SAUNDERS LAB VALUES
(CHAPTER 11) & PRIORITIZING
CLIENT CARE (CHAPTER 8) EVOLVE
ONLINE NCLEX STUDY GUIDE 2026
| GRADED A+ | GUARANTEED
SUCCESS
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales Included
,The nurse employed in a long-term care facility is A client who requires a 24-hour urine collection
planning the client assignments for the shift. Which client
should the nurse assign to the unlicensed assistive Rationale:
personnel (UAP)? The nurse must determine the most appropriate assignment on the basis of the
skills of the staff member and the needs of the client. The assignment of tasks
needs to be implemented on the basis of the job description of the individual, the
individual's level of clinical competence, and state law.
The nurse is assigned to care for four clients. When A client on a ventilator
planning client rounds, which client should the nurse
check first? Rationale:
The airway is always a priority, and the nurse first checks the client on a ventilator.
The nurse employed in an emergency department is A client with chest pain who states that he just ate pizza that was made with a very
assigned to assist with the triage of clients arriving to the spicy sauce
emergency department. The nurse should assign priority
to which client? Rationale:
In an emergency department, triage involves classifying clients according to their
need for care, and it includes establishing priorities of care. The type of illness, the
severity of the problem, and the resources available govern the process. Clients
with trauma, chest pain, severe respiratory distress, cardiac arrest, limb
amputation, or acute neurological deficits and those who sustained a chemical
splash to the eyes are classified as emergent, and these clients are the number 1
priority. Clients with conditions such as simple fractures, asthma without
respiratory distress, fever, hypertension, abdominal pain, or renal stones have
urgent needs, and these clients are classified as the number 2 priority. Clients with
conditions such as minor lacerations, sprains, or cold symptoms are classified as
nonurgent, and they are the number 3 priority.
The nurse is educating a new nurse about mass casualty "Mass casualty events do not require an increase in the number of staff that are
events (disasters). Which statement by the new nurse needed."
indicates a need for further teaching? Select all that
apply. "A mass casualty event occurs only within the heath care facility and could
endanger staff."
"A mass casualty event occurs if a fight between visitors occurs in the emergency
department."
Rationale:
Mass casualty events, also known as disasters, overwhelm local medical
capabilities and may require the collaboration of multiple agencies and health
care facilities to handle the crises. This type of event can occur in the health care
facility or outside of it. Fights in the emergency department are not termed mass
casualty events but are agency security and local enforcement issues. Mass
casualty events almost always require an increase in staffing to ensure safe patient
care.
The nurse is attending an agency orientation meeting Nursing staff are led by the nurse when providing care to a group of clients.
about the nursing model of practice implemented in the
facility. The nurse is told that the nursing model is a team Rationale:
nursing approach. The nurse understands that which is a In team nursing, nursing personnel are led by the nurse when providing care to a
characteristic of this type of nursing model of practice? group of clients.
, A client experiences a cardiac arrest. The nurse leader Autocratic
quickly responds to the emergency and assigns clearly
defined tasks to the work group. In this situation, the Rationale:
nurse is implementing which leadership style? Autocratic leadership is an approach in which the leader retains all authority and
is primarily concerned with task accomplishment. It is an effective leadership style
to implement in an emergency or crisis situation. The leader assigns clearly
defined tasks and establishes one-way communication with the work group, and
he or she makes all decisions independently. Situational leadership is a
comprehensive approach that incorporates the leader's style, the maturity of the
work group, and the situation at hand. Democratic leadership is a people-
centered approach that is primarily concerned with human relations and
teamwork. This leadership style facilitates goal accomplishment and contributes
to the growth and development of the staff. Laissez-faire leadership is a
permissive style in which the leader gives up control and delegates all decision
making to the work group.
The nurse has delegated several nursing tasks to staff Perform follow-up with each staff member regarding the performance and
members. Which is the nurse's primary responsibility after outcome of the task.
the delegation of the tasks?
Rationale:
The ultimate responsibility for a task lies with the person who delegated it.
Therefore, it is the nurse's primary responsibility to follow up with each staff
member regarding the performance of the task and the outcomes related to
implementing the task. Not all staff members have the education, knowledge, and
ability to make judgments about tasks being performed. The nurse documents that
the task has been completed, but this would not be done until follow-up was
implemented and outcomes were identified. It is not appropriate to assign the
tasks that were not completed to the next nursing shift.
The nurse is assigned to care for four clients. When A client receiving oxygen who is having difficulty breathing
planning client rounds, which client should the nurse
collect data from first? Rationale:
The airway is always a priority, and the nurse would attend to the client who has
been experiencing an airway problem first.
The nurse is told that the laboratory result for the serum Withhold the medication.
digoxin level is 2.4 ng/mL. Which action should the nurse
take? Rationale:
The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A value of 2.4 ng/mL
exceeds the therapeutic range and could be toxic to the client. The nursing action
is to hold further doses of digoxin. Because the value is not normal, option 3 can
be eliminated. Administration of the next dose would cause the client to become
more toxic. Checking the client's respiratory rate is not applicable at this time.
A client with atrial fibrillation who is receiving Withholding the next dose of warfarin sodium
maintenance therapy with warfarin sodium (Coumadin)
has a prothrombin time (PT) of 30 seconds. The nurse Rationale:
anticipates that which will be prescribed? The normal PT is 9.6 to 11.8 seconds for the adult male and 9.5 to 11.3 seconds for
the adult female. The goal of oral anticoagulation with warfarin sodium therapy is
to achieve a PT at 1.5 to 2 times the laboratory control value. A PT of 30 seconds
places the client at risk for bleeding, so the nurse should anticipate that the client
would not receive further doses at this time. If the level is too high, the antidote
(vitamin K) may be prescribed. The remaining options would make the client even
more prone to bleeding.
(CHAPTER 11) & PRIORITIZING
CLIENT CARE (CHAPTER 8) EVOLVE
ONLINE NCLEX STUDY GUIDE 2026
| GRADED A+ | GUARANTEED
SUCCESS
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales Included
,The nurse employed in a long-term care facility is A client who requires a 24-hour urine collection
planning the client assignments for the shift. Which client
should the nurse assign to the unlicensed assistive Rationale:
personnel (UAP)? The nurse must determine the most appropriate assignment on the basis of the
skills of the staff member and the needs of the client. The assignment of tasks
needs to be implemented on the basis of the job description of the individual, the
individual's level of clinical competence, and state law.
The nurse is assigned to care for four clients. When A client on a ventilator
planning client rounds, which client should the nurse
check first? Rationale:
The airway is always a priority, and the nurse first checks the client on a ventilator.
The nurse employed in an emergency department is A client with chest pain who states that he just ate pizza that was made with a very
assigned to assist with the triage of clients arriving to the spicy sauce
emergency department. The nurse should assign priority
to which client? Rationale:
In an emergency department, triage involves classifying clients according to their
need for care, and it includes establishing priorities of care. The type of illness, the
severity of the problem, and the resources available govern the process. Clients
with trauma, chest pain, severe respiratory distress, cardiac arrest, limb
amputation, or acute neurological deficits and those who sustained a chemical
splash to the eyes are classified as emergent, and these clients are the number 1
priority. Clients with conditions such as simple fractures, asthma without
respiratory distress, fever, hypertension, abdominal pain, or renal stones have
urgent needs, and these clients are classified as the number 2 priority. Clients with
conditions such as minor lacerations, sprains, or cold symptoms are classified as
nonurgent, and they are the number 3 priority.
The nurse is educating a new nurse about mass casualty "Mass casualty events do not require an increase in the number of staff that are
events (disasters). Which statement by the new nurse needed."
indicates a need for further teaching? Select all that
apply. "A mass casualty event occurs only within the heath care facility and could
endanger staff."
"A mass casualty event occurs if a fight between visitors occurs in the emergency
department."
Rationale:
Mass casualty events, also known as disasters, overwhelm local medical
capabilities and may require the collaboration of multiple agencies and health
care facilities to handle the crises. This type of event can occur in the health care
facility or outside of it. Fights in the emergency department are not termed mass
casualty events but are agency security and local enforcement issues. Mass
casualty events almost always require an increase in staffing to ensure safe patient
care.
The nurse is attending an agency orientation meeting Nursing staff are led by the nurse when providing care to a group of clients.
about the nursing model of practice implemented in the
facility. The nurse is told that the nursing model is a team Rationale:
nursing approach. The nurse understands that which is a In team nursing, nursing personnel are led by the nurse when providing care to a
characteristic of this type of nursing model of practice? group of clients.
, A client experiences a cardiac arrest. The nurse leader Autocratic
quickly responds to the emergency and assigns clearly
defined tasks to the work group. In this situation, the Rationale:
nurse is implementing which leadership style? Autocratic leadership is an approach in which the leader retains all authority and
is primarily concerned with task accomplishment. It is an effective leadership style
to implement in an emergency or crisis situation. The leader assigns clearly
defined tasks and establishes one-way communication with the work group, and
he or she makes all decisions independently. Situational leadership is a
comprehensive approach that incorporates the leader's style, the maturity of the
work group, and the situation at hand. Democratic leadership is a people-
centered approach that is primarily concerned with human relations and
teamwork. This leadership style facilitates goal accomplishment and contributes
to the growth and development of the staff. Laissez-faire leadership is a
permissive style in which the leader gives up control and delegates all decision
making to the work group.
The nurse has delegated several nursing tasks to staff Perform follow-up with each staff member regarding the performance and
members. Which is the nurse's primary responsibility after outcome of the task.
the delegation of the tasks?
Rationale:
The ultimate responsibility for a task lies with the person who delegated it.
Therefore, it is the nurse's primary responsibility to follow up with each staff
member regarding the performance of the task and the outcomes related to
implementing the task. Not all staff members have the education, knowledge, and
ability to make judgments about tasks being performed. The nurse documents that
the task has been completed, but this would not be done until follow-up was
implemented and outcomes were identified. It is not appropriate to assign the
tasks that were not completed to the next nursing shift.
The nurse is assigned to care for four clients. When A client receiving oxygen who is having difficulty breathing
planning client rounds, which client should the nurse
collect data from first? Rationale:
The airway is always a priority, and the nurse would attend to the client who has
been experiencing an airway problem first.
The nurse is told that the laboratory result for the serum Withhold the medication.
digoxin level is 2.4 ng/mL. Which action should the nurse
take? Rationale:
The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A value of 2.4 ng/mL
exceeds the therapeutic range and could be toxic to the client. The nursing action
is to hold further doses of digoxin. Because the value is not normal, option 3 can
be eliminated. Administration of the next dose would cause the client to become
more toxic. Checking the client's respiratory rate is not applicable at this time.
A client with atrial fibrillation who is receiving Withholding the next dose of warfarin sodium
maintenance therapy with warfarin sodium (Coumadin)
has a prothrombin time (PT) of 30 seconds. The nurse Rationale:
anticipates that which will be prescribed? The normal PT is 9.6 to 11.8 seconds for the adult male and 9.5 to 11.3 seconds for
the adult female. The goal of oral anticoagulation with warfarin sodium therapy is
to achieve a PT at 1.5 to 2 times the laboratory control value. A PT of 30 seconds
places the client at risk for bleeding, so the nurse should anticipate that the client
would not receive further doses at this time. If the level is too high, the antidote
(vitamin K) may be prescribed. The remaining options would make the client even
more prone to bleeding.
