The nurse is triaging clients in the emergency department (ED). Which

NCLEX Leadership and Management

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Question 1 of 5.

The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client

A. reporting pleuritic chest pain with a productive cough.

B. who is pregnant and reporting intermittent nausea and vomiting.

C. who has an isolated area of reddened vesicles and malaise.

D. with sudden onset of ataxia and dysarthria.

Explanation: Sudden ataxia and dysarthria (D) suggest a stroke, an emergent condition requiring immediate triage for time-sensitive intervention. Pleuritic cough (A), pregnancy nausea (B), and vesicles/malaise (C) are less urgent.

Question 2 of 5.

You are caring for a 33-year-old male client at the end of life. This married client has two children; the son is 14-years-old and the daughter is 8-years-old. Both of these children are being prepared for their father's imminent death. Which consideration should be incorporated into your explanations of death with these children?

A. Children before the age of 12 view death as terrifying so the nurse should not discuss death with these young children.

B. Children before the age of 12 do not have any perspectives about death, its meaning, and its finality or lack thereof.

C. The cognitive development of young children impacts their understanding of death.

D. The cognitive development of young children before 12 has no impact on their understanding of death

Explanation: Cognitive development (C) influences how children, like the 8-year-old, understand death. Younger children may view death as reversible or temporary, while adolescents, like the 14-year-old, grasp its finality. Tailoring explanations to their developmental stage is essential. Options A and B are incorrect as children do have perspectives, and avoiding discussion (A) is unhelpful. Option D contradicts developmental psychology.

Question 3 of 5.

The charge nurse is planning client care assignments for a licensed practical/vocational nurse (LPN/VN). Which of the following would be an appropriate assignment(s) for the LPN? Select all that apply.

A. A 67-year-old one-hour post-procedure from a cardiac catheterization.

B. An 88-year-old client who was just admitted for intractable pain secondary to metastatic cancer.

C. A 42-year-old being discharged following a diagnosis of type 2 diabetes mellitus.

D. A 75-year-old inpatient client with colon cancer needing colostomy care.

E. A 50-year-old client being treated for herpes zoster with prescribed oral antivirals.

Explanation: LPNs can manage stable clients with pain (B), colostomy care (D), and oral antivirals (E) within their scope. A client one-hour post-cardiac catheterization (A) requires RN monitoring for complications, and discharge teaching for diabetes (C) involves complex education best suited for an RN.

Question 4 of 5.

The nurse has been made aware of the following client situations. The nurse should first follow up with the client

A. receiving a chemotherapy infusion who reports nausea and vomiting.

B. newly diagnosed with polycystic kidney disease reporting hematuria and flank pain.

C. being treated for aplastic anemia and has a temperature of 101.1Â°F (38.4Â°C).

D. being treated for pulmonary tuberculosis and ambulating in the hallway wearing a surgical mask.

Explanation: A fever in a client with aplastic anemia (C) indicates potential infection, a life-threatening complication due to low white blood cells, requiring immediate attention. Nausea from chemotherapy (A), hematuria with kidney disease (B), and TB with a mask (D) are less urgent.

Question 5 of 5.

The nurse is preparing to insert an indwelling urinary catheter. Which action may be delegated to the unlicensed assistive personnel (UAP)?

A. Set up the sterile field

B. Palpate the bladder for distention

C. Explain the procedure to the client

D. Place the urinary catheter kit at the bedside

Explanation: Placing the catheter kit at the bedside (D) is a non-clinical task suitable for a UAP. Setting up a sterile field (A), palpating the bladder (B), and explaining the procedure (C) require clinical judgment or training beyond UAP scope.