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 ...
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
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller NurseAdvocate. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $8.49. You're not tied to anything after your purchase.
