clinical decision making practice questions

2) The nurse is prioritizing care for a client with several problems. List the order in which the nurse should address the client's needs. 1. Bleeding through nasogastric tube 2. Audible wheezes 3. Not understanding how to complete the menu 4. Requesting medication for arthritis pain 5. Dyspnea 6. Asking questions about teaching provided the other day

2,5,1,4,6,3

5) 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. 1. Measure blood pressure before administering antihypertensive medication. 2. Request dietary consult for gluten-free diet. 3. Remove an intravenous access device infusing chemotherapy. 4. Change a dressing on an arm wound. 5. Call a family member to bring in shoes. 6. Ambulate to the bathroom using a walker.

3,1,4,6,2,5

3) The nurse is prioritizing care for a client based upon nursing diagnoses. If following Maslow's hierarchy of needs, list the order in which the nurse should provide care to the client. 1. Fatigue 2. Anxiety 3. Alteration in Perfusion 4. Self-Care Deficit 5. Deficient Knowledge 6. Diarrhea

3,6,4,2,1,5

1) During a health history a client becomes upset because the nurse is asking many questions. What should the nurse respond to the client? A) "I use the answers you provide to determine what your current health needs are." 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

10) 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

3) A goal of care for a client with congestive heart failure is for serum sodium levels to be within normal limits. What information should the nurse expect to see documented in the medical record? 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

5) A client seen in an urgent care clinic is complaining of abdominal pain and believes that the food eaten the previous evening was tainted. 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 physician 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

5) An older 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. What is the most appropriate nursing diagnosis for this client? A) Risk for Injury B) Ineffective Breathing Pattern C) Activity Intolerance D) Impaired Memory

A

7) 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

3) The nursing instructor is evaluating a concept map created by a student for a client's plan of care. What characteristic or 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,B,C

7) After receiving the morning report, the nurse prioritizes care needed by several clients. What 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) Time of day

A,B,C,D

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

A,B,D

12) The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died. On which area(s) 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,C,D,E

8) The nurse manager is concerned that a staff nurse is having difficulty prioritizing client care needs. What did the manager observe the nurse perform that caused these concerns? Select all that apply. A) Relying upon 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,C,D,E

1) The nurse is preparing to provide care to a group of clients. On which specific area(s) 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,D,E

10) A nurse enters a client's room to check on the client's response to IV pain medication she gave on request 20 minutes earlier. She finds the client on her side lying very still and not wanting to move, and asks the client about her current pain level. Which aspect(s) of the nursing process does this action represent? Select all that apply. A) Assessment B) Diagnosis C) Planning D) Implementation E) Evaluation

A,D,E

6) A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. What should the nurse do first? A) Notify the physician. B) Complete a thorough cardiopulmonary assessment. C) Administer 10 L of oxygen per face mask. D) Reposition the client to help with breathing.

B

11) 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." Because he also keeps saying "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," the nurse also identifies "Anxiety" as another nursing diagnosis. Which diagnosis would receive priority for nursing intervention? A) Risk for Infection B) Ineffective Breathing Pattern C) Disturbed Sleep Pattern D) Anxiety

B

4) 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,C

6) The nurse is preparing to triage victims of a train derailment who are being transported to the Emergency Department. Which victim(s) 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,C

9) Which statement or statements accurately reflect the distinction between nursing diagnoses arrived at as part of the nursing process 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,C

4) The nurse is selected to participate on a committee to write critical pathways for a specific set of medical diagnoses. What will be the advantage(s) 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,C,D

2) The nurse is creating a four-column plan of care for a client. For which area(s) 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,C,D,E

8) A client who has just been diagnosed with diabetes mellitus is being instructed by the nurse regarding diet and exercise. Which client statement or 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,D

13) 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 physician and prepare to perform iced saline lavage. Which feature(s) of the Tanner Clinical Judgment Model did this nurse demonstrate? Select all that apply. A) Presencing B) Noticing C) Empowerment D) Interpreting E) Responding

B,D,E

11) A graduate nurse is planning care for an older 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

4) 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

8) The nurse is caring for a female 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 physician 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

9) The nurse is caring for a 10-year-old 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

1) A nurse has just received 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

2) A client with congestive heart failure 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? A) Delegating a task B) Priority-setting C) Conflict resolution D) Critical thinking

D

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? A) Set goals for the next class session. B) Pass a written test on how to bathe a newborn infant. C) Review the major points of the class. D) Provide a return demonstration of a bath on a newborn doll.

D

3) 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) A response to a change in the client's condition

D

4) 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

6) An older 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

7) 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