Saunders Comprehensive Review for the Nclex-RN Examination
1. 1. The nurse is assigned to care for four clients. In planning client rounds,
which client would the nurse assess first?
1. A postoperative client preparing for discharge with a new medication
2. A client requiring daily dressing changes of a recent surgical incision
3. A client scheduled for a chest x-ray after insertion of a nasogastric tube
4. A client with asthma who requested a breathing treatment during the
previous shift: Answer: 4
Rationale: Airway is always the highest priority, and the nurse would attend to the
client with asthma who requested a breathing treatment during the previous shift.
This could indicate that the client was experiencing difficulty breathing. The clients
described in options 1, 2, and 3 have needs that would be identified as intermediate
priorities.
2. 2. 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 would assign priority to which client?
1. A client complaining of muscle aches, a headache, and history of seizures
2. A client who twisted their ankle when rollerblading and is requesting
medication for pain
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 they just ate pizza that was made
with a very spicy sauce: Answer: 4
Rationale: In an emergency department, triage involves brief client assessment to
classify clients according to their need for care and includes establishing priorities
of care. The type of illness or injury, the severity of the problem, and the resources
available govern the process. Clients with trauma, chest pain, severe respiratory
distress or cardiac arrest, limb amputation, or acute neurological deficits and those
who have sustained chemical splashes to the eyes are classified as emergent and
are the 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
, Saunders Comprehensive Review for the Nclex-RN Examination
such as a minor laceration, sprain, or cold symptoms are classified as nonurgent
and are a third priority.
3. 3. A nursing graduate is attending an agency orientation regarding the
nursing model of practice implemented in the health care facility. The nurse
is told that the nursing model is a team nursing approach. The nurse
determines that which scenario is characteristic of the team-based model of
nursing practice?
1. Each staff member is assigned a specic task for a group of clients.
2. A staff member is assigned to determine the client's needs at home and
begin discharge planning.
3. A single registered nurse (RN) is responsible for providing care to a group
of six clients with the aid of an assistive personnel (AP).
4. An RN leads two licensed practical nurses (LPNs) and three APs in
providing care to a group of 12 clients.: Answer: 4
Rationale: In team nursing, nursing personnel are led by a registered nurse leader
in providing care to a group of clients. Option 1 identifies functional nursing.
Option 2 identifies a component of case management. Option 3 identifies primary
nursing (relationship-based practice).
4. The nurse has received the assignment for the day shift. After making initial
rounds and checking all of the assigned clients, which client would the nurse
plan to care for first?
1. A client who is ambulatory, demonstrating steady gait 2. A postoperative
client who has just received an opioid pain medication
3. A client scheduled for physical therapy for the first crutch-walking session
4. A client with a white blood cell count of 14,000 mm3 (14 × 109 /L) and a
temperature of 38.4° C: Answer: 4
Rationale: The nurse would plan to care for the client who has an elevated white
blood cell count and a fever first, because this client's needs are the priority. The
client who is ambulatory with steady gait and the client scheduled for physical
therapy for a crutch-walking session do not have priority needs. Waiting for pain
medication to take effect before providing care to the postoperative client is best.
1. 1. The nurse is assigned to care for four clients. In planning client rounds,
which client would the nurse assess first?
1. A postoperative client preparing for discharge with a new medication
2. A client requiring daily dressing changes of a recent surgical incision
3. A client scheduled for a chest x-ray after insertion of a nasogastric tube
4. A client with asthma who requested a breathing treatment during the
previous shift: Answer: 4
Rationale: Airway is always the highest priority, and the nurse would attend to the
client with asthma who requested a breathing treatment during the previous shift.
This could indicate that the client was experiencing difficulty breathing. The clients
described in options 1, 2, and 3 have needs that would be identified as intermediate
priorities.
2. 2. 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 would assign priority to which client?
1. A client complaining of muscle aches, a headache, and history of seizures
2. A client who twisted their ankle when rollerblading and is requesting
medication for pain
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 they just ate pizza that was made
with a very spicy sauce: Answer: 4
Rationale: In an emergency department, triage involves brief client assessment to
classify clients according to their need for care and includes establishing priorities
of care. The type of illness or injury, the severity of the problem, and the resources
available govern the process. Clients with trauma, chest pain, severe respiratory
distress or cardiac arrest, limb amputation, or acute neurological deficits and those
who have sustained chemical splashes to the eyes are classified as emergent and
are the 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
, Saunders Comprehensive Review for the Nclex-RN Examination
such as a minor laceration, sprain, or cold symptoms are classified as nonurgent
and are a third priority.
3. 3. A nursing graduate is attending an agency orientation regarding the
nursing model of practice implemented in the health care facility. The nurse
is told that the nursing model is a team nursing approach. The nurse
determines that which scenario is characteristic of the team-based model of
nursing practice?
1. Each staff member is assigned a specic task for a group of clients.
2. A staff member is assigned to determine the client's needs at home and
begin discharge planning.
3. A single registered nurse (RN) is responsible for providing care to a group
of six clients with the aid of an assistive personnel (AP).
4. An RN leads two licensed practical nurses (LPNs) and three APs in
providing care to a group of 12 clients.: Answer: 4
Rationale: In team nursing, nursing personnel are led by a registered nurse leader
in providing care to a group of clients. Option 1 identifies functional nursing.
Option 2 identifies a component of case management. Option 3 identifies primary
nursing (relationship-based practice).
4. The nurse has received the assignment for the day shift. After making initial
rounds and checking all of the assigned clients, which client would the nurse
plan to care for first?
1. A client who is ambulatory, demonstrating steady gait 2. A postoperative
client who has just received an opioid pain medication
3. A client scheduled for physical therapy for the first crutch-walking session
4. A client with a white blood cell count of 14,000 mm3 (14 × 109 /L) and a
temperature of 38.4° C: Answer: 4
Rationale: The nurse would plan to care for the client who has an elevated white
blood cell count and a fever first, because this client's needs are the priority. The
client who is ambulatory with steady gait and the client scheduled for physical
therapy for a crutch-walking session do not have priority needs. Waiting for pain
medication to take effect before providing care to the postoperative client is best.
