Question 1

A client begins to vomit blood.The nurse immediately measures the blood pressure and prepares to insert a nasogastric tube while directing others to notify the healthcare provider and prepare to perform iced saline lavage.Which features of the Tanner Clinical Judgment Model did this nurse demonstrate? Select all that apply.

Accepted Answer

A) Noticing is having a sense about what is happening in the client situation. Interpreting and responding involve the use of logical reasoning to gain understanding about a situation and determine appropriate actions. This includes analyzing a situation, choosing the best course of action, and performing responsive actions by the nurse. Presencing is being present for a client and engaging in face-to-face contact. Empowerment is encouraging a client to make autonomous health care decisions.
B) Noticing is having a sense about what is happening in the client situation. Interpreting and responding involve the use of logical reasoning to gain understanding about a situation and determine appropriate actions. This includes analyzing a situation, choosing the best course of action, and performing responsive actions by the nurse. Presencing is being present for a client and engaging in face-to-face contact. Empowerment is encouraging a client to make autonomous health care decisions.
C) Noticing is having a sense about what is happening in the client situation. Interpreting and responding involve the use of logical reasoning to gain understanding about a situation and determine appropriate actions. This includes analyzing a situation, choosing the best course of action, and performing responsive actions by the nurse. Presencing is being present for a client and engaging in face-to-face contact. Empowerment is encouraging a client to make autonomous health care decisions.
D) Noticing is having a sense about what is happening in the client situation. Interpreting and responding involve the use of logical reasoning to gain understanding about a situation and determine appropriate actions. This includes analyzing a situation, choosing the best course of action, and performing responsive actions by the nurse. Presencing is being present for a client and engaging in face-to-face contact. Empowerment is encouraging a client to make autonomous health care decisions.
E) Noticing is having a sense about what is happening in the client situation. Interpreting and responding involve the use of logical reasoning to gain understanding about a situation and determine appropriate actions. This includes analyzing a situation, choosing the best course of action, and performing responsive actions by the nurse. Presencing is being present for a client and engaging in face-to-face contact. Empowerment is encouraging a client to make autonomous health care decisions.

Question 2

The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques.Upon completion of the class,what should the nurse expect the participants to do?

Accepted Answer

A) The nursing process identifies needs, plans, goals, and interventions and then evaluates the effectiveness of the interventions. In this case, the evaluation includes having the client demonstrate the ability to care for an infant. The nurse would review major points before the end of the class and before evaluating the effectiveness of the teaching. Passing a written test does not allow the nurse to determine if the participants are able to complete the skills taught in the class. Goals for learning are completed after assessing the knowledge level of the class.
B) The nursing process identifies needs, plans, goals, and interventions and then evaluates the effectiveness of the interventions. In this case, the evaluation includes having the client demonstrate the ability to care for an infant. The nurse would review major points before the end of the class and before evaluating the effectiveness of the teaching. Passing a written test does not allow the nurse to determine if the participants are able to complete the skills taught in the class. Goals for learning are completed after assessing the knowledge level of the class.
C) The nursing process identifies needs, plans, goals, and interventions and then evaluates the effectiveness of the interventions. In this case, the evaluation includes having the client demonstrate the ability to care for an infant. The nurse would review major points before the end of the class and before evaluating the effectiveness of the teaching. Passing a written test does not allow the nurse to determine if the participants are able to complete the skills taught in the class. Goals for learning are completed after assessing the knowledge level of the class.
D) The nursing process identifies needs, plans, goals, and interventions and then evaluates the effectiveness of the interventions. In this case, the evaluation includes having the client demonstrate the ability to care for an infant. The nurse would review major points before the end of the class and before evaluating the effectiveness of the teaching. Passing a written test does not allow the nurse to determine if the participants are able to complete the skills taught in the class. Goals for learning are completed after assessing the knowledge level of the class.

Question 3

An older adult client is experiencing confusion,a temperature of 101.5°F,bruising to the arms and legs,and decreased urine output.The medical diagnosis is a urinary tract infection.Which is the most appropriate nursing diagnosis for this client?

Accepted Answer

A) The client has bruising and is confused. A priority nursing diagnosis would focus on client safety. The bruising and confusion place the client at risk for injury related to falls. There is no evidence that the client is having difficulty breathing. Activity intolerance could be a problem; however, the nurse cannot assume that the client has intolerance to activity due to age. Because the client is exhibiting confusion, which is a typical symptom of urinary infection in the elderly, the nurse would choose risk for injury as a priority over memory because it is not possible to assess the client's memory during confusion.
B) The client has bruising and is confused. A priority nursing diagnosis would focus on client safety. The bruising and confusion place the client at risk for injury related to falls. There is no evidence that the client is having difficulty breathing. Activity intolerance could be a problem; however, the nurse cannot assume that the client has intolerance to activity due to age. Because the client is exhibiting confusion, which is a typical symptom of urinary infection in the elderly, the nurse would choose risk for injury as a priority over memory because it is not possible to assess the client's memory during confusion.
C) The client has bruising and is confused. A priority nursing diagnosis would focus on client safety. The bruising and confusion place the client at risk for injury related to falls. There is no evidence that the client is having difficulty breathing. Activity intolerance could be a problem; however, the nurse cannot assume that the client has intolerance to activity due to age. Because the client is exhibiting confusion, which is a typical symptom of urinary infection in the elderly, the nurse would choose risk for injury as a priority over memory because it is not possible to assess the client's memory during confusion.
D) The client has bruising and is confused. A priority nursing diagnosis would focus on client safety. The bruising and confusion place the client at risk for injury related to falls. There is no evidence that the client is having difficulty breathing. Activity intolerance could be a problem; however, the nurse cannot assume that the client has intolerance to activity due to age. Because the client is exhibiting confusion, which is a typical symptom of urinary infection in the elderly, the nurse would choose risk for injury as a priority over memory because it is not possible to assess the client's memory during confusion.

Question 4

A nurse receives a shift report and is preparing to care for clients assigned on a medical-surgical unit.Which client should the nurse plan to assess first?

Accepted Answer

A) The nurse begins by assessing the client who is at the greatest risk, who in this case is the client having trouble breathing. The risk for the client with mild pain is not as severe as the client with dyspnea. The nurse can delegate the ambulation of a client to a nursing assistive individual. The nurse can also delegate assisting a client who needs help with a bath.
B) The nurse begins by assessing the client who is at the greatest risk, who in this case is the client having trouble breathing. The risk for the client with mild pain is not as severe as the client with dyspnea. The nurse can delegate the ambulation of a client to a nursing assistive individual. The nurse can also delegate assisting a client who needs help with a bath.
C) The nurse begins by assessing the client who is at the greatest risk, who in this case is the client having trouble breathing. The risk for the client with mild pain is not as severe as the client with dyspnea. The nurse can delegate the ambulation of a client to a nursing assistive individual. The nurse can also delegate assisting a client who needs help with a bath.
D) The nurse begins by assessing the client who is at the greatest risk, who in this case is the client having trouble breathing. The risk for the client with mild pain is not as severe as the client with dyspnea. The nurse can delegate the ambulation of a client to a nursing assistive individual. The nurse can also delegate assisting a client who needs help with a bath.

Question 5

A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours.At 4 hours the client's pain level is 8 on a rating scale of 1 to 10.The nurse decides to give the pain medication now.What does this nurse's action exemplify?

Accepted Answer

A) Each client has a plan of care, but, it is the nurse who constantly evaluates the client for changes that the nurse responds to, if needed. Prioritizing involves choosing tasks in order of importance. Time management is completing the assigned tasks in the given time frame by organizing and using efficiency. The goal has not been met if the client is experiencing pain.
B) Each client has a plan of care, but, it is the nurse who constantly evaluates the client for changes that the nurse responds to, if needed. Prioritizing involves choosing tasks in order of importance. Time management is completing the assigned tasks in the given time frame by organizing and using efficiency. The goal has not been met if the client is experiencing pain.
C) Each client has a plan of care, but, it is the nurse who constantly evaluates the client for changes that the nurse responds to, if needed. Prioritizing involves choosing tasks in order of importance. Time management is completing the assigned tasks in the given time frame by organizing and using efficiency. The goal has not been met if the client is experiencing pain.
D) Each client has a plan of care, but, it is the nurse who constantly evaluates the client for changes that the nurse responds to, if needed. Prioritizing involves choosing tasks in order of importance. Time management is completing the assigned tasks in the given time frame by organizing and using efficiency. The goal has not been met if the client is experiencing pain.

Question 6

A client asks the student nurse to explain the pathophysiology of diabetes.The student nurse does not know the answer to this question.What should the student respond to the client?

Accepted Answer

A) The student nurse best exhibits integrity by admitting not knowing the answer, but offering to find out and get back to the client. Honesty by the student nurse will build trust with the client. Just saying "I don't know" and leaving it at that will make the nurse appear untrustworthy and possibly uncaring. Questioning the client about the need for the information is defensive and might also be construed as a challenge by the client. Referring the question to the doctor is also not good ethics; nurses need to continue learning throughout their practice.
B) The student nurse best exhibits integrity by admitting not knowing the answer, but offering to find out and get back to the client. Honesty by the student nurse will build trust with the client. Just saying "I don't know" and leaving it at that will make the nurse appear untrustworthy and possibly uncaring. Questioning the client about the need for the information is defensive and might also be construed as a challenge by the client. Referring the question to the doctor is also not good ethics; nurses need to continue learning throughout their practice.
C) The student nurse best exhibits integrity by admitting not knowing the answer, but offering to find out and get back to the client. Honesty by the student nurse will build trust with the client. Just saying "I don't know" and leaving it at that will make the nurse appear untrustworthy and possibly uncaring. Questioning the client about the need for the information is defensive and might also be construed as a challenge by the client. Referring the question to the doctor is also not good ethics; nurses need to continue learning throughout their practice.
D) The student nurse best exhibits integrity by admitting not knowing the answer, but offering to find out and get back to the client. Honesty by the student nurse will build trust with the client. Just saying "I don't know" and leaving it at that will make the nurse appear untrustworthy and possibly uncaring. Questioning the client about the need for the information is defensive and might also be construed as a challenge by the client. Referring the question to the doctor is also not good ethics; nurses need to continue learning throughout their practice.

Question 7

A goal of care for a client with congestive heart failure (CHF)is for serum sodium levels to be within normal limits.Which information documented in the medical record would indicate that the client is not meeting this goal?

Accepted Answer

A) Communication is crucial in the medical field. The nurse who is taking over the client's care would note the goals of the current plan of care and would view the assessment to determine the reason for the nursing diagnosis and goals in order to be able to evaluate if goals have been met. Edema can be a result of a high sodium level. The nurse reviews the assessment to look for the reason the goal was set. Joint pain would be relevant for a different goal. Constipation would not be related to a high sodium level. Wheezing would be addressed by a different goal for the client.
B) Communication is crucial in the medical field. The nurse who is taking over the client's care would note the goals of the current plan of care and would view the assessment to determine the reason for the nursing diagnosis and goals in order to be able to evaluate if goals have been met. Edema can be a result of a high sodium level. The nurse reviews the assessment to look for the reason the goal was set. Joint pain would be relevant for a different goal. Constipation would not be related to a high sodium level. Wheezing would be addressed by a different goal for the client.
C) Communication is crucial in the medical field. The nurse who is taking over the client's care would note the goals of the current plan of care and would view the assessment to determine the reason for the nursing diagnosis and goals in order to be able to evaluate if goals have been met. Edema can be a result of a high sodium level. The nurse reviews the assessment to look for the reason the goal was set. Joint pain would be relevant for a different goal. Constipation would not be related to a high sodium level. Wheezing would be addressed by a different goal for the client.
D) Communication is crucial in the medical field. The nurse who is taking over the client's care would note the goals of the current plan of care and would view the assessment to determine the reason for the nursing diagnosis and goals in order to be able to evaluate if goals have been met. Edema can be a result of a high sodium level. The nurse reviews the assessment to look for the reason the goal was set. Joint pain would be relevant for a different goal. Constipation would not be related to a high sodium level. Wheezing would be addressed by a different goal for the client.

Question 8

The nurse is collecting data about a client's current health status.Which statement would assist in gathering subjective data about the client?

Accepted Answer

A) Subjective data is information that the client gives the nurse regarding feelings or happenings. Asking the client to explain why there is difficulty with sleeping will encourage the client to give a subjective response, such as that the client recently broke up with her boyfriend and is depressed. Noting that the client has bruises on the skin is an objective observation by the nurse and does not require a response from the client. Noting that the client has dry, irritated skin is an objective observation by the nurse and does not require a response from the client. Noting that the client has a red, swollen eyelid is an objective observation by the nurse and does not require a response from the client.
B) Subjective data is information that the client gives the nurse regarding feelings or happenings. Asking the client to explain why there is difficulty with sleeping will encourage the client to give a subjective response, such as that the client recently broke up with her boyfriend and is depressed. Noting that the client has bruises on the skin is an objective observation by the nurse and does not require a response from the client. Noting that the client has dry, irritated skin is an objective observation by the nurse and does not require a response from the client. Noting that the client has a red, swollen eyelid is an objective observation by the nurse and does not require a response from the client.
C) Subjective data is information that the client gives the nurse regarding feelings or happenings. Asking the client to explain why there is difficulty with sleeping will encourage the client to give a subjective response, such as that the client recently broke up with her boyfriend and is depressed. Noting that the client has bruises on the skin is an objective observation by the nurse and does not require a response from the client. Noting that the client has dry, irritated skin is an objective observation by the nurse and does not require a response from the client. Noting that the client has a red, swollen eyelid is an objective observation by the nurse and does not require a response from the client.
D) Subjective data is information that the client gives the nurse regarding feelings or happenings. Asking the client to explain why there is difficulty with sleeping will encourage the client to give a subjective response, such as that the client recently broke up with her boyfriend and is depressed. Noting that the client has bruises on the skin is an objective observation by the nurse and does not require a response from the client. Noting that the client has dry, irritated skin is an objective observation by the nurse and does not require a response from the client. Noting that the client has a red, swollen eyelid is an objective observation by the nurse and does not require a response from the client.

Question 9

The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died.On which areas should the nurse focus when performing this reflection? Select all that apply.

Accepted Answer

A) Reflection is the action of making sense of occurrences, situations, or decisions by carefully considering the totality of the experience, such as what worked or did not work, what could have been done differently to achieve better outcomes, what was done well, and what necessary resources were available. In order to reflect on an experience, nurses need to learn what to pay attention to or notice. Reflective thinking can change a situation that is obscure, uncertain, and disturbing to one that is clear, understandable, and settled. A "gut reaction" describes intuition, which is not a part of reflective thinking.
B) Reflection is the action of making sense of occurrences, situations, or decisions by carefully considering the totality of the experience, such as what worked or did not work, what could have been done differently to achieve better outcomes, what was done well, and what necessary resources were available. In order to reflect on an experience, nurses need to learn what to pay attention to or notice. Reflective thinking can change a situation that is obscure, uncertain, and disturbing to one that is clear, understandable, and settled. A "gut reaction" describes intuition, which is not a part of reflective thinking.
C) Reflection is the action of making sense of occurrences, situations, or decisions by carefully considering the totality of the experience, such as what worked or did not work, what could have been done differently to achieve better outcomes, what was done well, and what necessary resources were available. In order to reflect on an experience, nurses need to learn what to pay attention to or notice. Reflective thinking can change a situation that is obscure, uncertain, and disturbing to one that is clear, understandable, and settled. A "gut reaction" describes intuition, which is not a part of reflective thinking.
D) Reflection is the action of making sense of occurrences, situations, or decisions by carefully considering the totality of the experience, such as what worked or did not work, what could have been done differently to achieve better outcomes, what was done well, and what necessary resources were available. In order to reflect on an experience, nurses need to learn what to pay attention to or notice. Reflective thinking can change a situation that is obscure, uncertain, and disturbing to one that is clear, understandable, and settled. A "gut reaction" describes intuition, which is not a part of reflective thinking.
E) Reflection is the action of making sense of occurrences, situations, or decisions by carefully considering the totality of the experience, such as what worked or did not work, what could have been done differently to achieve better outcomes, what was done well, and what necessary resources were available. In order to reflect on an experience, nurses need to learn what to pay attention to or notice. Reflective thinking can change a situation that is obscure, uncertain, and disturbing to one that is clear, understandable, and settled. A "gut reaction" describes intuition, which is not a part of reflective thinking.

Question 10

The nurse is caring for an older adult client with decreased energy who needs to get up to prevent the development of pressure ulcers.The client is unable to ambulate and wants to be alone.What should the nurse do?

Accepted Answer

A) The nurse would use knowledge and creativity to think critically about getting the client to cooperate with the medical regimen. For example, the nurse would ask the family to become involved in order to gain compliance. It is not an option to leave the client alone and not address some method of ensuring intact skin. The compliance of the client rests with the nurse, not the physician. It would not be a good idea to force the client against the client's will; the nurse would use critical thinking to find another way to meet the goal.
B) The nurse would use knowledge and creativity to think critically about getting the client to cooperate with the medical regimen. For example, the nurse would ask the family to become involved in order to gain compliance. It is not an option to leave the client alone and not address some method of ensuring intact skin. The compliance of the client rests with the nurse, not the physician. It would not be a good idea to force the client against the client's will; the nurse would use critical thinking to find another way to meet the goal.
C) The nurse would use knowledge and creativity to think critically about getting the client to cooperate with the medical regimen. For example, the nurse would ask the family to become involved in order to gain compliance. It is not an option to leave the client alone and not address some method of ensuring intact skin. The compliance of the client rests with the nurse, not the physician. It would not be a good idea to force the client against the client's will; the nurse would use critical thinking to find another way to meet the goal.
D) The nurse would use knowledge and creativity to think critically about getting the client to cooperate with the medical regimen. For example, the nurse would ask the family to become involved in order to gain compliance. It is not an option to leave the client alone and not address some method of ensuring intact skin. The compliance of the client rests with the nurse, not the physician. It would not be a good idea to force the client against the client's will; the nurse would use critical thinking to find another way to meet the goal.

Question 11

A client recovering from knee surgery is being prepared to ambulate for the first time.Prior to getting the client up,what should the nurse do?

Accepted Answer

A) Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Most clients are not going to want to get up after surgery and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.
B) Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Most clients are not going to want to get up after surgery and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.
C) Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Most clients are not going to want to get up after surgery and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.
D) Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Most clients are not going to want to get up after surgery and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.

Question 12

An older adult client with heart failure is experiencing activity intolerance due to dyspnea on exertion.Which nursing intervention is a priority for the client?

Accepted Answer

A) The client with little energy reserve is best served by pacing care throughout the shift to allow for rest periods between activities. Completing all care at once can hurt the client's ability to heal by tiring the client too severely. Delegating care does not help the client to conserve energy. Waiting until the end of the shift would have the same effect as doing all care in the morning. The key is not to overtax the client's reserves at any time during the shift.
B) The client with little energy reserve is best served by pacing care throughout the shift to allow for rest periods between activities. Completing all care at once can hurt the client's ability to heal by tiring the client too severely. Delegating care does not help the client to conserve energy. Waiting until the end of the shift would have the same effect as doing all care in the morning. The key is not to overtax the client's reserves at any time during the shift.
C) The client with little energy reserve is best served by pacing care throughout the shift to allow for rest periods between activities. Completing all care at once can hurt the client's ability to heal by tiring the client too severely. Delegating care does not help the client to conserve energy. Waiting until the end of the shift would have the same effect as doing all care in the morning. The key is not to overtax the client's reserves at any time during the shift.
D) The client with little energy reserve is best served by pacing care throughout the shift to allow for rest periods between activities. Completing all care at once can hurt the client's ability to heal by tiring the client too severely. Delegating care does not help the client to conserve energy. Waiting until the end of the shift would have the same effect as doing all care in the morning. The key is not to overtax the client's reserves at any time during the shift.

Question 13

A client with aspiration pneumonia is diaphoretic,pale,and taking gasping breaths.Which is the priority nursing action?

Accepted Answer

A) The first step in the nursing process is to complete an assessment of the client. The client is indeed experiencing difficulty, but the nurse needs to assess the extent of the need and the reason for the problem before taking action. The healthcare provider will ask the nurse to identify the reason for the problem and the extent of the problem. Administering oxygen could be dangerous to the client in some cases, such as if the client has chronic obstructive pulmonary disease. The client may have simply slipped down in the bed and need repositioning; on the other hand, the client may be in trouble, so making the decision to simply reposition the client without assessment could cause harm.
B) The first step in the nursing process is to complete an assessment of the client. The client is indeed experiencing difficulty, but the nurse needs to assess the extent of the need and the reason for the problem before taking action. The healthcare provider will ask the nurse to identify the reason for the problem and the extent of the problem. Administering oxygen could be dangerous to the client in some cases, such as if the client has chronic obstructive pulmonary disease. The client may have simply slipped down in the bed and need repositioning; on the other hand, the client may be in trouble, so making the decision to simply reposition the client without assessment could cause harm.
C) The first step in the nursing process is to complete an assessment of the client. The client is indeed experiencing difficulty, but the nurse needs to assess the extent of the need and the reason for the problem before taking action. The healthcare provider will ask the nurse to identify the reason for the problem and the extent of the problem. Administering oxygen could be dangerous to the client in some cases, such as if the client has chronic obstructive pulmonary disease. The client may have simply slipped down in the bed and need repositioning; on the other hand, the client may be in trouble, so making the decision to simply reposition the client without assessment could cause harm.
D) The first step in the nursing process is to complete an assessment of the client. The client is indeed experiencing difficulty, but the nurse needs to assess the extent of the need and the reason for the problem before taking action. The healthcare provider will ask the nurse to identify the reason for the problem and the extent of the problem. Administering oxygen could be dangerous to the client in some cases, such as if the client has chronic obstructive pulmonary disease. The client may have simply slipped down in the bed and need repositioning; on the other hand, the client may be in trouble, so making the decision to simply reposition the client without assessment could cause harm.

Question 14

The urgent care clinic nurse is treating a client who is experiencing abdominal pain.The client states,"I think I ate tainted food last night." What should the nurse do after the client states that the food was tainted?

Accepted Answer

A) The nurse must recognize that the client has not given the nurse enough information. The client could, indeed, have eaten bad food or may be experiencing appendicitis. The nurse asks more questions followed by a physical examination. Short-cut decisions here could be harmful for this client. The nurse would not give advice about taking a medication. The nurse does not have enough information to make the decision to call an ambulance. Because the nurse does not have enough information, telling the client that a physician does not need to assess the client is inappropriate.
B) The nurse must recognize that the client has not given the nurse enough information. The client could, indeed, have eaten bad food or may be experiencing appendicitis. The nurse asks more questions followed by a physical examination. Short-cut decisions here could be harmful for this client. The nurse would not give advice about taking a medication. The nurse does not have enough information to make the decision to call an ambulance. Because the nurse does not have enough information, telling the client that a healthcare provider does not need to assess the client is inappropriate.
C) The nurse must recognize that the client has not given the nurse enough information. The client could, indeed, have eaten bad food or may be experiencing appendicitis. The nurse asks more questions followed by a physical examination. Short-cut decisions here could be harmful for this client. The nurse would not give advice about taking a medication. The nurse does not have enough information to make the decision to call an ambulance. Because the nurse does not have enough information, telling the client that a healthcare provider does not need to assess the client is inappropriate.
D) The nurse must recognize that the client has not given the nurse enough information. The client could, indeed, have eaten bad food or may be experiencing appendicitis. The nurse asks more questions followed by a physical examination. Short-cut decisions here could be harmful for this client. The nurse would not give advice about taking a medication. The nurse does not have enough information to make the decision to call an ambulance. Because the nurse does not have enough information, telling the client that a healthcare provider does not need to assess the client is inappropriate.

Question 15

A novice nurse is planning care for an older adult client with a wound infection and systemic blood infection.The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking?

Accepted Answer

A) The new nurse should recognize self-limitations and should plan to seek assistance and review of thinking by a more experienced nurse. Seeking out other opinions increases the knowledge base and exposes the new nurse to other ways of thinking, which will enhance critical thinking. The nurse would seek the opinion of another nurse, not the physician or the client, as the goal is to enhance the nurse's ability to use the nursing process. The nurse could put the plan on the chart, but the new nurse would learn more about critical thinking by requesting assistance from a more experienced nurse.
B) The new nurse should recognize self-limitations and should plan to seek assistance and review of thinking by a more experienced nurse. Seeking out other opinions increases the knowledge base and exposes the new nurse to other ways of thinking, which will enhance critical thinking. The nurse would seek the opinion of another nurse, not the physician or the client, as the goal is to enhance the nurse's ability to use the nursing process. The nurse could put the plan on the chart, but the new nurse would learn more about critical thinking by requesting assistance from a more experienced nurse.
C) The new nurse should recognize self-limitations and should plan to seek assistance and review of thinking by a more experienced nurse. Seeking out other opinions increases the knowledge base and exposes the new nurse to other ways of thinking, which will enhance critical thinking. The nurse would seek the opinion of another nurse, not the physician or the client, as the goal is to enhance the nurse's ability to use the nursing process. The nurse could put the plan on the chart, but the new nurse would learn more about critical thinking by requesting assistance from a more experienced nurse.
D) The new nurse should recognize self-limitations and should plan to seek assistance and review of thinking by a more experienced nurse. Seeking out other opinions increases the knowledge base and exposes the new nurse to other ways of thinking, which will enhance critical thinking. The nurse would seek the opinion of another nurse, not the physician or the client, as the goal is to enhance the nurse's ability to use the nursing process. The nurse could put the plan on the chart, but the new nurse would learn more about critical thinking by requesting assistance from a more experienced nurse.

Question 16

During a health history a client becomes upset because the nurse is asking many questions.Which response by the nurse is the most appropriate in this situation?

Accepted Answer

A) Many clients may see the health history as an intrusion. The nurse would explain the reason for the questions so the client understands why the questions are being asked. Apologizing to the client is not really appropriate, as the nurse needs information about the client. Skipping questions could cause the nurse to miss areas of client need. Telling the client that the nurse cannot help without answers to the questions is true, but can be seen as a threat and would not be considered a therapeutic response.
B) Many clients may see the health history as an intrusion. The nurse would explain the reason for the questions so the client understands why the questions are being asked. Apologizing to the client is not really appropriate, as the nurse needs information about the client. Skipping questions could cause the nurse to miss areas of client need. Telling the client that the nurse cannot help without answers to the questions is true, but can be seen as a threat and would not be considered a therapeutic response.
C) Many clients may see the health history as an intrusion. The nurse would explain the reason for the questions so the client understands why the questions are being asked. Apologizing to the client is not really appropriate, as the nurse needs information about the client. Skipping questions could cause the nurse to miss areas of client need. Telling the client that the nurse cannot help without answers to the questions is true, but can be seen as a threat and would not be considered a therapeutic response.
D) Many clients may see the health history as an intrusion. The nurse would explain the reason for the questions so the client understands why the questions are being asked. Apologizing to the client is not really appropriate, as the nurse needs information about the client. Skipping questions could cause the nurse to miss areas of client need. Telling the client that the nurse cannot help without answers to the questions is true, but can be seen as a threat and would not be considered a therapeutic response.

Question 17

The nurse is assigned two clients.One client needs postoperative teaching in preparation for discharge and the other client with pneumonia has a PaCO₂ of 85.Why does the nurse decide to see the client with pneumonia first?

Accepted Answer

A) The client with a PaCO₂ of 85 could be in serious trouble. The nurse would decide to assess that client first in order to prevent dire consequences for the client. The client with pneumonia probably needs more care than the client preparing for discharge, but the reason for the decision is based on a potentially critical need by the client with pneumonia. The nurse cannot delegate discharge teaching to a UAP; even if delegation were permitted, the nurse would see the client with a high PaCO₂ as being the greater priority. Placement of the client's room can be a decision that is made when considering time management issues; however, the physiological needs of the clients are the first consideration of the nurse. B) The client with a PaCO₂ of 85 could be in serious trouble. The nurse would decide to assess that client first in order to prevent dire consequences for the client. The client with pneumonia probably needs more care than the client preparing for discharge, but the reason for the decision is based on a potentially critical need by the client with pneumonia. The nurse cannot delegate discharge teaching to a UAP; even if delegation were permitted, the nurse would see the client with a high PaCO₂ as being the greater priority. Placement of the client's room can be a decision that is made when considering time management issues; however, the physiological needs of the clients are the first consideration of the nurse. C) The client with a PaCO₂ of 85 could be in serious trouble. The nurse would decide to assess that client first in order to prevent dire consequences for the client. The client with pneumonia probably needs more care than the client preparing for discharge, but the reason for the decision is based on a potentially critical need by the client with pneumonia. The nurse cannot delegate discharge teaching to a UAP; even if delegation were permitted, the nurse would see the client with a high PaCO₂ as being the greater priority. Placement of the client's room can be a decision that is made when considering time management issues; however, the physiological needs of the clients are the first consideration of the nurse. D) The client with a PaCO₂ of 85 could be in serious trouble. The nurse would decide to assess that client first in order to prevent dire consequences for the client. The client with pneumonia probably needs more care than the client preparing for discharge, but the reason for the decision is based on a potentially critical need by the client with pneumonia. The nurse cannot delegate discharge teaching to a UAP; even if delegation were permitted, the nurse would see the client with a high PaCO₂ as being the greater priority. Placement of the client's room can be a decision that is made when considering time management issues; however, the physiological needs of the clients are the first consideration of the nurse.

Question 18

The nurse is caring for an older school-age client who is sleeping when the menu choices for dinner are brought to the room.Which intervention should the nurse use to meet the dietary needs of this client?

Accepted Answer

A) The nurse would ask the dietary worker to come back later rather than risk making an error picking a meal or insulting the client. The nurse could use deductive reasoning and pick a meal that most children like, but the client could be allergic to certain foods or just not like them. Waking the client is not an option because the body heals during sleep. If the parents are present, the nurse might ask them if they are comfortable making choices for the child, but asking them to bring food in is inappropriate.
B) The nurse would ask the dietary worker to come back later rather than risk making an error picking a meal or insulting the client. The nurse could use deductive reasoning and pick a meal that most children like, but the client could be allergic to certain foods or just not like them. Waking the client is not an option because the body heals during sleep. If the parents are present, the nurse might ask them if they are comfortable making choices for the child, but asking them to bring food in is inappropriate.
C) The nurse would ask the dietary worker to come back later rather than risk making an error picking a meal or insulting the client. The nurse could use deductive reasoning and pick a meal that most children like, but the client could be allergic to certain foods or just not like them. Waking the client is not an option because the body heals during sleep. If the parents are present, the nurse might ask them if they are comfortable making choices for the child, but asking them to bring food in is inappropriate.
D) The nurse would ask the dietary worker to come back later rather than risk making an error picking a meal or insulting the client. The nurse could use deductive reasoning and pick a meal that most children like, but the client could be allergic to certain foods or just not like them. Waking the client is not an option because the body heals during sleep. If the parents are present, the nurse might ask them if they are comfortable making choices for the child, but asking them to bring food in is inappropriate.

Question 19

The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery.The client has lost 10 pounds,is continuing to experience pain,and is not eating.What should be the nurse's next action?

Accepted Answer

A) The nurse evaluates that pain goals for this client have not been met and examines pain relief interventions to determine the problem. The goal of pain management is pain relief and that goal would not change; what might change is the interventions to meet the goal. Contacting Meals on Wheels may not be appropriate if the problem is pain relief. Pain relief is a medical issue that is addressed by the nurse and physician, not social services.
B) The nurse evaluates that pain goals for this client have not been met and examines pain relief interventions to determine the problem. The goal of pain management is pain relief and that goal would not change; what might change is the interventions to meet the goal. Contacting Meals on Wheels may not be appropriate if the problem is pain relief. Pain relief is a medical issue that is addressed by the nurse and physician, not social services.
C) The nurse evaluates that pain goals for this client have not been met and examines pain relief interventions to determine the problem. The goal of pain management is pain relief and that goal would not change; what might change is the interventions to meet the goal. Contacting Meals on Wheels may not be appropriate if the problem is pain relief. Pain relief is a medical issue that is addressed by the nurse and physician, not social services.
D) The nurse evaluates that pain goals for this client have not been met and examines pain relief interventions to determine the problem. The goal of pain management is pain relief and that goal would not change; what might change is the interventions to meet the goal. Contacting Meals on Wheels may not be appropriate if the problem is pain relief. Pain relief is a medical issue that is addressed by the nurse and physician, not social services.

Question 20

A client with congestive heart failure (CHF)is having difficulty breathing.Before leaving the room the nurse ensures the client has an over-bed table to lean on when awake if needed to ease breathing.Which technique did the nurse use to make this decision?

Accepted Answer

A) After assessing the client, the nurse sets goals for and with the client. To arrive at the goal, the nurse uses critical thinking to make the decision to provide the client with optimum ability to breathe. Delegating involves giving the task to another team member. There is no conflict in this decision. Conflict resolution usually involves a compromise that affects two sides that are in disagreement. Priority-setting involves deciding which task to perform first.
B) After assessing the client, the nurse sets goals for and with the client. To arrive at the goal, the nurse uses critical thinking to make the decision to provide the client with optimum ability to breathe. Delegating involves giving the task to another team member. There is no conflict in this decision. Conflict resolution usually involves a compromise that affects two sides that are in disagreement. Priority-setting involves deciding which task to perform first.
C) After assessing the client, the nurse sets goals for and with the client. To arrive at the goal, the nurse uses critical thinking to make the decision to provide the client with optimum ability to breathe. Delegating involves giving the task to another team member. There is no conflict in this decision. Conflict resolution usually involves a compromise that affects two sides that are in disagreement. Priority-setting involves deciding which task to perform first.
D) After assessing the client, the nurse sets goals for and with the client. To arrive at the goal, the nurse uses critical thinking to make the decision to provide the client with optimum ability to breathe. Delegating involves giving the task to another team member. There is no conflict in this decision. Conflict resolution usually involves a compromise that affects two sides that are in disagreement. Priority-setting involves deciding which task to perform first.

Quiz 36: Clinical Decision Making

The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques.Upon completion of the class,what should the nurse expect the participants to do?

An older adult client is experiencing confusion,a temperature of 101.5°F,bruising to the arms and legs,and decreased urine output.The medical diagnosis is a urinary tract infection.Which is the most appropriate nursing diagnosis for this client?

A nurse receives a shift report and is preparing to care for clients assigned on a medical-surgical unit.Which client should the nurse plan to assess first?

A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours.At 4 hours the client's pain level is 8 on a rating scale of 1 to 10.The nurse decides to give the pain medication now.What does this nurse's action exemplify?

A client asks the student nurse to explain the pathophysiology of diabetes.The student nurse does not know the answer to this question.What should the student respond to the client?

A goal of care for a client with congestive heart failure (CHF) is for serum sodium levels to be within normal limits.Which information documented in the medical record would indicate that the client is not meeting this goal?

The nurse is collecting data about a client's current health status.Which statement would assist in gathering subjective data about the client?

The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died.On which areas should the nurse focus when performing this reflection? Select all that apply.

The nurse is caring for an older adult client with decreased energy who needs to get up to prevent the development of pressure ulcers.The client is unable to ambulate and wants to be alone.What should the nurse do?

A client recovering from knee surgery is being prepared to ambulate for the first time.Prior to getting the client up,what should the nurse do?

An older adult client with heart failure is experiencing activity intolerance due to dyspnea on exertion.Which nursing intervention is a priority for the client?

A client with aspiration pneumonia is diaphoretic,pale,and taking gasping breaths.Which is the priority nursing action?

The urgent care clinic nurse is treating a client who is experiencing abdominal pain.The client states,"I think I ate tainted food last night." What should the nurse do after the client states that the food was tainted?

A novice nurse is planning care for an older adult client with a wound infection and systemic blood infection.The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking?

During a health history a client becomes upset because the nurse is asking many questions.Which response by the nurse is the most appropriate in this situation?

The nurse is assigned two clients.One client needs postoperative teaching in preparation for discharge and the other client with pneumonia has a PaCO₂ of 85.Why does the nurse decide to see the client with pneumonia first?

The nurse is caring for an older school-age client who is sleeping when the menu choices for dinner are brought to the room.Which intervention should the nurse use to meet the dietary needs of this client?

The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery.The client has lost 10 pounds,is continuing to experience pain,and is not eating.What should be the nurse's next action?

A client with congestive heart failure (CHF) is having difficulty breathing.Before leaving the room the nurse ensures the client has an over-bed table to lean on when awake if needed to ease breathing.Which technique did the nurse use to make this decision?

Quiz 36: Clinical Decision Making

The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques.Upon completion of the class,what should the nurse expect the participants to do?

An older adult client is experiencing confusion,a temperature of 101.5°F,bruising to the arms and legs,and decreased urine output.The medical diagnosis is a urinary tract infection.Which is the most appropriate nursing diagnosis for this client?

A nurse receives a shift report and is preparing to care for clients assigned on a medical-surgical unit.Which client should the nurse plan to assess first?

A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours.At 4 hours the client's pain level is 8 on a rating scale of 1 to 10.The nurse decides to give the pain medication now.What does this nurse's action exemplify?

A client asks the student nurse to explain the pathophysiology of diabetes.The student nurse does not know the answer to this question.What should the student respond to the client?

A goal of care for a client with congestive heart failure (CHF) is for serum sodium levels to be within normal limits.Which information documented in the medical record would indicate that the client is not meeting this goal?

The nurse is collecting data about a client's current health status.Which statement would assist in gathering subjective data about the client?

The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died.On which areas should the nurse focus when performing this reflection? Select all that apply.

The nurse is caring for an older adult client with decreased energy who needs to get up to prevent the development of pressure ulcers.The client is unable to ambulate and wants to be alone.What should the nurse do?

A client recovering from knee surgery is being prepared to ambulate for the first time.Prior to getting the client up,what should the nurse do?

An older adult client with heart failure is experiencing activity intolerance due to dyspnea on exertion.Which nursing intervention is a priority for the client?

A client with aspiration pneumonia is diaphoretic,pale,and taking gasping breaths.Which is the priority nursing action?

The urgent care clinic nurse is treating a client who is experiencing abdominal pain.The client states,"I think I ate tainted food last night." What should the nurse do after the client states that the food was tainted?

A novice nurse is planning care for an older adult client with a wound infection and systemic blood infection.The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking?

During a health history a client becomes upset because the nurse is asking many questions.Which response by the nurse is the most appropriate in this situation?

The nurse is assigned two clients.One client needs postoperative teaching in preparation for discharge and the other client with pneumonia has a PaCO2 of 85.Why does the nurse decide to see the client with pneumonia first?

The nurse is caring for an older school-age client who is sleeping when the menu choices for dinner are brought to the room.Which intervention should the nurse use to meet the dietary needs of this client?

The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery.The client has lost 10 pounds,is continuing to experience pain,and is not eating.What should be the nurse's next action?

A client with congestive heart failure (CHF) is having difficulty breathing.Before leaving the room the nurse ensures the client has an over-bed table to lean on when awake if needed to ease breathing.Which technique did the nurse use to make this decision?

The nurse is assigned two clients.One client needs postoperative teaching in preparation for discharge and the other client with pneumonia has a PaCO₂ of 85.Why does the nurse decide to see the client with pneumonia first?