Test Strategies,

Prioritization, &
Delegation
Archer Review Crash Course

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 Prioritization

ABC’s
● Airway ● Breathing ● Circulation
○ Are they getting good
○ Foreign body in the ○ Adequate blood flow to their
airway respirations tissues.
○ Obstruction ■ RR is sufficient ○ Providing oxygen to
○ Edema ■ Shallow? organs
○ Goal is a patent ○ Bilateral breath ○ Good pulses
airway sounds ○ Brisk cap-refill
○ No patent airway? ○ Good air entry ○ Warm skin
■ Intubate ○ Breathing ○ Appropriate color
■ Trach insufficient? Breathe ○ Insufficient
for them. circulation?
■ BMV ■ Fluids
■ Pressors
NCLEX Question
A client in septic shock in the intensive care unit is receiving a Dopamine
infusion. Upon assessment, the nurse notices that the client’s; blood pressure
is 195/120 mm Hg. Which initial nursing action would the nurse implement?

a. Discontinue dopamine.
b. Notify the physician
c. Administer Furosemide.
d. Assess the clients’ GCS

Answer: A
A is correct. The initial action for the nurse is to discontinue Dopamine, which is a
vasoconstrictor, the medication that causes the client’s high blood pressure. B is
incorrect. The nurse needs to notify the physician in order to arrange an
adjustment of the medication dosage. However, this should not be the initial action
of the nurse. C is incorrect. The nurse can give Furosemide to decrease the
patient's blood pressure. But the nurse should terminate the exact cause of
hypertension which is Dopamine. D is incorrect. The nurse can assess the client's
GCS, but the nurse should decrease the client's blood pressure.
NCLEX Question
A client in his early 60s is brought to the ER complaining of shortness of
breath. Initial assessment findings include crackles, finger clubbing, and dry
cough. The client states that he has previously worked in construction for 15
years. The ER physician suspects asbestosis. Which nursing problem should
the nurse prioritize in the client?

a. Impaired gas exchange

b. Imbalanced nutrition: Less than body requirements
c. Fatigue
d. Ineffective airway clearance

Answer: A
A is correct. In asbestosis, there is filling and inflammation of lung spaces with asbestos
fibers. These fibers move into the alveolar space and cause fibrosis, leading to increased
production in secretions impairing gas exchange. This should be a priority problem for
the nurse. B is incorrect. There is imbalanced nutrition on the patient because of his
difficulty of breathing and intolerance to activity. However, it should not be prioritized
over the gas exchange. C is incorrect. Because of the client’s impaired oxygenation,
there is not enough oxygen that reaches the muscles to sustain activity. However, this
problem must not take priority over the gas exchange. D is incorrect. Due to the
increased secretions brought about by the asbestos fibers, there is an ineffective airway
clearance. Although equally crucial with gas exchange, the nurse should prioritize
impaired gas exchange over airway clearance because treatment for asbestosis is
focused on the relief of symptoms. Oxygen delivery to the cells holds more importance.
 Stability
Most stable to least stable

Unstable Stable
● Changing condition
● Chronic
● Acute
● Expected findings
● Unexpected
● Ready for discharge
● Recently admitted
● Consistent lab values
● New onset
● Consistent vital signs
● Newly diagnosed
● Unchanging
● Critical lab values
● Hemorrhage

NCLEX Question
A nurse employed in an emergency department is doing triage on the evening
shift. Which of the following clients should be assigned the highest priority?

a. A client complaining of muscle aches, a headache, and malaise that

has been on for 5 hours
b. A client who twisted her ankle when she fell while skateboarding
c. A client with a minor laceration on the index finger sustained while
slicing vegetables
d. A client with chest pain who claims that he just ate a very spicy pizza 2
hours ago
Answer: D
In the emergency department, triage involves brief client assessment to classify clients
according to their need for care and includes prioritization of care. The type of illness or
injury, the severity of the problem, and the resources available are considered in the
process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest,
limb amputation, and acute neurological deficits, or who have sustained chemical
splashes to the eyes are classified as emergent and are the number 1 or highest
priority. Clients with conditions such as a simple fracture, asthma without respiratory
distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and
are classified as a second priority. Clients with conditions such as a minor laceration,
sprain, or cold symptoms are classified as nonurgent and are the third priority. Thus,
the correct answer is D, while options A, B, and C are incorrect.
NCLEX Question
You are caring for a 46 year old woman who has just been diagnosed with
Stage IV breast cancer. She shares with you that she was estranged from her
father over a decade ago, but now that she is sick is thinking about reaching
back out to him. As the nurse, you know this falls under which category in
Maslow’s Hierarchy of Needs?

A. Love and belonging

B. Physiological
C. Esteem
D. Self-actualization

Answer: A
A is correct. Love and belonging is the level on Maslow’s hierarchy of needs where this
patient’s relationship with her mother would fall.

B is incorrect. Physiological needs include items such as oxygen, fluids, nutrition, shelter,
and elimination. The patient’s relationship with her mother would fall under love and
belonging.

C is incorrect. Esteem needs include things such as self-confidence, recognition,

self-worth, status, and respect. The patient’s relationship with her mother would fall
under love and belonging.

D is incorrect. Self-actualization needs include things such as Full potential of self,

effective coping, and problem solving capabilities. The patient’s relationship with her
mother would fall under love and belonging.
NCLEX Question
During handoff, the nurse was informed that a patient’s serum potassium is
2.8 mEq/L. During rounds, the first thing that the nurse should assess in this
client should be:

a. Ability to balance while walking

b. Quality of peripheral pulses
c. Respiratory status looking out for shallow respirations
d. Frequency of bowel movement

Answer: C
Rationale: Hypokalemia affects the musculoskeletal, cardiovascular, neurologic, and
respiratory systems. The skeletal muscles become weak, causing the patient to collapse
while ambulating; the peripheral pulses are expected to be thready and weak, making
palpation difficult and causes decreased peristalsis, which may lead to constipation.
However, it is the respiratory system that is severely affected by hypokalemia through
the weakness of the muscles needed for breathing. This may lead to shallow
respirations and lead to respiratory insufficiency, being a major cause of death. Thus,
respiratory status should be assessed first in any client with hypokalemia, making
option C the correct answer. Options A, B, and D should also be included in the
assessment but are not the utmost priority and are, therefore, incorrect.
 The Nursing Process

Assessment
● Data collection
○ Subjective
○ Objective
● Interpret data
● Know your normals!
● Document assessment
Diagnosis
● Analyzing the data
● Identifies problems or risks
● Decide what the primary problem is

Plan
● Choose interventions
● Prioritize interventions
● SMART goals
● Develop plan of care
Implementation
● Put your plan into place!
● Implement interventions
● Take action on SMART goals

Evaluation
● Evaluate how the intervention affected the patient
● VS changes
● Therapy goals
● Document in plan of care
NCLEX Question
The nurse looks up at the telemetry monitor and notes the following. What is
her priority nursing action:

A. Defibrillate the patient

B. Assess the patient
C. Call for help
D. Start chest compressions

Answer: B
A is incorrect. The nurse first needs to assess the patient. If they patient is in
asystole, chest compressions should be started. Defibrillation is not
appropriate for a patient in asystole.

B is correct. The priority nursing action is to assess the patient. It is possible

the patient disconnected their leads, or the equipment has malfunctioned.
Assess the patient first!

C is incorrect. A is incorrect. The nurse first needs to assess the patient. If they
patient is in asystole, THEN yell for help!

D is incorrect. The nurse first needs to assess the patient. If they patient is in
asystole, THEN chest compressions should be started.
 Delegation

The five rights of delegation

● Right task
● Right circumstance
● Right Person
● Right communication
● Right supervision 
Right task
● Can this task be delegated?
● Is it within the scope of an LPN, or an unlicensed assistive personnel such
as a nursing assistant? 
● Is it a low risk task?
● Is it within the scope of practice of the RN to delegate?

Right circumstance
● What is going on with that patient?

○ Are they stable? If unstable - RN should not delegate!

● How about with the person you’re delegating to?

○ How much training do they have?

○ How many patients do they have - are they able to complete the task you’re delegating to
them?

○ Do you feel comfortable delegating this task?

Right person
● Who are you delegating to?
● Do they have the appropriate training?
● Do they have experience with this take?
● Are they competent in the task you are delegating?
● Should you delegate to an LPN or an UAP?

Right communication
● ALWAYS explain what you are delegating!
● What do you expect them to do?
● Do you expect them to follow up and report back to you?
Right supervision
● The RN should always ensure the task was completed properly. 
● Accountability is not transferred to the person you are delegating to, the
RN is ultimately responsible!!

Unlicensed Assistive Personnel (UAP)

YES
Scope of practice
● Ambulating
● Turning NO
● Bathing ● IVs
● Intake and output ● Administering
● Oral care medication
● Toileting ● Assessments
● Feeding ● Delegate any task
● Vital signs
● Weights
● Linen change
LPN Scope of practice
YES NO
● Duties depend on the state, the facility, and the LPN’s training.  ● Teaching and
● Ambulating education 
● Weights
● Turning
● Gathering data ● Assessment
● Bathing
● Oral care
● Taking care of stable patients  ● Planning
● Toileting
● Wound care
● Evaluation 
● Ostomy care
● Feeding
● Reinforcement of teaching
● Interpreting data 
● Vital signs
● Taking care of
unstable patients 
Insert IVs?? DEPENDS ON THE STATE.
Administer narcotics?? DEPENDS ON THE STATE.

The NCLEX will not give you an impossible question! Don’t get hung up on the specifics.
Focus on the general: stable patients, reinforcement, NOT THE NURSING PROCESS…..

Registered Nurse scope of practice

● Assessment
● Evaluation
● Teaching
● Education
● All medications
● Blood transfusions
● Invasive procedures
● Developing care plans 
From the Board of Nursing….
● “The licensed nurse who delegates ‘responsibility’ maintains overall
accountability for the patient”
● “The licensed nurse cannot delegate nursing judgement or any activity
that will involve nursing judgement or critical decision making”

NCLEX Question
A nurse working in a busy long-term care facility needs to delegate to the
unlicensed assistive personnel she is working with. Which of the following
tasks would be appropriate to delegate? Select all that apply.

A. Performing an initial assessment

B. Checking vital signs
C. Setting up oxygen
D. Listen to the patient’s lung sounds
Answer: B and C
A is incorrect. Performing an initial assessment is not an appropriate task to
delegate. Assessment is out of the scope of practice of unlicensed assistive
personnel.

B is correct. Checking vital signs is an appropriate task to delegate.

C is correct. Setting up oxygen is part of routine room set up and is an

appropriate task to delegate.

D is incorrect. Listening to the patient’s lung sounds requires assessment,

which is out of the scope of practice of unlicensed assistive personnel.

Break! Back at….

 Testing Strategies

Eliminate what you KNOW is wrong first.

● Read each answer choice individually

● If you know it is wrong, mark it out.

● If part of the answer is wrong, the WHOLE answer is wrong. Mark it out!
NCLEX Question
The nurse just administered IM toradol to a 15 year old female. What is the
correct way for her to dispose of the needle?

A. Cap the needle and place it in the sharps container.

B. Place the needle in a biohazard bag
C. Place the uncapped needle in the sharps container immediately
D. Cap the needle and dispose of it in the regular trash.

Answer: C
A is incorrect: Capping the needle and placing it in the sharps container is not
appropriate. Needles should never be recapped due to the increased risk of
injury to staff.

B is incorrect: Used sharps should not be placed in a biohazard bag. This is

unsafe and improper disposal of potentially infectious waste.

C is correct: It is appropriate to place the uncapped needle in the sharps

container immediately. Not recapping the needle decreases risk of a
needlestick injury, and the sharps container is an appropriate location for
potentially infectious waste such as used sharps.

D is incorrect: It is not appropriate to either cap the needle or dispose of it in

the regular trash.
 NCLEX Question
A client has been placed on a sodium-restricted diet following a myocardial
infarction. Which of the following would be the most appropriate meals to
suggest?

A. Turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1
orange
B. Broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk
C. Canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
D. A bologna sandwich, fresh eggplant, 2 oz. fresh fruit, tea, and apple juice

Answer: A
The correct answer is A. People with heart failure may improve their symptoms by reducing the
amount of sodium in their diet. Sodium is a mineral found in many foods, especially salt.
Overeating salt causes the body to keep or retain too much water, worsening the fluid buildup.
Patients should be encouraged to follow a low-sodium diet to help manage symptoms of
hypertension and to reduce edema. One of the most natural things a patient can do at home to
reduce sodium intake is to eat fresh vegetables rather than canned. If canned vegetables are the
only option, the patient should rinse the plants with clean water and cook them with new, unsalted
water.

B is incorrect. Canned vegetables should be avoided.

C and D are incorrect. Canned or processed meats are higher in sodium and should be avoided.

NCSBN Client Need

Topic: Physiological Integrity
Subtopic: Basic Care and Comfort
Fundamentals of Nursing
Chapter 51: Circulation
Lesson: Alterations in Cardiac Functioning/Dietary Consideration
Group drug classes together and remember what
their names look like.
● -pam = anti-anxiety agent

● You don’t need to memorize every drug

● -ptyline = TCA
from your Davis Drug Guide.
● -pril = ACE inhibitor

● Study the major groups from the

●
pharmacology crash course and learn
-lol = beta blocker

what the names sound/look like. ● -mycin = antibiotic

● -cillin = penicillin abx

● -azole = antifungal

● -mide = loop diuretic

If a question asks you who is THE MOST at risk or

THE MOST likely etc….. Tally up ‘risk factors’ and
choose the patient with the most!
● The might all have some risk/likelihood

● The right answer will be the patient with THE MOST

● 3 risk factors wins over 2!

NCLEX Question
Which of the following is most consistent with a patient who has
hypothyroidism?

A. Thin, anxious-appearing female with exophthalmos with rapid pulse and

complaints of diarrhea
B. Slightly obese, perspiring female who complains of feeling cold all the
time and frequent diarrhea
C. Thin, perspiring male with a hoarse voice, facial edema, and a thick
tongue with complaints of diarrhea
D. Slightly obese female with periorbital edema who complains of cold
intolerance, brittle hair, and dry skin

Answer: D
The correct answer is D. The patient with hypothyroidism would demonstrate clinical signs
and symptoms of a low metabolic rate resulting from the depletion of circulating thyroid
hormone.

A is incorrect. Exophthalmos may occur when hyperthyroidism is present.

B is incorrect. The patient is not likely to perspire, as lower than normal body temperature is
usually present.

C is incorrect. Constipation is a likely complaint among those with hypothyroidism.

NCSBN Client Need

Topic: Physiological Integrity
Subtopic: Physiological Adaptation
Resource: Fundamentals of Nursing 8th Edition (Wolters/Klewer)
Don’t pick an answer if you don’t know what it
means.
● If I haven't heard of it no one else has either

● You are a brand new nurse!

● The NCLEX knows that!

Know the WHY behind signs and symptoms

● Think through WHY something is happening.

● Polyuria → fluid volume deficit→ shock

● Heart failure → pump not moving blood forward → decreased blood flow
to kidneys → decreased UOP → fluid retention

● Hypoxia → not enough oxygen to the tissues → not enough oxygen to the
brain → anxious patient/change in LOC
NCLEX Question
Which of the following heart sounds would the nurse expect to
auscultate in her patient diagnosed with heart failure? Select all that
apply.

a. S1
b. S2
c. S3
d. S4

Answer: A, B, and C
A is correct. The nurse would expect to hear an S1 heart sound in her patient with heart failure. S1 is a normal heart
sound caused by the closing of the mitral and tricuspid valves. This heart sound should still be auscultated in a
patient with heart failure.

B is correct. The nurse would expect to hear an S2 heart sound in her patient with heart failure. S2 is a normal heart
sound produced by the closure of the aortic and pulmonic valves. This heart sound should still be auscultated in a
patient with heart failure.

C is correct. The nurse would expect to hear an S3 heart sound in her patient with heart failure. This is an abnormal
heart sound also known as a ventricular gallop. It occurs after S2 with the opening of the mitral valve, and is caused
by a large amount of blood hitting a compliant left ventricle. Because this abnormal heart sound is associated with a
large amount of blood, it is related to fluid volume overload. We see fluid volume overload in heart failure patients
whose hearts are not effectively moving blood forward. That is why S3 is heart in patients with heart failure.

D is incorrect. The nurse would not expect to hear an S4 heart sound in her patient with heart failure. S4 is also
known as an “atrial gallop” it occurs before S1 when the atria contract to force blood into the left ventricle. It is caused
by a stiff, noncompliant left ventricle.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatrics
Lesson: Cardiac
NCLEX Question
A client suddenly develops syndrome of inappropriate antidiuretic hormone
(SIADH) after undergoing cranial surgery. Which manifestations should the
nurse expect to see from the patient? Select all that apply.

a. Edema and weight gain

b. Decreased urine production
c. Hypotension
d. A low urine specific gravity

Answers: ADand B
Answers:
SIADH is an abnormal release of the antidiuretic hormone, which causes the client to retain water abnormally.
SIADH
This leads is an abnormal
to manifestations suchrelease
as weightof the
gain antidiuretic
without hormone,
peripheral edema which
or pulmonary causes the
edema,
and low urine output. It is a euvolemic condition because sodium gets excreted and only water is retained
client to retain water abnormally. This leads to manifestations such as edema,
Excessive urine production, low blood pressure, and a little urine specific gravity are manifestations of Diabetes
weight gain, and low urine output. Excessive urine production, low blood
Insipidus
pressure, and a little urine specific gravity are manifestations of Diabetes
insipidus.
Think like a NEW nurse!
The NCLEX expects you to have 2 weeks of nursing knowledge.

They DO NOT expect you to know everything.

They DO expect you to keep your patient safe.

ALWAYS protect the patient

Safety first

This test is to protect the public

Assume the worst - fix the problem.

If there is a question about it there is something to worry about.

NCLEX Question
A nurse is calling the physician regarding a new medication order because the
dosage prescribed is higher than the usual recommended dosage. The nurse,
however, is unable to locate the physician, and the medication is due to be
administered. Which action should the nurse implement first?

a. Contact the unit’s nursing supervisor

b. Administer the dose as prescribed since the nurse is protected by a
written order
c. Hold the medication until the physician can be contacted and the
order is clarified
d. Administer what the nurse knows as the recommended dose until the
physician can be located
Answer: AC
Answer:

The correct
The correct answer
answerisisA.C.IfIfthe
thephysician
physicianwrites
writesaa prescription
prescription thatthat
is is
questionable or requires clarification, the nurse is responsibility is to contact
the physician. If there is no resolution regarding the order because the
physician cannotbe
physician cannot belocated
locatedor orbecause
becausethethephysician
physician insists
insists onon keeping
keeping thethe
medicine as it was written, the nurse should contact the nurse manager or
nursing supervisor for further clarification as to the proper steps that should
be taken. Under no circumstances should the nurse proceed to carry out the
prescription until obtaining description.

Pick the least invasive option first.

● Nonpharmacologic interventions before medication.

● Non-opioid analgesic before opioid

● PT/OT before surgery

● Restraints as a last resort

Only call the healthcare provider if there is nothing
that YOU the nurse can do for your patient.
● If there is an immediate intervention YOU can take to help, do that first!

● Prolapsed umbilical cord – priority is lift the presenting part of the fetus off
the cord, NOT call the HCP.

NCLEX Question
The nurse walks into her patient’s room and see that his chest tube has
become dislodged and is lying on the floor. Which of the following is the
priority nursing action?

A. Cover the site with a sterile dressing

B. Call the provider
C. Press the code bell
D. Reinsert the chest tube
Answer: A
A is correct. Covering the site with a sterile dressing is the immediate nursing
action. This will prevent air from entering the pleural space. The nurse should
tape the dressing down on three sides allowing air to escape so that she does
not cause a pneumothorax.

B is incorrect. The nurse would call the provider after placing a sterile dressing
over the site.

C is incorrect. The nurse does not need to press the code bell unless the
patient codes.

D is incorrect. It is NEVER appropriate to reinsert a chest tube!!

NCLEX Question
The nurse is reassessing her patient diagnosed with appendicitis. The patient
expressed 8/10 pain at her last assessment, and now states she has no pain.
The nurse did not administer any pain medication. What is the appropriate
nursing action?

a. Document the pain score

b. Assess the patient’s abdomen
c. Notify the healthcare provider
d. Palpate McBurney’s point
Answer: C
A is incorrect. When a patient diagnosed with appendicitis has sudden relief of pain, it is a sign of possible
rupture of the appendix. This is a surgical emergency and the patient must be taken to the operating room
quickly. It is not appropriate for the nurse to document the pain score without further intervention.

B is incorrect. It is not appropriate to simply assess the patient’s abdomen without further intervention.
Sudden relief of pain is concerning for rupture of the appendix and requires another action.

C is correct. The nurse should immediately notify the healthcare provider of this change in the patient’s
status. A sudden change of 8/10 pain to no pain in the patient diagnosed with appendicitis could indicate
rupture, and the healthcare provider needs to be immediately notified.

D is incorrect. The patient with appendicitis will likely have pain at McBurney’s point, but this patient is
expressing a sudden relief of their pain. This needs to be evaluated for possible rupture, and therefore the
nurse should immediately notify the healthcare provider.

NCSBN Client Need:

Topic: Physiological Integrity Subtopic: Physiological adaptation

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatric
Lesson: Endocrine

For priority questions, pick the answer most likely

to kill your patient.
Pain doesn’t kill your patient.

Hypoxia kills.

Acidosis kills.

Respiratory distress kills. Losing an airway kills.

SOME arrhythmias kill. VT, VF, asystole = fatal

 NCLEX Question
The nurse is assessing a 4 year old who was sent to the ED from urgent care. Assessment
reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling.
Vital signs are:
Temp: 39 C
HR: 188
RR: 46
O2: 82 %
Which of the following is the priority nursing action at this time?

a. Keep the child calm and call for emergency airway equipment
b. Obtain IV access
c. Assess the throat for a cherry red epiglottis
d. Place the child on a high flow nasal cannula at 100% FiO2

Answer: A
A is correct. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with
excessive drooling, distress, and stridor is highly suspicious for this medical emergency. In addition, this patient is already
showing signs of circulatory compromise including circumoral cyanosis and mottling. The priority nursing action in this
emergency is keeping the child calm and calling for emergency airway equipment. The child is at risk of losing their airway, and
airway is always the priority!

B is incorrect. It is inappropriate to attempt to obtain IV access on a child suspected of epiglottitis before emergency airway
equipment is available. The priority action at this time is keeping the child calm and calling for emergency airway equipment.

C is incorrect. It is inappropriate to assess the throat for a cherry red epiglottis at this time. Although presence of a cherry red
epiglottis would confirm the diagnosis of epiglottitis, this child is at risk of losing their airway. The priority action will be to
protect that airway before assessing the throat. .

D is incorrect. Placing the child on a high flow nasal cannula at 100% FiO2 is not the priority at this time. This answer probably
sounded right, because you see the O2 is 82% and they have circumoral cyanosis. Oxygen sounds like the right answer! But this
intervention addresses the ‘C’ in your ABC’s - circulation. And the priority is always ‘A’, airway! This child is at risk of losing their
airway, so all interventions need to wait until there is emergency airway equipment close by. If anything upsets the child their
airway could spams and obstruct completely making it impossible to intubate them. That is why keeping the child calm and
calling for emergency airway equipment is the priority in epiglottitis patients.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatric
Lesson: Respiratory
If the answer puts work off on someone else, it is
wrong.
● YOU should be doing the work.

● “Save for the next shift” = wrong

If the answer ignores what a patient is saying, it is

wrong.
● Patient focused answers

● Always listen to the patient

● Always take the patient’s concerns seriously

● Use therapeutic communication

 NCLEX Question
The nurse observes a parent swaddling their infant with an unrepaired omphalocele.
Which of the following statements would be appropriate?

a. “Stop, you’ll kill your baby!!”

b. “That is a nice, tight swaddle. It will really help sooth your new baby”
c. “May I help you? We will need to be careful with their intestines, we do not
want the swaddle to push them back inside.”
d. “Swaddling is not allowed for these babies, please stop.”

Answer: C
A is incorrect. This is inappropriate to say to a parent as it would cause panic and upset them. The nurse wants to
promote the parent bonding with their infant, and phrases like this will scare the parent and make them afraid to
touch the baby, which is not therapeutic.

B is incorrect. It is not appropriate to tightly swaddle an infant with an omphalocele. This would place pressure on
their exposed intestines and could push them back inside of the baby, which we do not want.

C is correct. This is a therapeutic statement. It educates the parent about the need to swaddle the baby only very
loosely, and avoid any pressure on the exposed intestines so that they do not get pushed back inside of the baby. It
also promotes bonding with the infant, as it encourages the parent to touch and care for their baby.

D is incorrect. This is not appropriate. Swaddling is not ideal for an infant with an omphalocele due to the exposed
intestines, but if it is done loosely and avoids placing pressure on the defect it can certainly be done. Telling the
parent to stop will not promote bonding and decrease their interaction with the baby. The nurse should educate the
parent on the necessary precautions when traveling and help them develop a positive relationship with their new
baby.

NCSBN Client Need:

Topic: Physiological Integrity Subtopic: Physiological adaptation

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatric
Lesson: Gastrointestinal
Select all that apply - treat each answer choice as a
true or false question. They are all independent of
each other.
● All of the answers could be right.

● Only one could be right.

NCLEX Question
You are working in an ICU caring for a 62 year old male who was prescribed
vancomycin for an infection. He develops persistent, watery diarrhea. Which
of the following precautions do you take? Select all that apply.

A. Sanitize your hands before and after entering the room

B. Place the patient is a negative pressure room
C. Wear an N95 and face shield when entering the room.
D. Use single use equipment and leave it inside of the room
Answer: D
A is incorrect. The nurse should suspect C. diff in the patient that develops watery diarrhea after an
antibiotic course. Sanitizing your hands before and after entering the room will not kill the C. diff
spores. The nurse will need to wash her hands with soap and water.

B is incorrect. Placing the patient is a negative pressure room is not necessary. The nurse suspects C.
diff, which requires special enteric precautions. A negative pressure room is indicated for airborne
precautions.

C is incorrect. Wear an N95 and face shield when entering the room. is not necessary. The nurse
suspects C. diff, which requires special enteric precautions. A N95 and face shield is indicated for
airborne precautions.

D is correct. Using single use equipment and leaving it inside of the room is important for special
enteric precautions. The nurse should take this precaution.

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