NCLEX Prioritization and Delegation exam Questions and
Correct Answers (100% COMPLETE ANSWERS)
ALREADY GRADED A+ | 100% satisfaction guarantee
The experienced LPN is caring for the client with acute substernal chest pain. Which actions should the
nurse delegate to the LPN? Select all that apply.
1. Give 325 mg chewable aspirin to the client
2. Give heparin 5000 units IV
3. Administer morphine sulfate 4 mg IV
4. Apply oxygen at 2-4 liters through NP
5. Place leads on the client's chest for cardiac monitoring - ANSWER-1, 4, & 5
1. It is within the LPN's scope of practice to administer oral medication
4. It is within the LPN's scope of practice to administer oxygen
5. It is within the scope of practice of the LPN to attach cardiac monitor leads
The nurse's morning assessment of the client with HF reveals bounding peripheral pulses, weight gain of
2 lbs, pitting ankle edema, and moist crackles bilaterally. Which prescribed intervention should be the
nurses priority at this time?
1. Lasix 40 mg IV push q8h x3 doses
2. Enalapril 10 mg PO daily
3. Restrict fluids to 1500 mL per day
4. Echocardiogram as soon as possible - ANSWER-1. Findings suggest fluid volume overload. Diuretics
such as Lasix are the first-line treatment for fluid volume overload in the client with HF and should be
the priority
The nurse is working with the UAP on a telemetry unit caring for the client who had an MI three days
ago. Which task is appropriate to delegate to the UAP?
1. Administering nitro if chest discomfort occurs during client activities
2. Monitoring vital signs and oxygen saturation before and after client ambulation
3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand
4. Explaining the rationale for alternating rest periods with exercise to the client and family - ANSWER-2.
Monitoring vital signs and oxygen saturation is within the UAP's scope of practice
,The hospitalized client with HF is receiving dobutamine IV. Of the associated responsibilities in the care
of the client, which statement is most appropriate for the RN when delegating to the experienced NA?
1. "Teach the client about the reasons for remaining on bedrest".
2. "Take the client's vital signs every hour and report them to me".
3 Turn off the infusion pump if the client becomes hypotensive".
4. "Inform the HCP on the rounds that the client's urine output is low - ANSWER-2. An experienced NA
would be able to monitor the client's vital signs and should know to report significant changes to the RN
The RN and NA are assigned to care for a group of clients. During shift report, the RN learns that a BP
taken 1 hour previously for the client was 198/94 mmHg and that the previous shift RN did not
intervene. Prioritize the order that the RN should implement the interventions.
1. Notify the client's HCP
2. Ask the NA to retake the client's vital signs now, and have the NA set an automatic BP machine to
retake the BP every 15 minutes
3. Administer the newly prescribed lasix and enalapril
4. Assess the client asking specific questions related to headache, dizziness, and orientation
5. Inform the charge nurse of the client's critically high BP and the actions taken - ANSWER-2, 4, 1, 3, 5
2. Ask the NA to retake the client's vital signs now, and have the NA set an automatic BP machine to
retake the BP every 15 minutes should be first. Current values are needed prior to notifying the HCP
4. Assess the client asking specific questions related to headache, dizziness, and orientation after the NA
obtains the BP. A stroke can result from uncontrolled hypertension
1. Notify the client's HCP about the client's elevated BP is next. Essential information is needed before
calling
3. Administer the newly prescribed lasix and enalapril. Interventions are needed to quickly lower the
client's BP
5. Inform the charge nurse of the client's critically high BP and the actions taken. If the situation is under
control and the charge nurse's assistance is not needed, then the charge nurse can be informed of the
situation after actions are taken
The adult client is newly admitted to the PACU from surgery. Which assessment finding should be the
nurse's priority?
1. The surgical site dressing has a scant amount of blood
,2. The client is sleeping but easily arouses when touched
3. The client's respiration's are 6-8 BPM
4. The client's blood pressure 5 minutes ago was 110/68 mmHg - ANSWER-3. A low respiratory rate is
the priority because anesthetic agents decrease respiration's. Adult respiration's should be 12-20 BPM
The UAP reports a sudden increase in temperature of 102.4F (39C) in the 48-hour postoperative client.
Which instruction should the nurse give to the UAP when the nurse observes a cup of steaming coffee at
the client's bedside?
1. "Encourage oral fluids to prevent the client from becoming dehydrated"
2. "Recheck the temperature 15 minutes after the client finishes the coffee"
3. "Ask the client to drink only cold water and juices for the next 24 hours"
4. "Document this temperature elevation on the flow sheet in client's chart" - ANSWER-2. Assessment of
any previous activity that would alter temperature should be make (i.e. smoking or oral intake) and
avoided prior to taking the temperature. Asking the UAP to recheck the temperature in 15 minutes is
more appropriate
The NA is assisting in the preoperative preparation of the client. Which tasks should the nurse delegate
to the NA? Select all that apply.
1. Inserting the client's NG tube
2. Obtaining the client's vital signs
3. Recording output after emptying a urinary drainage bag
4. Completing the preoperative checklist
5. Witnessing the client's signature on an operative consent form - ANSWER-2 & 3
2. Obtaining vital signs is within the NA's scope of practice. The nurse should consider the knowledge
and skills of the person receiving the delegation
3. Emptying a urinary drainage bag and recording output are within the NA's scope of practice
The nurse and the experienced LPN are working together to care for the client who is unconscious.
Which tasks should the nurse plan to delegate to the LPN? Select all that apply.
1. Listen to the client's lung sounds every 4 hours
2. Check pupil size and reactivity every 2 hours
3. Check an axillary temperature every 4 hours
, 4. Check enteral feeding residual volumes every 4 hours
5. Turn and massage the client's back every 2 hours - ANSWER-3, 4, & 5
3. The experienced LPN is able to check axillary temperatures every 4 hours and should know to report
significant changes to the RN
4. The experienced LPN should be able to check enteral feeding residual volumes every 4 hours and
should know to report significant findings to the RN
5. Turning and rubbing the client is necessary to prevent skin breakdown and is appropriate to delegate
to the LPN
The nurse observes the LPN providing care for the client who had contact precautions due to a c.diff.
infection. Which action by the LPN requires the nurse's immediate correction?
1. Donning medical examination gloves upon entering the client's room
2. Wearing a gown while giving the client a bed bath and changing the bed linen
3. Informing a visitor to wash hands with soap and water upon leaving the client's room
4. Using an alcohol-based hand cleanser for hand hygiene when exiting the client's room - ANSWER-4.
Alcohol-based hand cleansers should not be used for hand hygiene with c.diff. The organism forms
spores, and alcohol-based antiseptic agents have poor activity against spores
The nurse is caring for the client with an STI who is immobile. Which task is most appropriate to
delegate to the UAP?
1. Bathing the client including involved areas to provide local comfort
2. Teaching the client to perform frequent hand washing to prevent secondary infection
3. Encouraging the client to use condoms to help prevent the spread of infection
4. Informing the client about the need for sexual partner(s) to receive treatment - ANSWER-1. It is best
to delegate bathing because it is within the UAP's scope of practice
The nurse is working with the LPN who is helping care for the HIV-positive client with sever esophagitis
caused by Candida albicans. Which action by the LPN requires the nurse to intervene immediately?
1. Suggests that the client might like to order chile con carne for the next meal
2. Places a "no visitors" sign on the door of the room at the client's request
3. Performs hand hygiene and puts on a mask and gown before entering the client's room
Correct Answers (100% COMPLETE ANSWERS)
ALREADY GRADED A+ | 100% satisfaction guarantee
The experienced LPN is caring for the client with acute substernal chest pain. Which actions should the
nurse delegate to the LPN? Select all that apply.
1. Give 325 mg chewable aspirin to the client
2. Give heparin 5000 units IV
3. Administer morphine sulfate 4 mg IV
4. Apply oxygen at 2-4 liters through NP
5. Place leads on the client's chest for cardiac monitoring - ANSWER-1, 4, & 5
1. It is within the LPN's scope of practice to administer oral medication
4. It is within the LPN's scope of practice to administer oxygen
5. It is within the scope of practice of the LPN to attach cardiac monitor leads
The nurse's morning assessment of the client with HF reveals bounding peripheral pulses, weight gain of
2 lbs, pitting ankle edema, and moist crackles bilaterally. Which prescribed intervention should be the
nurses priority at this time?
1. Lasix 40 mg IV push q8h x3 doses
2. Enalapril 10 mg PO daily
3. Restrict fluids to 1500 mL per day
4. Echocardiogram as soon as possible - ANSWER-1. Findings suggest fluid volume overload. Diuretics
such as Lasix are the first-line treatment for fluid volume overload in the client with HF and should be
the priority
The nurse is working with the UAP on a telemetry unit caring for the client who had an MI three days
ago. Which task is appropriate to delegate to the UAP?
1. Administering nitro if chest discomfort occurs during client activities
2. Monitoring vital signs and oxygen saturation before and after client ambulation
3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand
4. Explaining the rationale for alternating rest periods with exercise to the client and family - ANSWER-2.
Monitoring vital signs and oxygen saturation is within the UAP's scope of practice
,The hospitalized client with HF is receiving dobutamine IV. Of the associated responsibilities in the care
of the client, which statement is most appropriate for the RN when delegating to the experienced NA?
1. "Teach the client about the reasons for remaining on bedrest".
2. "Take the client's vital signs every hour and report them to me".
3 Turn off the infusion pump if the client becomes hypotensive".
4. "Inform the HCP on the rounds that the client's urine output is low - ANSWER-2. An experienced NA
would be able to monitor the client's vital signs and should know to report significant changes to the RN
The RN and NA are assigned to care for a group of clients. During shift report, the RN learns that a BP
taken 1 hour previously for the client was 198/94 mmHg and that the previous shift RN did not
intervene. Prioritize the order that the RN should implement the interventions.
1. Notify the client's HCP
2. Ask the NA to retake the client's vital signs now, and have the NA set an automatic BP machine to
retake the BP every 15 minutes
3. Administer the newly prescribed lasix and enalapril
4. Assess the client asking specific questions related to headache, dizziness, and orientation
5. Inform the charge nurse of the client's critically high BP and the actions taken - ANSWER-2, 4, 1, 3, 5
2. Ask the NA to retake the client's vital signs now, and have the NA set an automatic BP machine to
retake the BP every 15 minutes should be first. Current values are needed prior to notifying the HCP
4. Assess the client asking specific questions related to headache, dizziness, and orientation after the NA
obtains the BP. A stroke can result from uncontrolled hypertension
1. Notify the client's HCP about the client's elevated BP is next. Essential information is needed before
calling
3. Administer the newly prescribed lasix and enalapril. Interventions are needed to quickly lower the
client's BP
5. Inform the charge nurse of the client's critically high BP and the actions taken. If the situation is under
control and the charge nurse's assistance is not needed, then the charge nurse can be informed of the
situation after actions are taken
The adult client is newly admitted to the PACU from surgery. Which assessment finding should be the
nurse's priority?
1. The surgical site dressing has a scant amount of blood
,2. The client is sleeping but easily arouses when touched
3. The client's respiration's are 6-8 BPM
4. The client's blood pressure 5 minutes ago was 110/68 mmHg - ANSWER-3. A low respiratory rate is
the priority because anesthetic agents decrease respiration's. Adult respiration's should be 12-20 BPM
The UAP reports a sudden increase in temperature of 102.4F (39C) in the 48-hour postoperative client.
Which instruction should the nurse give to the UAP when the nurse observes a cup of steaming coffee at
the client's bedside?
1. "Encourage oral fluids to prevent the client from becoming dehydrated"
2. "Recheck the temperature 15 minutes after the client finishes the coffee"
3. "Ask the client to drink only cold water and juices for the next 24 hours"
4. "Document this temperature elevation on the flow sheet in client's chart" - ANSWER-2. Assessment of
any previous activity that would alter temperature should be make (i.e. smoking or oral intake) and
avoided prior to taking the temperature. Asking the UAP to recheck the temperature in 15 minutes is
more appropriate
The NA is assisting in the preoperative preparation of the client. Which tasks should the nurse delegate
to the NA? Select all that apply.
1. Inserting the client's NG tube
2. Obtaining the client's vital signs
3. Recording output after emptying a urinary drainage bag
4. Completing the preoperative checklist
5. Witnessing the client's signature on an operative consent form - ANSWER-2 & 3
2. Obtaining vital signs is within the NA's scope of practice. The nurse should consider the knowledge
and skills of the person receiving the delegation
3. Emptying a urinary drainage bag and recording output are within the NA's scope of practice
The nurse and the experienced LPN are working together to care for the client who is unconscious.
Which tasks should the nurse plan to delegate to the LPN? Select all that apply.
1. Listen to the client's lung sounds every 4 hours
2. Check pupil size and reactivity every 2 hours
3. Check an axillary temperature every 4 hours
, 4. Check enteral feeding residual volumes every 4 hours
5. Turn and massage the client's back every 2 hours - ANSWER-3, 4, & 5
3. The experienced LPN is able to check axillary temperatures every 4 hours and should know to report
significant changes to the RN
4. The experienced LPN should be able to check enteral feeding residual volumes every 4 hours and
should know to report significant findings to the RN
5. Turning and rubbing the client is necessary to prevent skin breakdown and is appropriate to delegate
to the LPN
The nurse observes the LPN providing care for the client who had contact precautions due to a c.diff.
infection. Which action by the LPN requires the nurse's immediate correction?
1. Donning medical examination gloves upon entering the client's room
2. Wearing a gown while giving the client a bed bath and changing the bed linen
3. Informing a visitor to wash hands with soap and water upon leaving the client's room
4. Using an alcohol-based hand cleanser for hand hygiene when exiting the client's room - ANSWER-4.
Alcohol-based hand cleansers should not be used for hand hygiene with c.diff. The organism forms
spores, and alcohol-based antiseptic agents have poor activity against spores
The nurse is caring for the client with an STI who is immobile. Which task is most appropriate to
delegate to the UAP?
1. Bathing the client including involved areas to provide local comfort
2. Teaching the client to perform frequent hand washing to prevent secondary infection
3. Encouraging the client to use condoms to help prevent the spread of infection
4. Informing the client about the need for sexual partner(s) to receive treatment - ANSWER-1. It is best
to delegate bathing because it is within the UAP's scope of practice
The nurse is working with the LPN who is helping care for the HIV-positive client with sever esophagitis
caused by Candida albicans. Which action by the LPN requires the nurse to intervene immediately?
1. Suggests that the client might like to order chile con carne for the next meal
2. Places a "no visitors" sign on the door of the room at the client's request
3. Performs hand hygiene and puts on a mask and gown before entering the client's room
