:
C A S E S T U D Y 3458
Page 460 and 461:
QuestionsThe RN is the leader of a
Page 462 and 463:
9. The UAP is delegated the task of
Page 464 and 465:
1. Check bilateral pedal pulses eve
Page 466 and 467:
educational scope of the UAP. Focus
Page 468 and 469:
Page 470 and 471:
QuestionsMs. J is a 63-year-old wom
Page 472 and 473:
1. Assisting the patient to replace
Page 474 and 475:
19. What intervention is required a
Page 476 and 477:
high. Focus: Prioritization.7. Ans:
Page 478 and 479:
failure) are essential at this time
Page 480 and 481:
Diabetic Ketoacidosis480
Page 482 and 483:
2. Checking and reporting Mr. D's b
Page 484 and 485:
interested in knowing?1. Mental sta
Page 486 and 487:
19. Which member of the health care
Page 488 and 489:
Answer Key1. Ans: 1, 2, 4, 5, 6 The
Page 490 and 491:
range.11. Ans: 2 Her calculations a
Page 492 and 493:
Page 494 and 495:
QuestionsThe nurse who is working f
Page 496 and 497:
1. Discontinue the patient's oxygen
Page 498 and 499:
13. The nurse still has visits to m
Page 500 and 501:
Answer Key1. Ans: 1, 4, 5, 6 Ms. A'
Page 502 and 503:
12. Ans: 2 The focus in home health
Page 504 and 505:
Page 506 and 507:
QuestionsMr. M is a 32-year-old man
Page 508 and 509:
1. Set up an oxygen delivery system
Page 510 and 511:
5. Teach the client to perform self
Page 512 and 513:
scope of practice for a UAP. The nu
Page 514 and 515:
role performance, and self-concept.
Page 516 and 517:
Multiple Patients With Adrenal Glan
Page 518 and 519:
6. Fluid restrictions to maintain b
Page 520 and 521:
UAP is best for indicating fluid re
Page 522 and 523:
Answer Key1. Ans: 3 The patient's s
Page 524 and 525:
indicator of fluid retention. The b
Page 526 and 527:
Page 528 and 529:
QuestionsAn RN is the leader of a t
Page 530 and 531:
pending. Ms. H asks, “What should
Page 532 and 533:
16. The UAP asks, “Why can’t Ms
Page 534 and 535:
unsure about follow-up.5. The nursi
Page 536 and 537:
Answer Key1. Ans: 6 Mr. R has sever
Page 538 and 539:
mouth will decrease fecal mass and
Page 540 and 541:
26. Ans: 4 In this circumstance, th
Page 542 and 543:
C A S E S T U D Y 1 0542
Page 544 and 545:
QuestionsThe RN is the leader of a
Page 546 and 547:
6. The team leader is talking to Ms
Page 548 and 549:
4. “I know you are having pain. L
Page 550 and 551:
he is going to have pain. He's a dr
Page 552 and 553:
getting enough pain medication. He
Page 554 and 555:
Answer Key1. Ans: 6, 3, 2, 1, 5, 4
Page 556 and 557:
staff members should be watchful fo
Page 558 and 559:
25. Ans: 3 Mr. H may be experiencin
Page 560 and 561:
position if assessments of the skin
Page 562 and 563:
Multiple Clients With Cancer562
Page 564 and 565:
5. Noting the presence and complexi
Page 566 and 567:
11. The team leader is teaching the
Page 568 and 569:
demonstration of any aspect of colo
Page 570 and 571:
currently receiving high-flow oxyge
Page 572 and 573:
Answer Key1. Ans: 1, 2, 5, 6 When t
Page 574 and 575:
instilled through the catheter, and
Page 576 and 577:
30. Ans: 1 For Mr. U, the tension p
Page 578 and 579:
Gastrointestinal Bleeding578
Page 580 and 581:
3. Insert an NG tube and observe ga
Page 582 and 583:
2. HCP should be notified for possi
Page 584 and 585:
2. Call the HCP and politely state
Page 586 and 587:
insert the tube into the most paten
Page 588 and 589:
awareness of and avoidance of deali
Page 590 and 591:
C A S E S T U D Y 1 3590
Page 592 and 593:
QuestionsMs. A, a 20-year-old colle
Page 594 and 595:
Ms. A's ongoing care?1. RN from a t
Page 596 and 597:
2. Blood pressure3. O 2 saturation4
Page 598 and 599:
21. As the shift ends, the nurse is
Page 600 and 601:
also be appropriate, but a more dir
Page 602 and 603:
client. Next, the nurse discusses p
Page 604 and 605:
Septic Shock604
Page 606 and 607:
protocols. Which action should the
Page 608 and 609:
10. When assessing the norepinephri
Page 610 and 611:
3. Experienced ICU RN who has been
Page 612 and 613:
before the intubation attempt. To m
Page 614 and 615:
C A S E S T U D Y 1 5614
Page 616 and 617:
QuestionsThe nurse admits Ms. C, an
Page 618 and 619:
4. Assessing lung sounds10. Ms. C's
Page 620 and 621:
dyspnea. She has been receiving dig
Page 622 and 623:
7. Ans: 4 Morphine is used in pulmo
Page 624 and 625:
this client's assessment indicates
Page 626 and 627:
Multiple Patients With PeripheralVa
Page 628 and 629:
the student nurse to avoid?1. Auscu
Page 630 and 631:
13. At noon, the LPN/LVN goes to ca
Page 632 and 633:
6. Check daily international normal
Page 634 and 635:
Answer Key1. Ans: 2, 3, 5 Hypertens
Page 636 and 637:
Assignment, Supervision.11. Ans: 1
Page 638 and 639:
involves surgical revascularization
Page 640 and 641:
Respiratory Difficulty After Surger
Page 642 and 643:
nurse ask the laboratory to draw bl
Page 644 and 645:
9. The HCP assesses Mr. E and presc
Page 646 and 647:
5. Provide oral care several times
Page 648 and 649:
Answer Key1. Ans: 3 The marked decr
Page 650 and 651:
clients who are unconscious or para
Page 652 and 653:
is experiencing. Focus: Prioritizat
Page 654 and 655:
Long-Term Care654
Page 656 and 657:
3. Gently dry after each cleansing.
Page 658 and 659:
2. Administer diphenoxylate 5 mg PO
Page 660 and 661:
Answer Key1. Ans: 2 IAD describes t
Page 662 and 663:
of UAP. In some states, long-term c
Page 664 and 665:
C A S E S T U D Y 1 9664
Page 666 and 667:
QuestionsThe charge nurse is workin
Page 668 and 669:
3. Crackles auscultated on inspirat
Page 670 and 671:
history.4. Perform blood glucose te
Page 672 and 673:
2. A sign of bronchial remodeling3.
Page 674 and 675:
and drained 120 mL over 12 hours. H
Page 676 and 677:
asthma attack. The mother's frustra
Page 678 and 679:
mother should be notified and advis
Page 680 and 681:
Total parenteral nutrition is not s
Page 682 and 683:
C A S E S T U D Y 2 0682
Page 684 and 685:
QuestionsNote: In this case study,
Page 686 and 687:
2. Mr. P (paranoid schizophrenia)3.
Page 688 and 689:
2. Ms. M appears heavily sedated at
Page 690 and 691:
that?”21. Clozapine is prescribed
Page 692 and 693:
4. Other nonpharmacologic therapies
Page 694 and 695:
up his belongings36. As the charge
Page 696 and 697:
historian, and prolonged questionin
Page 698 and 699:
16. Ans: 3 Acknowledging feelings i
Page 700 and 701:
restlessness and agitation are the
Page 702 and 703:
C A S E S T U D Y 2 1702
Page 704 and 705:
QuestionsMs. N is a 20-year-old gra
Page 706 and 707:
5. Call a social worker for a consu
Page 708 and 709:
also get the Tdap vaccine. The clie
Page 710 and 711:
the student at this time that would
Page 712 and 713:
postpartum hemorrhage?1. Hypotensio
Page 714 and 715:
etonogestrel 68 mg. She is happy to
Page 716 and 717:
distress, neonatal death, necrotizi
Page 718 and 719:
18. Ans: 4 The heart rate and respi
Page 720 and 721:
therapeutic way but to always keep
Page 722 and 723:
Chapter 115. From Gray Morris D: Ca
Page 724 and 725:
Chapter 728. From Ignatavicius D, W
Page 726 and 727:
Chapter 1132. From Ignatavicius D,
Page 728 and 729:
Chapter 1331. From Ignatavicius D,
Page 730 and 731:
Chapter 1523. From Ogden SJ, Fluhar
Page 732 and 733:
Chapter 2142. From Aehlert B: EKGs
Page 734 and 735:
Case Study 133. From Ignatavicius D
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