UPDATE!!!2025/2026|GUARANTEED
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 -
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 - ANSWER ANSWER: 4
1
, 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?
1. Each staff member is assigned a specic task for a group of clients.
2. A staff member is assigned to determine the client's needs at home and begin discharge
planning.
3. A single registered nurse (RN) is responsible for providing care to a group of six clients
with the aid of an assistive personnel (AP).
4. An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a
group of 12 clients. - ANSWER 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?
1. A client who is ambulatory, demonstrating steady gait 2. A postoperative client who has
just received an opioid pain medication
2
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 -
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 - ANSWER ANSWER: 4
1
, 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?
1. Each staff member is assigned a specic task for a group of clients.
2. A staff member is assigned to determine the client's needs at home and begin discharge
planning.
3. A single registered nurse (RN) is responsible for providing care to a group of six clients
with the aid of an assistive personnel (AP).
4. An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a
group of 12 clients. - ANSWER 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?
1. A client who is ambulatory, demonstrating steady gait 2. A postoperative client who has
just received an opioid pain medication
2
