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
... [Show More] 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 plan to care for first?... [Show Less]