NClex

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from 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 oxygen who is having difficulty breathing Rationale: The airway is always a 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 would have intermediate priority.

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?

1. Gurgling respirations 2. Increased blood pressure 3. Decreased hematocrit level 4. Increased specific gravity of the urine Rationale: Clients taking diuretics on a long-term basis are at risk for fluid volume deficit. Findings of fluid volume deficit include increased respiration and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness. Gurgling respirations, increased blood pressure, and decreased hematocrit as a result of hemodilution are seen in a client with fluid volume excess.

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should the nurse look for on the cardiac monitor as a result of this laboratory value?

1. ST elevation 2. Peaked P waves 3. Prominent U waves 4. Narrow, peaked T waves Rationale: A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?

1. The client with cirrhosis 2. The client with a ileostomy 3. The client with heart failure 4. The client with decreased kidney function Rationale: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and ileostomy. A client with cirrhosis, heart failure (HF), or decreased kidney function is at risk for fluid volume excess.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?

1. The client with sepsis 2. The client with cirrhosis 3. The client with kidney failure 4. The client with diabetes mellitus Rationale: Fluid that shifts into the interstitial space and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply.

1. "An event is termed a mass casualty when it overwhelms local medical capabilities." 2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." 4. "Mass casualty events may require the collaboration of many local agencies to handle the situation." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department." Rationale: Mass casualty events, also known as disasters, overwhelm local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crises. This type of event can occur in the health care facility or outside of it. Fights in the emergency department are not termed mass casualty events but are agency security and local enforcement issues. Mass casualty events almost always require an increase in staffing to ensure safe client care. 2,3,5

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice?

1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. 3. Nursing staff are led by the nurse when providing care to a group of clients. 4. A single registered nurse is responsible for providing nursing care to a group of clients. Rationale: In team nursing, nursing personnel are led by the nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire Rationale: Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication with the work group, and he or she makes all decisions independently. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. Laissez-faire leadership is a permissive style in which the leader gives up control and delegates all decision making to the work group.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse understands that a potassium value at this level would be noted with which condition?

1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives Rationale: A serum potassium level that exceeds 5.0 mEq/L (5.0 mmol/L) is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks?

1. Document that the task was completed. 2. Assign the tasks that were not completed to the next nursing shift. 3. Allow each staff member to make judgments when performing the tasks. 4. Perform follow-up with each staff member regarding the performance and outcome of the task. Rationale: The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's primary responsibility to follow-up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse documents that the task has been completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

1. The client with Addison's disease 2. The client with metabolic acidosis 3. The client with intestinal obstruction 4. The client receiving nasogastric suction Rationale: Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, and metabolic acidosis is at risk for hyperkalemia.

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

1. The client with a draining wound 2. The client with a urinary catheter 3. The client with a fast respiratory rate 4. The client with a nasogastric tube to low suction Rationale: Sensible losses are those that the person is aware of, such as those that occur through wound drainage, gastrointestinal (GI) tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.