Saunders Comprehensive Review for the Nclex-RN Examination

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NCLEX EXAM PREVIEW

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• The nurse is assigned to care for four clients. In

planning client rounds, which client would the nurse assess first?

• A postoperative client preparing for discharge with a

new medication

• A client requiring daily dressing changes of a recent

surgical incision

• A client scheduled for a chest x-ray after insertion of a

nasogastric tube

• 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.

• 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?

• A client complaining of muscle aches, a headache, and

history of seizures

• A client who twisted their ankle when rollerblading and

is requesting medication for pain

• A client with a minor laceration on the index finger

sustained while cutting an eggplant

• 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 such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a third priority.

• 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?

• Each staff member is assigned a specic task for a group

of clients.

• A staff member is assigned to determine the client's

needs at home and begin discharge planning.

• A single registered nurse (RN) is responsible for

providing care to a group of six clients with the aid of an assistive personnel (AP).

• 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).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?

• A client who is ambulatory, demonstrating steady gait 2.

A postoperative client who has just received an opioid pain medication

• A client scheduled for physical therapy for the first

crutch-walking session

• 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.The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

• Finish the bed bath and then administer the pain

medication to the other client.

• Ask the AP to find out when the last pain medication

was given to the client.

• Ask the AP to tell the client in pain that medication will

be administered as soon as the bed bath is complete.

• Cover the client, raise the side rails, tell the client that

you will return shortly, and administer the pain medication to the other client.

Answer: 4

Rationale: The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP?

• Ignore the resistance.
• Exert coercion on the AP.
• Provide a positive reward system for the AP.
• Confront the AP to encourage verbalization of feelings

regarding the change.

Answer: 4

Rationale: Confrontation is an important strategy to meet resistance head-on.

Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance but will not address the concern specifically.The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?

• A client requiring a colostomy irrigation
• A client receiving continuous tube feedings
• A client who requires urine specimen collections
• A client with difculty swallowing food and fluids

Answer: 3

Rationale: The nurse must determine the most appropriate assignment based on

the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client who requires urine specimen collections. The AP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration.The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and three assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse?

• A client who requires a bed bath
• An older client requiring frequent ambulation
• A client who requires hourly measurement of vital signs
• A client requiring abdominal wound irrigations and

dressing changes every 3 hours

Answer: 4

Rationale: When delegating nursing assignments, the nurse needs to consider the

skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be assigned most appropriately to an AP. The licensed practical nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.The charge nurse is planning the assignment for the day.Which factors would the nurse remain mindful of when delegating tasks? Select all that apply.

• The acuity level of the clients
• Specic requests from the staff
• The clustering of the rooms on the unit
• The number of anticipated client discharges
• Client needs and workers' needs and abilitie

Answer: 1, 5

Rationale: There are guidelines that the nurse would use when delegating tasks.

These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience (as in clustering of client rooms), and anticipated changes in unit census are not specific guidelines to use when delegating tasks, but may be considered when making assignments.

The nurse manager is discussing with the staff the facility's protocol in the event of a tornado. Which instructions would the nurse manager include in the discussion?Select all that apply.

• Open doors to client rooms.
• Move beds away from windows.
• Close window shades and curtains.
• Place blankets over clients who are confined to bed.
• Relocate ambulatory clients from the hallways back

into their rooms.

Answer: 2, 3, 4

Rationale: In this weather event, the appropriate nursing actions focus on

protecting clients from flying debris or glass. The nurse would close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets need to be placed over clients confined to bed. Ambulatory clients need to be moved into the hallways from their rooms, away from windows.The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

• Weight loss and dry skin
• Flat neck and hand veins and decreased urinary output
• An increase in blood pressure and increased

respirations

• Weakness and decreased central venous pressure

(CVP)

Answer: 3

Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

• Sustained tissue damage
• Requires nasogastric suction
• Has a history of Addison's disease
• Uric acid level of 9.4 mg/dL (557 mcmol/L

Answer: 2

Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0

mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level ranges from 2.7 to 8.5 mg/ dL (160 to 501 mcmol/L).The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns would the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

• U waves
• Absent P waves
• Inverted T waves
• Depressed ST segment
• Widened QRS complex

Answer: 1, 3, 4

Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0

mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.