Module 36 - Clinical Decision Making

After receiving the morning report, the nurse prioritizes care needed by several clients. Which factors should the nurse keep in mind when creating this priority list? Select all that apply. A) Client condition B) Safety C) Time available D) Client preferences E) Nurse preferences Answer: A, B, C, D

A) Client condition B) Safety C) Time available D) Client preferences

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) "I do not know, but I will find out." B) "You'll have to ask the doctor that question." C) "Why do you need to know that?" D) "I do not know."

A) "I do not know, but I will find out."

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? A) "I use the answers to determine your current health needs." B) "I am sorry the questions disturb you." C) "I will skip the questions that bother you." D) "I cannot help you if you do not answer me."

A) "I use the answers to determine your current health needs."

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) Ask the client open-ended questions to further assess the situation. B) Tell the client the healthcare provider does not need to assess the client. C) Call an ambulance before assessing the client any further. D) Advise the client to take an antacid.

A) Ask the client open-ended questions to further assess the situation.

The nurse is preparing to provide care to a group of clients. On which specific areas should the nurse focus in order to prioritize the clients' care needs? Select all that apply. A) Asking if any clients have complex issues B) Noting number of licensed staff assigned for the shift C) Noting time when the attending physicians make rounds D) Identifying clients with specific medication times E) Noting which clients have particular safety needs

A) Asking if any clients have complex issues D) Identifying clients with specific medication times E) Noting which clients have particular safety needs

A nurse enters a client's room to evaluate the response to IV pain medication administered by request 20 minutes earlier. The nurse finds the client in the same position as when the medication was administered. The client states, "I do not want to move." The nurse asks the client to rate the current level of pain. Which aspects of the nursing process do these action represent? Select all that apply. A) Assessment B) Diagnosis C) Planning D) Implementation E) Evaluation

A) Assessment D) Implementation E) Evaluation

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) Examine the current interventions for pain relief. B) Refer the client to social services. C) Contact Meals on Wheels so that the client will eat. D) Revise the goals in the current plan of care.

A) Examine the current interventions for pain relief.

The nurse decides to use a standardized plan of care to address a client's health problems. Which criterion differentiates this plan of care from other types? Select all that apply. A) Is preprinted B) Has blank lines C) Has various shapes connected with lines D) Has checklists E) Includes different colors

A) Is preprinted B) Has blank lines D) Has checklists

The nursing instructor is evaluating a concept map created by a student for a client's plan of care. Which characteristics on the map indicate that the student created the map appropriately? Select all that apply. A) Legend created identifying nursing process phases and client information categories B) Lines drawn between assessment data and associated nursing diagnoses C) Different colors used to represent the phases of the nursing process D) A column entitled "evaluation" located on the outer edge of the document E) A checklist located at the bottom of the document

A) Legend created identifying nursing process phases and client information categories B) Lines drawn between assessment data and associated nursing diagnoses C) Different colors used to represent the phases of the nursing process

The nurse manager is concerned that a staff nurse is having difficulty prioritizing client care needs. Which did the manager observe the nurse perform that caused these concerns? Select all that apply. A) Relying on another nurse's assessment B) Reviewing the medication administration record C) Not completing an assessment D) Doing easiest tasks first E) Asking unlicensed assistive personnel to perform complicated care

A) Relying on another nurse's assessment C) Not completing an assessment D) Doing easiest tasks first E) Asking unlicensed assistive personnel to perform complicated care

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) Risk for Injury B) Ineffective Breathing Pattern C) Activity Intolerance D) Impaired Memory

A) Risk for Injury

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? A) The client is experiencing dependent edema. B) The client experiences joint pain. C) The client is constipated. D) The client is experiencing wheezing respirations.

A) The client is experiencing dependent edema.

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. A) Things that could have been done differently B) Gut reactions to the situation C) Things that were done well D) Resources that were used at the time E) Resources that were needed but not available

A) Things that could have been done differently C) Things that were done well D) Resources that were used at the time E) Resources that were needed but not available

A client who has just been diagnosed with type 2 diabetes mellitus is being instructed by the nurse regarding diet and exercise. Which client statements indicate that further teaching is required? Select all that apply. A) "I should talk to the doctor about an exercise program." B) "I don't need to watch my diet as long as I take my insulin." C) "I need to limit the amount of fat in my diet." D) "I should eat a candy bar when my energy is low." E) "I will test my blood sugar before meals and at bedtime."

B) "I don't need to watch my diet as long as I take my insulin." D) "I should eat a candy bar when my energy is low."

Which statements accurately reflect the distinction between nursing diagnoses and medical diagnoses? Select all that apply. A) A nursing diagnosis is determined following an assessment and analysis of data gathered only by registered nurses; a medical diagnosis is determined following an assessment and analysis of data gathered only by physicians. B) A nursing diagnosis changes as the client's responses to an illness or health situation change; a medical diagnosis remains the same as long as the disease process persists. C) A nursing diagnosis describes a client's physical, sociocultural, psychological, and spiritual responses to an illness or health condition; a medical diagnosis refers to disease processes. D) A nursing diagnosis considers the etiology of the health problem to give direction to required nursing care; a medical diagnosis does not consider the etiology of the health problem to give direction to medical care.

B) A nursing diagnosis changes as the client's responses to an illness or health situation change; a medical diagnosis remains the same as long as the disease process persists. C) A nursing diagnosis describes a client's physical, sociocultural, psychological, and spiritual responses to an illness or health condition; a medical diagnosis refers to disease processes.

The nurse is prioritizing care for a client with several problems. List the order in which the nurse should address the client's needs. A) Bleeding through nasogastric tube B) Audible wheezes C) Not understanding how to complete the menu D) Requesting medication for arthritis pain E) Dyspnea F) Asking questions about teaching provided the other day

B) Audible wheezes E) Dyspnea A) Bleeding through nasogastric tube D) Requesting medication for arthritis pain F) Asking questions about teaching provided the other day C) Not understanding how to complete the menu

A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. Which is the priority nursing action? A) Notify the healthcare provider. B) Complete a thorough cardiopulmonary assessment. C) Administer 10 L of oxygen per face mask. D) Reposition the client to help with breathing.

B) Complete a thorough cardiopulmonary assessment.

A construction worker admitted to the unit with a chest injury and broken ribs from a fall from a ladder has nursing diagnoses of "Disturbed Sleep Pattern," "Ineffective Breathing Pattern," and "Risk for Infection." The client states, "I've never been sick a day in my life and am really worried about how I can support my family while I'm out of work." When evaluating the client's plan of care during the shift, the nurse adds the nursing diagnosis "Anxiety" to the plan of care. Which diagnosis would be the priority for nursing interventions? A) Risk for Infection B) Ineffective Breathing Pattern C) Disturbed Sleep Pattern D) Anxiety

B) Ineffective Breathing Pattern

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. A) Presencing B) Noticing C) Reflecting D) Interpreting E) Responding

B) Noticing D) Interpreting E) Responding

The nurse is creating a four-column plan of care for a client. For which areas should the nurse prepare to document when creating this care plan? Select all that apply. A) Medications B) Nursing diagnosis C) Goals D) Interventions E) Evaluation

B) Nursing diagnosis C) Goals D) Interventions E) Evaluation

The nurse is prioritizing care needed for a group of clients according to urgency. Which care should the nurse identify as being medium priority? Select all that apply. A) Instructing on changing ostomy appliance B) Performing passive range of motion every 4 hours C) Removing splints and providing complete skin care every 2 hours D) Administering 2 units of fresh frozen plasma E) Performing endotracheal suction

B) Performing passive range of motion every 4 hours C) Removing splints and providing complete skin care every 2 hours

The nurse who uses clinical decision making to start CPR on a client is concerned about what other nursing concept? A) Cognition B) Perfusion C) Thermoregulation D) Acid-base balance

B) Perfusion

The nurse is preparing to triage victims of a train derailment who are being transported to the emergency department. Which victims would need immediate care? Select all that apply. A) Holding broken arm, sitting in a chair B) Respiratory rate of 8 and irregular C) Bleeding from fractured limb with a blood pressure of 78/40 mmHg D) Bleeding from superficial facial wounds and talking to family E) Walking with a slight limp, asking for something to drink

B) Respiratory rate of 8 and irregular C) Bleeding from fractured limb with a blood pressure of 78/40 mmHg

The nurse is selected to participate on a committee to write clinical pathways for a specific set of medical diagnoses. Which are advantages of using this approach when providing client care? Select all that apply. A) Link nursing diagnoses with specific assessment data B) Sequence the care that is to be given on a particular day C) Identify interventions, time frames, and expected outcomes D) List medical treatments to be performed by other providers E) Provide specific columns for diagnosis, interventions, and evaluation

B) Sequence the care that is to be given on a particular day C) Identify interventions, time frames, and expected outcomes D) List medical treatments to be performed by other providers

The nurse is prioritizing care for a client based on nursing diagnoses. If following Maslow's hierarchy of needs, list the order in which the nurse should provide care to the client. A) Fatigue B) Anxiety C) Alteration in Perfusion D) Self-Care Deficit E) Deficient Knowledge F) Diarrhea

C) Alteration in Perfusion F) Diarrhea D) Self-Care Deficit B) Anxiety A) Fatigue E) Deficient Knowledge

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? A) Wake the child to choose a meal for dinner. B) Order chicken nuggets because most children like this meal. C) Ask the dietary worker to come back later. D) Ask the parents to bring dinner from home for the client.

C) Ask the dietary worker to come back later.

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) Notify the healthcare provider of the client's noncompliance. B) Leave the client alone until ready to get out of bed. C) Gain knowledge about the client from family to gain compliance. D) Proceed to get help to get the client out of bed.

C) Gain knowledge about the client from family to gain compliance.

The nurse is prioritizing care activities that are to be completed for a group of clients. From highest to lowest priority, list the order in which the nurse should complete the listed activities. A) Measure blood pressure before administering antihypertensive medication. B) Request dietary consult for gluten-free diet. C) Remove an intravenous access device infusing chemotherapy. D) Change a dressing on an arm wound. E) Call a family member to bring in shoes. F) Ambulate to the bathroom using a walker.

C) Remove an intravenous access device infusing chemotherapy. A) Measure blood pressure before administering antihypertensive medication. D) Change a dressing on an arm wound. F) Ambulate to the bathroom using a walker. B) Request dietary consult for gluten-free diet. E) Call a family member to bring in shoes.

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? A) Discuss the plan with the physician. B) Request that the client review the plan. C) Request a review of the plan with the nurse's preceptor. D) Place the plan on the client's chart.

C) Request a review of the plan with the nurse's preceptor.

A nurse has recently joined an orthopedic unit in the United States that specializes in perioperative care of clients undergoing knee or hip replacement. Which nursing plan of care is this nurse likely to use most often? A) Column plan B) Concept map C) Standardized plan D) Clinical pathway

C) Standardized plan

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? A) The nurse can delegate postoperative teaching to unlicensed assistive personnel (UAP). B) The client with pneumonia needs more care than the client needing postoperative teaching. C) The client with pneumonia may be experiencing respiratory distress. D) The room of the client with pneumonia is closer than that of the client needing postoperative teaching.

C) The client with pneumonia may be experiencing respiratory distress.

The nurse is collecting data about a client's current health status. Which statement would assist in gathering subjective data about the client? A) "Your eyelid is red and swollen." B) "Your skin appears to be dry and irritated." C) "I see that you have bruises on your legs." D) "Tell me why you have difficulty sleeping."

D) "Tell me why you have difficulty sleeping."

A client with congestive heart failure (CHF) is having difficulty breathing. Before leaving the room, the nurse ensures the client has an overbed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? A) Delegating a task B) Priority setting C) Conflict resolution D) Critical thinking

D) Critical thinking

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? A) Ask the client about readiness to walk. B) Call for a wheelchair to start the process. C) Conduct a breathing assessment. D) Evaluate the client's level of pain.

D) Evaluate the client's level of pain.

The novice nurse is writing his first nursing plan of care. He includes category headings for each phase of the nursing process, includes specific and detailed information related to interventions using complete sentences, considers the client's preferences in the chosen interventions, and incorporates preventive and restorative interventions. He then signs and dates the nursing plan of care. What did the nurse do wrong when creating the plan of care? A) He should not have used category headings for each phase of the nursing process. B) He should not have included preventive measures in the care plan until restorative goals were met. C) He should have included the physician's preferences for care rather than the client's preferences. D) He should have used approved abbreviations and key words rather than complete sentences.

D) He should have used approved abbreviations and key words rather than complete sentences.

What is one of the primary reasons that it is important for nurses to prioritize care? A) Nurses need to plan how to accomplish all activities within one shift. B) Nurses can accomplish more if they perform the easiest or fastest interventions first. C) Nurses should perform interventions related to client preferences early in the shift. D) Nurses only have a limited amount of time to perform nursing interventions.

D) Nurses only have a limited amount of time to perform nursing interventions.

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) Complete all nursing care at the end of the shift. B) Delegate care for the client to an aide. C) Complete all nursing care in the morning. D) Pace nursing care throughout the shift.

D) Pace nursing care throughout the shift.

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) Meeting a client goal B) Time management skills C) Prioritizing the client's care D) Responding to a change in the client's condition

D) Responding to a change in the client's condition

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) The client who needs assistance with activities of daily living B) The client who needs help ambulating to the bathroom C) The client with a pain rating of 3/10 D) The client experiencing shortness of breath

D) The client experiencing shortness of breath

The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques. What goal will allow the nurse to best evaluate the mothers' learning? A) The mothers will be able to set goals for the next class session. B) The mothers will be able to pass a written test on how to bathe a newborn infant. C) The mothers will be able to review the major points of the class. D) The mothers will be able to provide a return demonstration of a bath on a newborn doll.

D) The mothers will be able to provide a return demonstration of a bath on a newborn doll.