SAUNDERS NCLEX REVIEW CH 8 EXAM QUESTIONS 100%
SOLVED
8.26. The nurse is assigned to care for four clients. In planning clients rounds,
which client should the nurse assess first?
1. A client scheduled for a chest x-ray.
2. A client requiring daily dressing changes.
3. A postoperative client preparing for discharge.
4. A client receiving nasal oxygen who had difficulty breathing during the
previous shift.
Answer: 4.
Rationale: Airway is always the highest priority, and the nurse would attend to the client
who has been experiencing an airway problem first. The clients described in options 1,
2, and 3 have needs that would be identified as intermediate priorities.
Test-Taking Strategy: Note the strategic word first. Use Maslow's Hierarchy of Needs
theory and the ABCs - airway, breathing, and circulation - to answer the question.
Remember airway is always the highest priority. This will direct you to the correct
option.
Reference: Saunders, p. 78
8.27. The nurse employed in an emergency department is assigned to triage
clients coming to the emergency department for treatment on the evening shift.
The nurse should assign priority to which client?
1. A client complaining of muscle aches, a headache, and malaise.
2. A client who twisted her ankle when she fell while rollerblading.
3. A client with a minor laceration on the index finger sustained while cutting an
eggplant.
4. A client with chest pain who states that he just ate a pizza that was made with
very spicy sauce.
, Answer: 4.
Rationale: In an emergency department, triage involves brief client assessment to
classify clients according to their needs for care and includes establishing priorities of
care. The type of illness or injury, the severity of the problem, and the types of
resources available govern the process. clients with trauma, chest pain, severe
respiratory distress or cardiac arrest, limp amputation, and acute neurological deficits,
or who have sustained chemical splashes to the eyes, are classified as emergent and
are the number 1 priority.
Reference: Saunders, p. 78
8.28. A nursing graduate is attending an agency orientation regarding the nursing
model or pracitce implemented in the health care facility. The nurse is told that
the nursing model is a team nursing approach. The nurse understands that
planning care delivery will be based on which characteristic of this type of
nursing model of practice?
1. The task approach method is used to provide care to clients.
2. Managed care concepts and tools are used in providing client care.
3. A single registered nurse is responsible for providing care to a group of
clients.
4. A registered nurse leads nursing personnel in providing care to a group of
clients.
Answer: 4
Rationale: In team nursing, nursing personnel are lef by a registered nurse leader in
providing care to a group of clients. Option 1 identifies functional nursing. Option 2
identifies a component of care management. Option 3 identifies primary nursing
(relationship-based practice).
Test-Taking Strategy: Focus on the subject, team nursing. Keep this subject in mind
and select the option that best describes a team approach. The correct option is the
only one that identifies the concept of a team approach.
References: Saunders, p. 78
8.29. A nurse has received the assignment for the day shift. After making initial
rounds and checking all of the assigned clients, which client should the nurse
SOLVED
8.26. The nurse is assigned to care for four clients. In planning clients rounds,
which client should the nurse assess first?
1. A client scheduled for a chest x-ray.
2. A client requiring daily dressing changes.
3. A postoperative client preparing for discharge.
4. A client receiving nasal oxygen who had difficulty breathing during the
previous shift.
Answer: 4.
Rationale: Airway is always the highest priority, and the nurse would attend to the client
who has been experiencing an airway problem first. The clients described in options 1,
2, and 3 have needs that would be identified as intermediate priorities.
Test-Taking Strategy: Note the strategic word first. Use Maslow's Hierarchy of Needs
theory and the ABCs - airway, breathing, and circulation - to answer the question.
Remember airway is always the highest priority. This will direct you to the correct
option.
Reference: Saunders, p. 78
8.27. The nurse employed in an emergency department is assigned to triage
clients coming to the emergency department for treatment on the evening shift.
The nurse should assign priority to which client?
1. A client complaining of muscle aches, a headache, and malaise.
2. A client who twisted her ankle when she fell while rollerblading.
3. A client with a minor laceration on the index finger sustained while cutting an
eggplant.
4. A client with chest pain who states that he just ate a pizza that was made with
very spicy sauce.
, Answer: 4.
Rationale: In an emergency department, triage involves brief client assessment to
classify clients according to their needs for care and includes establishing priorities of
care. The type of illness or injury, the severity of the problem, and the types of
resources available govern the process. clients with trauma, chest pain, severe
respiratory distress or cardiac arrest, limp amputation, and acute neurological deficits,
or who have sustained chemical splashes to the eyes, are classified as emergent and
are the number 1 priority.
Reference: Saunders, p. 78
8.28. A nursing graduate is attending an agency orientation regarding the nursing
model or pracitce implemented in the health care facility. The nurse is told that
the nursing model is a team nursing approach. The nurse understands that
planning care delivery will be based on which characteristic of this type of
nursing model of practice?
1. The task approach method is used to provide care to clients.
2. Managed care concepts and tools are used in providing client care.
3. A single registered nurse is responsible for providing care to a group of
clients.
4. A registered nurse leads nursing personnel in providing care to a group of
clients.
Answer: 4
Rationale: In team nursing, nursing personnel are lef by a registered nurse leader in
providing care to a group of clients. Option 1 identifies functional nursing. Option 2
identifies a component of care management. Option 3 identifies primary nursing
(relationship-based practice).
Test-Taking Strategy: Focus on the subject, team nursing. Keep this subject in mind
and select the option that best describes a team approach. The correct option is the
only one that identifies the concept of a team approach.
References: Saunders, p. 78
8.29. A nurse has received the assignment for the day shift. After making initial
rounds and checking all of the assigned clients, which client should the nurse
