Clinical Decision Making / Clinical Judgment

The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?

10 to 15 minutes The onset of action of rapid-acting lispro insulin is within 10 to 15 minutes. It is used to rapidly reduce the glucose level.

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260 Intake includes all the components listed in the intake column, which amounts to 710 mL. The output, which is the urine of 450 mL, is subtracted from the total intake.

A patient who is 5 feet 10 inches tall is being measured for crutches. The nurse determines which crutches as being the appropriate length?

54 inches When using a patient's height to determine the appropriate crutch length, the nurse subtracts 16 inches (40 cm) from the patient's height

Which is a clinical manifestation of cholelithiasis?

Clay-colored stools

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus. The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process.

The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation?

Dry skin thoroughly after washing The nurse should teach the client without peristomal skin irritation to dry the skin thoroughly after washing. Barrier powder, triamcinolone acetonide spray, and nystatin powder are used when the client has peristomal skin irritation and/or fungal infection.

The nurse has administered preanesthetic medication. What action should the nurse take next?

Place the client on bed rest with the side rails up. Preanesthetic medication can make the client lightheaded and dizzy. Safety is a priority, so the client should remain in bed with the side rails up.

A client with a history of asthma is brought to the emergency department in respiratory distress. Which is the priority action by the nurse?

Position in Fowler's position, initiate oxygen, and administer bronchodilators as ordered. Priority actions are important to maximize effective ventilation because of the narrowing and spasms of the bronchioles and excessive secretions. It is important to position the client in the high Fowler's position and to oxygenate.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.

Which of the following would lead a nurse to suspect that a client is experiencing acute prostatitis? Select all that apply.

- Nocturia - Perineal pain - Dysuria Acute prostatitis is often manifested by a sudden onset of fever, dysuria, perineal prostatic pain, and severe lower urinary tract symptoms such as dysuria, urinary frequency, urinary urgency, urinary hesitancy, and nocturia.

A registered nurse (RN) suspects that a licensed practical/vocational nurse (LPN/VN) on the unit is using controlled substances. The LPN/VN is often late, recently appears unkempt, frequently nervous, and is often behind in client care duties. According to the ANA Code of Ethics for Nurses, what should the RN do to address her concerns? Select all that apply.

- Report the behaviors to the unit manager for further investigation. - Talk compassionately to the LPN/VN and discuss the RN's concerns and observations. It does not matter where the nurse obtains the drugs; she is still liable for her actions. The nurse should talk to the suspected nurse and report to management.

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?

Allow the client to wear the ring and cover it with tape. Most facilities will allow a client to wear a wedding band during a surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the client has already refused to remove the ring.

A client is undergoing treatment for prostate cancer. He has chemotherapy sessions regularly. However, of late he is showing symptoms of food allergy and loss of appetite. He has lost considerable weight as a result. Which is an appropriate nursing task in this situation?

Ask the client to keep a diet diary. The appropriate nursing task in this situation is to assess the amount of food eaten. This assessment will help determine nutrient intake.

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

Attaching braces or splints to each foot and leg Attaching braces or splints to each foot and leg prevents footdrop (a lower leg contracture) by supporting the feet in proper alignment.

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?

Wound infection Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers

A continuous infusion of total parenteral nutrition Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required.

A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?

An antiviral agent such as acyclovir Herpes labialis is an infection that is caused by herpes simplex virus type 1 (HSV-1). It is characterized by an eruption of small, painful blisters on the skin of the lips, mouth, gums, tongue, or the skin around the mouth.

Which of the following is accurate regarding a hemorrhagic stroke?

Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache."

Which joint is most commonly affected in gout?

Metatarsophalangeal The metatarsophalangeal joint of the big toe is the most commonly affected joint (90% of clients); this is referred to as podagra.

Which positioning strategy should be used for the client diagnosed with hypovolemic shock?

Modified Trendelenburg A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur. The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly.

Which assessment would a nurse perform on a client with Cushing's syndrome who is at high risk of developing a peptic ulcer?

Observe stool color. The nurse should observe the color of each stool and test the stool for occult blood.

The nurse asks the client to hold her left wrist in complete flexion for approximately 1 minute. The client states she feels tingling and numbness when she does this, pointing to the medial nerve. What does the nurse anticipate the client will be prepared for after this assessment?

The client will be prepared for further diagnostic tests such as an electromyogram (EMG). The Phalen maneuver is performed by having the person hold the wrist in complete flexion for approximately a minute. If numbness and paresthesia along the median nerve are reproduced or exaggerated, the test result is considered to be positive. EMG and nerve conduction studies often are done to confirm the diagnosis and exclude other causes of the disorder.

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?

The nursing assistant is pouring a glass of water to wet the client's mouth. When completing a procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort. Upon returning to the nursing unit, the gag reflex must be assessed before providing any food or fluids to the client.

The patient has just received a central venous catheter placed by the physician. Which of the following should the nurse anticipate next?

The patient will have an X-ray to confirm placement of the device.

A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?

Urge Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet.

The nurse is checking the orders for pain management for a client that had coronary surgery 24 hours ago. The nurse identifies that the client has been receiving Celebrex and a narcotic postoperatively for pain management. What is the most appropriate response of the nurse?

Withhold the Celebrex and notify the health care provider. Celebrex should not be used for pain management after coronary surgery due to the risk of cardiovascular thrombosis, myocardial infarction, and stroke.

The nurse is reviewing laboratory values on a client with heart failure and atrial fibrillation. The client has a potassium level of 2.8 mEq/L (2.8 mmol/L). The client is scheduled to receive their 0900 dose of digoxin. What is the nurse's best action?

Withhold the dose of digoxin and notify the healthcare provider. Administering the dose of digoxin should not be done. The effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur.

The nurse is administering a narcotic analgesic for the control of a newly postoperative client's pain. What medication will the nurse administer to this client?

Fentanyl (Duragesic) Opioid and opiate analgesics such as morphine and fentanyl (Duragesic) are controlled substances referred to as narcotics.

During a disaster, the nurse triages a victim with a fractured wrist. Which color triage tag should the nurse apply?

Green A green triage tag (priority 3, or minimal) indicates injuries that are minor, and treatment can be delayed hours to days. A red triage tag (priority 1, or immediate) indicates injuries that are life threatening but survivable with minimal intervention. A yellow triage tag (priority 2, or delayed) indicates injuries that are significant and require medical care, but they can wait hours without threat to life or limb.

The nurse is assessing a client who is stating gastrointestinal upset and a feeling of bloating. Which type of meal would the nurse anticipate causing these types of symptoms?

Hamburger and French fries Fatty foods delay stomach emptying (bloating) and can cause symptoms of gastrointestinal upset.

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc?

Have the client lie on the back and lift the leg, keeping it straight. A client who can lie on the back and raise a leg in a straight position will have pain radiating into the leg if there is a herniated lumbar disc. This action stretches the sciatic nerve.

The nurse is assessing the breast of a female patient and observes a prominent venous pattern on the left breast. What does the nurse understand that this can be indicative of?

Increased blood supply required by a tumor A prominent venous pattern can signal increased blood supply required by a tumor.

A client visits an orthopedic specialist because of pain beginning in the low back and radiating behind the right thigh and down below the right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between which intervertebral disks?

L4, L5, and S1 The lower lumbar disks, L4-L5 and L5-S1, are subject to the greatest mechanical stress and the greatest degenerative changes.

The nurse is working in a community mental health clinic. A client who is diagnosed with schizophrenia is taking clozapine and reports of a sore throat. What is the most appropriate action for the nurse to take?

Obtain an order for the client to have a white blood cell count drawn. The report of a sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells.

The most common cause of cholinergic crisis includes which of the following?

Overmedication A cholinergic crisis, which is essentially a problem of overmedication, results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretion that may result in respiratory failure.

Which is a classic sign of hypovolemic shock?

Pallor The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

A nurse is caring for a client with hypoparathyroidism. During assessment, the nurse elicits a positive Trousseau's sign. What does the nurse observe to verify this finding?

hand flexing inward The nurse observes the client for spasm of the hand (carpopedal spasm), which is evidenced by the hand flexing inward.

The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate?

international normalized ratio (INR) The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body?

left ventricle

A nurse notices that a client's left upper eyelid is drooping. The nurse has observed:

ptosis Ptosis is drooping or falling of the upper or lower eyelid. Ptolemy is not a medical condition. Proptosis is the extended or protruded upper eyelid that delays closing or remains partially open. Nystagmus is uncontrolled oscillating movement of the eyeball.

The nurse is caring for a combative and confused client with a fractured hip who is trying to get out of bed. What actions are appropriate for the nurse to take? Choose all that apply.

- Obtain a physician's order to restrain the client. - Ask a family member to sit with the client. It is mandatory in most settings to have a physician's order before restraining a client. Before restraints are used, other strategies, such as asking family members to sit with the client or using a specially trained sitter, should be tried.

A female patient comes to the clinic for evaluation. As part of the assessment, the nurse determines the patient's ideal body weight. The patient is 5' 5" tall and has an average frame. What would be her ideal body weight in lbs? Enter the correct number only.

125 To calculate the ideal body weight for a woman, allow 100 lb for 5 feet of height and then add 5 lb for each additional inch over 5 feet.

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?

27% The TBSA would be 27%. 18% for the anterior trunk and 9% for the left arm.

A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well controlled?

6.5% Normally, the level of glycosylated hemoglobin is less than 7%. Thus, a level of 6.5% would indicate that the client's blood glucose level is well controlled.

The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for?

Bone pain in the back of the ribs Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma is bone pain, usually in the back or ribs.

A client with a nasogastric (NG) tube who is 2 days postoperative bowel resection is reporting increased abdominal pain and nausea. Which action by the nurse would be most appropriate?

Check the patency and amount of drainage from the NG tube. The client is experiencing abdominal pain and nausea. This subjective assessment data indicate that the NG tube may not be functioning, so assessment of its patency and the amount of drainage would be the first step.

The nurse working on a cancer treatment floor assesses her assigned clients. It is most important for the nurse to report which assessment finding?

Coolness and mottling of a newly constructed breast site Mottling or an obvious decrease in skin temperature may signify flap loss and needs to be reported to the surgeon immediately.

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Lamictal Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).

A patient is being seen in the clinic for possible kidney disease. What major sensitive indicator of kidney disease does the nurse anticipate the patient will be tested for?

Creatinine clearance level Creatinine is an endogenous waste product of skeletal muscle that is filtered at the glomerulus, passed through the tubules with minimal change, and excreted in the urine. Hence, creatinine clearance is a good measure of the glomerular filtration rate (GFR), the amount of plasma filtered through the glomeruli per unit of time

When assessing a client prescribed hemodialysis, the nurse notes the client's blood pressure is 140/82 mm Hg, heart rate is 82 beats/min, and respirations are 12 breaths/min. The nurse also notes a continuous vibration over the client's fistula. What is the appropriate action by the nurse?

Document presence of a thrill. The continuous vibration noted when palpating a hemodialysis fistula is known as a thrill. This is an expected finding so the nurse should document the presence of the thrill. There is no need to contact the healthcare provider or to hold the hemodialysis.

The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering?

Fentanyl Opioid analgesic agents are divided into two major groups: (1) mu agonist opioids (also called morphine-like drugs) and (2) agonist-antagonist opioids. The mu agonist opioids comprise the larger of the two groups and include morphine, hydromorphone, hydrocodone, fentanyl, oxycodone, and methadone, among others.

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?

Lichenification Lichenification is a thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, and scratching and that commonly occurs in contact dermatitis.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove the dressing, clean the site, and apply a new dressing. A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing.

The nurse is aware, when caring for patients with renal disease, that which substance made in the glomeruli directly controls blood pressure?

Renin Renin is directly involved in the control of arterial blood pressure. It is also essential for the proper functioning of the glomerulus and management of the body's renin-angiotensin system (RAS).

A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction?

Rh-negative mother; Rh-positive child A mother who is Rh negative and gives birth to an Rh positive child is at greatest risk for a febrile nonhemolytic reaction because exposure to an Rh-positive fetus raises antibody levels in the Rh negative mother.

Which of the following ventilation-perfusion mismatch would correlate with acute respiratory distress syndrome (ARDS)?

Silent unit A silent unit (a combination of shunting and dead-space ventilation) occurs when little or no ventilation and perfusion is present, such as in ARDS.

A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?

The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

cover the opening with petroleum gauze. If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape.

Which test used to diagnose heart disease is least invasive?

transthoracic echocardiography Transthoracic echocardiography uses high-frequency sound waves that pass through the chest wall (transthoracic) and are displayed on an oscilloscope. MRI uses magnetism to identify disorders that affect many different structures in the body without performing surgery. While an MRI does not expose clients to radiation, it does require intravenous infusion to instill medication and contrast medium.