NCLEX Questions-Prioritizing Client Care

NCLEX Questions-Prioritizing Client Care

• The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse

assess first?

• A client scheduled for a chest x-ray
• A client requiring daily dressing changes
• A postoperative client preparing for discharge
• A client receiving nasal oxygen who had difficulty breathing during the previous shift. - 1. D- 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 option 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 should assign priority to which client?

• A client complaining of muscle aches, a headache, and malaise
• A client who twisted her ankle when she fell while rollerblading
• A client with a minor laceration on the index finger sustained while cutting an eggplant
• A client with chest pain who states that he just are pizza that was made with a very spicy sauce. - 2. D-

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, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 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 number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number 3 priority.

• A nursing graduate is attending an agency orientation regarding the nursing model of practice

implanted in the health care facility. The nurse is told that the 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.

• A task approach method is used to provide care to clients
• Managed care concepts and tools are used in providing client care.
• A single registered nurse is responsible for providing care to a group of clients
• A registered nurse leads nursing personnel in providing care to a group of clients. - 3. D- 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).

• 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 plan to care for first?

• A client who is ambulatory
• A client scheduled for physical therapy at 1 pm
• A client with a fever who is diaphoretic and restless
• A postoperative client who has just received pain medication - 4. C- The nurse should plan to care for

the client who has a fever and is diaphoretic and restless first because this client's needs are the priority.The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care. 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 unlicensed assistive personnel (UAP)

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 UAP to find out when the last pain medication was given to the client
• Ask the UAP 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. - 5. D- 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 responsibility of the UAP.

• The nurse manager has implemented a change in the method of the nursing delivery system from

functional to team nursing. An unlicensed assistive personnel (UAP) 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 UAP?

• Ignore the resistance
• Exert coercion on the UAP
• Provide a positive reward system for the UAP
• Confront the UAP to encourage verbalization of feelings regarding the change - 6. D- 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 unlicensed assistive personnel (UAP)?

• A client requiring a colostomy irrigation
• A client receiving continuous feedings
• A client who requires urine specimen collections
• A client with difficulty swallowing food and fluids - 7. C- 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 UAP would be to care for the client who requires urine specimen collections. The UAP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration

• A new unit nurse manager is holding her first staff meeting. The manager greets the staff and

comments that she has been employed to bring about quality improvement. The manager provides a plan that she developed and a list of tasks and activities for which each staff member must volunteer to perform. In addition, she instructs staff members to report any problems directly to her. What type of leader and manager approach do the new manager's characteristics suggest?

• Autocratic
• Situational
• Democratic
• Laissez-faire - 8. A- The autocratic leader is focused, maintains strong control, makes decisions, and

addresses all problems. The autocrat dominates the group and commands rather than seeks suggestions or input. In this situation, the manager addresses a problem (quality improvement) with the staff, designs a plan without input, and wants all problems reported directly back to her. A situational leader will use a combination of styles, depending on the needs of the group and the tasks to be achieved. The situational leader would work with the group to validate that the information that the leader gained as a new employee was accurate and that a problem existed then the leader would take the time to get to know the group determine which approach to change (if needed) would work best according to the needs of the group and the nature and substance of the change that was required. A democratic leader is participative and would likely meet with each staff person individually to determine the staff member's perception of the problem. The democratic leader would also speak with the staff about any issues and ask the staff for input with developing a plan. A laissez-faire leader is passive and nondirective. The laissez-faire leader would state what the problem was and inform the staff that the staff needed to come up with a plan to "fix it."

• 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 (vocational) nurse and three unlicensed assistive personnel (UAP) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse?

• A client who requires a bed bath
• An older client requiring frequent ambulation
• A client who requires hourly vital sign measurements
• A client requiring abdominal wound irrigations and dressing changes every 3 hours - 9. D- 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 provided most appropriately by the unlicensed assistive personnel (UAP). The licensed practical