NCLEX Module 1 Spring 2019

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first?

Evaluate whether the client has inhaled smoke

A 60-year-old client is admitted with a head injury following a disaster. Which triage level should the nurse assign to the client?

Urgent

Which client injury would receive a black tag by the triage nurse during a mass casualty incident?

Full-thickness body burns 80% total body surface area (TBSA)

What principal components are associated with a nurse's time management skill? Select all that apply.

Goal setting Priority setting Interruption control

The registered nurse (RN) is caring for a client who underwent brain surgery. The registered nurse delegated the task of reinforcing ambulation to the licensed practical nurse (LPN). Who is accountable for the client's care?

Registered Nurse

The team leader is making client assignments. Which team member should be assigned a client with a tracheostomy, chest tube, and blood transfusion?

Registered Nurse (RN)

The nurse is trained to work as a member of a disaster preparedness team. Which activities should the nurse be prepared to perform if a disaster were to occur? Select all that apply.

Triage Decontamination procedures Evaluation of the disaster plan

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what?

Urinary Output

Which healthcare settings are appropriate for delegating care according to the functional model of nursing? Select all that apply.

Emergency units Ambulatory clinics

The nurse is assigned four different clients in an emergency department. Which client care can be given least priority?

Client with skin rashes

An older adult client is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" What is the best response by the nurse?

"You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."

An emergency nursing staff member is performing defibrillation/cardioversion and special resuscitation for clients who sustained injuries in a tsunami. Which certification does the emergency nursing staff member possess?

Advanced Cardiac Life Support (ACLS)

The nurse is caring for a client with bomb blast injuries. Which are priority emergency assessments that need to be performed? Select all that apply.

Airway Breathing Circulation Exposure of environmental control

A hospital is planning to implement the functional model of nursing. Which action performed by a nurse leader would be effective under this model?

Assigning individual duties to different nurses and nursing students for different tasks

The nurse is learning about the rules of leaders. Which actions of the nurse indicate effective implementation of these rules in the profession? Select all that apply.

Communicating in a simple language with followers Giving a chance to the followers to express their views Ensuring proper eye contact while communicating with followers

The registered nurse is delegating work to four delegatees. Which delegatee has an established relationship with the delegator?

Delegatee B..."Your way of doing is right; continue to do it in the same way."

The nurse is reassessing level of consciousness and mental status in a client who survived a fire. Which type of emergency assessment of trauma client is the nurse performing?

Disability

One component of a hospital disaster plan would include a workplace violence protection plan. Which unit in the hospital would be the priority for implementation and evaluation of this plan?

Emergency Department

A nurse leader wants to communicate and explain changes to hospital rules to team members. Which approaches should the nurse leader follow for effective communication? Select all that apply.

Explaining the reason behind the change Providing the opportunity for dialogue and feedback Giving information that addresses the listener's self-interests

Which activity indicates improper follow-through on the part of the delegatee?

Failure to report results

A client was admitted with a burn injury caused by a quick heat flash. The nurse examined the skin and noticed erythema and mild swelling. What type of burn does the nurse suspect?

First-degree burn

The registered nurse (RN) is caring for a client with epilepsy. Which tasks delegated by the registered nurse (RN) to the assistive personnel indicates active delegation? Select all that apply.

Instructing the licensed practical nurse (LPN) to monitor the vital signs Instructing the unlicensed assistive personnel (UAP) to reposition the client Instructing the unlicensed assistive personnel (UAP) to place the oxygen mask

A married couple in their 80s is living independently. They have three adult children. The husband, who is alert but forgetful, has an enlarged prostate and at times is incontinent of urine. The wife has diabetes and rheumatoid arthritis and walks with difficulty. Both need assistance with bathing, dressing, and meal preparation. What does the nurse suggest as the most suitable plan for this couple?

Keep them in their home with a home health aide.

A nurse is caring for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head. Which nursing goal is the priority during the emergent phase of a burn injury?

Managing fluid loss

What information should the nurse provide for a client who is discharged from the health care facility with a surgical wound? Select all that apply.

Skill to care for the surgical wound Safe and effective use of medications List of appropriate community resources