PN 2.0 Clinical Judgment Practice 1

A nurse in a clinic is caring for an infant at the 6-month well child visit. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 The client is at highest risk for developing _____________ as evidenced by the client's _____________________.

The client is at highest risk for developing brain damage as evidenced by the client's VP shunt malfunction.

A nurse on a medical surgical floor is caring for a newly admitted client following a motor vehicle accident. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Complete the following sentence by using the list of options. The nurse should first address the client's _____________ followed by the client's _____________.

The nurse should first address the client's agitation followed by the client's blood pressure.

A nurse is caring for a client who has COPD. Click to highlight the actions the nurse should take. To deselect a finding, click on the finding again. - Change oxygen delivery system to a non-rebreather mask. - Assist the client with controlled coughing. - Instruct the client to use pursed lip breathing. - Obtain an order for an additional dose of albuterol. - Reposition the client to their left side.

- Assist the client with controlled coughing. - Instruct the client to use pursed lip breathing. - Obtain an order for an additional dose of albuterol.

A nurse is caring for a client in a clinic. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 For each finding, click to specify whether it indicates no change in the client's condition, an improvement in the client's condition, or if the client's condition is worsening.

- HbA1c: worsening - Blood glucose: worsening - Blood pressure: Improving - Lung sounds: no change - Weight: worsening - LDL: improving

A nurse is caring for a client in a prenatal clinic. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Which of the following findings should the nurse identify as a potential indication of a complication of pregnancy? Select all that apply. - Liver panel results - Nonstress test results - Fundal height - Hemoglobin - Fetal movement - Respiratory Rate - Blood pressure - Platelet count

- Liver panel results - Nonstress test results - Fundal height - Fetal movement - Blood pressure - Platelet count

A nurse is caring for a school-age child who is newly admitted to the facility. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 For each finding, click to specify if the assessment finding is consistent with asthma, cystic fibrosis, or bacterial pneumonia. Each finding may support more than one disease process.

- WBC level: Cystic fibrosis, Bacterial pneumonia - Chest x-ray results: Cystic fibrosis, Bacterial pneumonia - Respiratory rate: Asthma, Cystic fibrosis, Bacterial pneumonia - Oxygen saturation level: Asthma, Cystic fibrosis, Bacterial pneumonia - Heart rate: Asthma, Cystic fibrosis, Bacterial pneumonia - Clubbing fingers: Cystic fibrosis - Lung sounds: Asthma, Cystic fibrosis, Bacterial pneumonia

A nurse is caring for a client in a clinic. Exhibit 1 Exhibit 2 Select the 4 findings that require immediate follow-up. - Vital signs - Weight - Reports of helplessness - Medication regime - Sleep patterns - Employment performance - GI issues

- Weight - Report of helplessness - Medications regime - Sleep patterns