SAUNDERS COMPREHENSIVE
REVIEW FOR THE NCLEX-RN
EXAMINATION QUESTIONS &
ANSWERS GRADED A+
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 - correct answer ✔✔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. 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 - correct
answer ✔✔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. 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 - correct answer ✔✔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.
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?
REVIEW FOR THE NCLEX-RN
EXAMINATION QUESTIONS &
ANSWERS GRADED A+
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 - correct answer ✔✔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. 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 - correct
answer ✔✔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. 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 - correct answer ✔✔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.
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?
