NCLEX CRUSADE ACADEMY TEST - 2 ADVANCE PRIORITY STRATEGY PRT II

1. A nurse is preparing to intervene in a patient's care but realizes that no full assessment has been performed. What is the nurse's priority action?. Call the physician immediately. Perform a comprehensive assessment first. Implement nursing interventions immediately. Prepare emergency equipment.

2. A monitor shows ventricular tachycardia when the nurse enters the room. What is the first action?. Call a Code Blue immediately. Defibrillate the patient. Assess the patient's pulse. Administer antiarrhythmic medication.

3. A cardiac monitor shows asystole, but the patient is awake and speaking. What is the nurses priority action?. Start CPR. Call the physician. Defibrillate immediately. Troubleshoot the monitor.

4. A patient experiences sudden severe eye pain following cataract surgery. What is the nurses priority action?. Administer analgesics. Reposition the patient. Call the physician immediately. Apply an eye patch.

5. When several interventions appear correct and urgent, what strategy should the nurse use?. Choose the quickest task. Choose the least invasive intervention. Select the 'umbrella' action. Ask another nurse.

6. A patient presents with facial droop, slurred speech, and lethargy. What is the priority action?. Perform a full neurological assessment. Call the physician. Activate a stroke code. Monitor the patient.

7. A COPD patient with oxygen saturation of 89% presents with respiratory distress. What is the least invasive initial action?. Intubate the patient. Place the patient in high Fowlers position. Administer high flow oxygen. Start mechanical ventilation.

8. A child requires a final IV dose of medication but the IV has infiltrated. What is the appropriate action?. Administer medication IM. Restart the IV or contact the provider. Skip the medication. What is the appropriate action? A. Administer medication IM B. Restart the IV or contact the provider C. Skip the medication D. Administer orally.

9. In Select AlI That Apply (SATA) questions, how should options be evaluated?. Compare answers against each other. Choose the most common options. Evaluate each option as a true or false statement. Choose only two answers.

10. A myocardial infarction patient develops crackles and edema. Which intervention is appropriate?. Encourage fluids. Administer IV furosemide. Ignore symptoms. Delay treatment.

11. When prioritizing patients in a typical clinical situation, which patient is seen first?. The patient who arrived first. The most unstable patient. The patient requesting pain medication. The patient awaiting discharge.

12. During a mass casualty event, priority is given to which patient?. The sickest patient. The patient with the highest chance of survival. The oldest patient. The patient who arrived first.

13. A patient with a sucking chest wound during a disaster triage scenario would most likely be categorized as: Minor. Expectant. Delayed. Immediate.

14. A patient with catastrophic injuries unlikely to survive during a mass casualty event would be categorized as: Green tag. Yellow tag. Black tag. Red tag.

15. Which patient can legally provide consent independently?. A 10 year old child. A cognitively impaired adult. A competent adult. A confused elderly patient.

16. Which minor may legally provide consent for treatment?. A 12 year old with parents present. A married 16 year old. A 14 year old student. A 15 year old with siblings.

17. A 72 year old patient with dementia attempts to sign consent for surgery. What is the nurses action?. Accept the consent. Ignore the consent. Obtain consent from a legal guardian. Delay surgery indefinitely.

18. A nurse suspects domestic abuse in an adult patient who refuses reporting. What should the nurse do?. Immediately call police. Respect confidentiality. Ignore the injuries. Discharge the patient.

19. If abuse is suspected in a minor patient, what is the nurses legal responsibility?. Maintain confidentiality. Report to authorities. Ask parents for permission. Document only.

20. What is the first step in the NCLEX decision tree strategy?. Identify if it is a mass casualty event. Call the physician. Administer medication. Start treatment.

21. If a patient has not been assessed, what answer should usually be chosen?. Implementation action. Assessment answer. Physician notification. Medication administration.

22. If multiple actions are required in a scenario, what strategy is recommended?. Choose the fastest task. Choose the umbrella intervention. Choose medication. Call the physician.

23. When deciding between two interventions, which should generally be chosen first?. The most invasive. The least invasive. The fastest. The physician order.

24. When should the nurse call the physician?. When the situation is an unexpected complication. For routine care. Before assessment. For minor issues.

25. The NCLEX decisionImaking framework emphasizes relying primarily on: Intuition. Anxiety. Systematic algorithms. Guessing.