NCLEX Questions on Delegation (1-5)

Read and answer carefully the following NCLEX Questions on Delegation.

1. A mother brings her child to the emergency department because an insect has flown into the child’s ear. The child is complaining of buzzing sound in the ear. The nurse should take which action first?

a) place mineral oil into the ear
b) use a flashlight to coax the insect out of the ear
c) use an ear forceps to try to remove the insect
d) place diluted alcohol into the ear

2. NCLEX Questions on Delegation about an emergency department nurse is performing an assessment of a client who sustained circumferential burns of both legs. The nurse should assess which of the following first?

a) peripheral pulses
b) temperature
c) heart rate
d) blood pressure

3. A nurse is carrying out emergency physician orders for a client who has just experienced a pulmonary embolism. The nurse carries out which order first?

a) administers morphine sulfate
b) applies oxygen
c) stats an intravenous line
d) obtains an electrocardiogram

4. NCLEX Questions on Delegation about a client has received electroconvulsive therapy (ECT). In the post-treatment area upon the client’s awakening, the nurse will first:

a) monitor the client’s vital signs
b) offer the client frequent reassurance and repeat orientation statements
c) assist the client from the stretcher to a wheelchair
d) encourage the client to eat breakfast and resume activity

5. A client is admitted to the emergency department with complaints of severe, radiating chest pain, and a myocardial infarction is suspected. The client is extremely restless, frightened, and dyspneic. Immediate admission orders include oxygen by nasal cannula at 4 L/min, blood troponin levels, a chest x-ray, a 12-lead electrocardiogram (ECG), and the administration of morphine sulfate. Which initial should the nurse take?

a) obtain the 12-lead ECG
b) call the laboratory to order the blood work
c) call the radiology department to order the chest x-ray
d) administer the morphine sulfate

NCLEX Questions on Delegation
Answers and Rationale

1) B
- Insects that make their way into an ear can be coaxed out with a flashlight or a humming noise. If this is unsuccessful, then the insect must be killed before removal. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed with an ear forceps.

2) A
- The client who receives circumferential burns to the extremities is at risk for impaired peripheral circulation. The priority assessment would be to check for peripheral pulses to ensure that adequate circulation is present. Although the temperature, heart rate, and BP would also be assessed, the priority with a circumferential burn is the assessment for the presence of peripheral pulses.

3) B
NCLEX Questions on Delegation Rationale: The client needs immediate oxygen because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should have an intravenous line for administration of emergency medications, such as morphine sulfate. An electrocardiogram is useful in determining right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.

4) A
- The nurse would first monitor vital signs and review with the client that the client had just received an ECT treatment. The nursing interventions outlined in options B, C, and D will follow accordingly.

5) D
- Pain control is a priority because the chest pain indicates cardiac ischemia. Pain also stimulates the autonomic nervous system and increases preload, increasing myocardial demands. Oxygen administration is also a priority. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, pain control is the priority to prevent further cardiac damage. The blood work is not priority. Although troponin levels can help in determining the choice of treatment, they are a means of assessment while the situation requires action. Although the chest x-ray can show cardiac enlargement, having the chest x-ray would not influence immediate treatment. The chest x-ray is not a priority because the client's dyspnea is cardiac related.

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