PassPoint NCLEX Clinical Decision Making/Clinical Judgement

The nurse is caring for a client who has developed infiltration at the peripheral intravenous site. The client has normal saline at 50 ml/hour infusing and antibiotics prescribed every 6 hours. What should the nurse do? Select all that apply.

Discontinue the intravenous line. Start an intravenous line in another site. Explanation: The nurse should discontinue the intravenous line so the vein and tissue around the vein can heal. Applying a warm moist compress is done for phlebitis. Slowing the rate of the normal saline infusion will make the infiltration worse because the vessel wall is penetrated, and fluid is escaping into the subcutaneous tissue. The client is placed on the left side for an air embolus, not for infiltration. The nurse should start an intravenous line in another site to continue the normal saline and antibiotics.

The nurse is preparing a client for a cardiac catheterization. Which client statement would the nurse need to report to the healthcare provider immediately?

"I took my metformin this morning." Explanation: The priority would be to notify the healthcare provider of the metformin because it cannot be taken 48 hours before or after contrast, as there is an increased risk of lactic acidosis and acute renal failure with iodinated contrast material. It would be appropriate for the client to take nothing by mouth. It is important to determine the client's allergies; however, it is not the priority. Claustrophobia would not be an issue during a cardiac catheterization.

The client rushes out of the day room where he has been watching television with other clients. He is hyperventilating and flushed and his fists are clenched. He states to the nurse, "That bastard! I almost hit him." What would be the nurse's best response?

"You're angry, and you did well to leave the situation. Let's walk up and down the hall while you tell me about it." Explanation: The nurse acknowledges and labels the client's emotion and acknowledges his appropriate behavior. Recognizing the client's physiologic arousal, the nurse suggests an activity to decrease anxiety and stays with him. Setting limits on the client's language does not acknowledge his control and does not help the client manage his anxiety. The client needs to engage in physical activity to decrease muscle tension and anxiety. Offering the client medication suggests that he cannot control his behavior. Medication would be used only if other interventions failed to reduce the anxiety level.

A nurse is assisting in the birthing room. The healthcare provider prepares to perform a midline episiotomy. On the illustration, identify the area where the healthcare provider makes the incision.

A midline episiotomy occurs in the center of the perineum. An episiotomy is surgical enlargement of the vaginal opening that allows easier birth of the fetus and prevents tearing of the perineum. The incision is made in the perineum and can be midline or right or left mediolateral.

A 35-year-old female client is diagnosed with aplastic anemia. Which is the most important nursing measure to incorporate into the client's plan of care?

Alternate periods of activity with rest to decrease fatigue. Explanation: Activity intolerance is a common problem for clients with aplastic anemia due to decreased hemoglobin. Alternating activity with periods of rest and assisting the client with activities of daily living are appropriate nursing interventions.Antibiotics will not be administered prophylactically. The client should be taught self-care activities to decrease the likelihood of developing an infection.Adequate fluid intake is important, but the client does not need to force fluids. Hemoconcentration is not a problem in aplastic anemia. The client should be taught good handwashing techniques and limit contact with individuals who have respiratory illnesses; however, the client does not have to avoid all social situations.

The nurse was unsuccessful starting a peripheral intravenous line in the right forearm of a client with a history of a left axillary lymph node removal. What should the nurse do next?

Ask another nurse to attempt to start a peripheral intravenous line. Explanation: Another nurse needs to attempt to start an intravenous line. That nurse may be successful with starting the intravenous line. The nurse should not begin by notifying the health care provider. This action should only be performed if multiple attempts have been made to insert an intravenous line without success. The nurse will not set up for placement of a triple-lumen central venous catheter without notifying the health care provider and getting an order. The client should not have an intravenous line started in the left forearm because of the lymph node removal. The removal of lymph nodes increases the risk of lymphedema, which can lead to an infection.

A client is admitted to the telemetry unit following a ST segment-elevation myocardial infarction (STEMI). The electrocardiogram (EKG) tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse should take?

Assess the client's airway, breathing, pulses, and level of conciseness. Explanation: If the client is experiencing ventricular tachycardia, the priority for the nurse is to assess the client's airway, breathing, and level of consciousness before any further action is taken.

A client who had transurethral resection of the prostate (TURP) 2 days earlier has lower abdominal pain. What should the nurse do first?

Assess the patency of the urethral catheter. Explanation: The lower abdominal pain is most likely caused by bladder spasms. A common cause of bladder spasms after TURP is blood clots obstructing the catheter; therefore, the nurse's first action should be to assess the patency of the catheter. Auscultating the abdomen for bowel sounds would be appropriate after patency of the catheter has been established. The nurse should assess for bladder spasms before administering an analgesic. A sitz bath would not relieve bladder spasms that are caused by an obstructed catheter.

A client is experiencing an acute hemolytic reaction. What actions should the nurse take? Select all that apply.

Check for low back pain. Assess for anxiety and mental status changes. Notify the health care provider. Explanation: The intravenous line is needed to give fluids and medications through. The blood container and tubing need to be sent back to the blood bank for repeat typing and culture. Low back pain is a symptom of acute hemolytic reaction. Anxiety and mental status changes are symptoms of acute hemolytic reaction. The health care provider needs to be notified because he/she may need to see the client and order further treatments.

Which action should the nurse take next after noting that an 8-month-old child's posterior fontanel is slightly open?

Check the child's head circumference. Explanation: This is not a normal finding because the posterior fontanel usually closes by age 2 months. Therefore, the nurse should measure the head circumference to determine if the child's head is larger than the established norms because hydrocephalus can cause separation of the cranium sutures.

The nurse starts an infusion of tissue plasminogen alteplase (tPA) for a client with a cerebrovascular accident (CVA). What are the priority nursing interventions during treatment with this medication?

Conduct frequent neurologic assessments to determine whether the stroke is evolving or acute complications are developing. Explanation: Because tPA dissolves clots--clots that are anywhere in the body, not specific to the thrombosed area--neurologic checks are essential. Lowering the head of the bed is incorrect because the nurse wants slight head elevation to promote cerebral drainage of fluid. The pressure should be maintained to avoid further bleeding and/or swelling. The urine output would need frequent monitoring after administration of this medication to assess for any bleeding.

A client admitted with anorexia nervosa lost 30 lb (13.6 kg) during the previous 3 months. When planning this client's care, what should a nurse select as a priority intervention?

Consult with a dietitian about the client's dietary needs. Explanation: The nurse must first assess and plan interventions for the client's nutrition and other immediate physical needs. The nurse should consult with a dietitian to determine the client's dietary requirements, set nutritional goals, and explore ways to meet those goals. Obtaining strict intake and output, providing a safe environment during mealtime, and instructing the client to eat at least 1000 calories a day are also important interventions. However, they don't meet basic physical needs and aren't priority interventions at this time.

The nurse is planning care for a client with severe postoperative pain. There is a prescription for morphine written as "10 mg MSO4" on the medical record. What should the nurse do first?

Contact the health care provider (HCP) who prescribed the medication. Explanation: The nurse should first contact the HCP because the prescription for the morphine is not complete. The Joint Commission of the United States and the Institute for Safe Medication Practices Canada recommend not to use MSO4 because it can apply to morphine as well as to magnesium sulfate. There is no mention of an IV system being needed. The morphine should not be in the medication cabinet because the prescription is not complete. Although pharmacy may offer a suggestion as to what the medication prescribed is, the best means to confirm the intent of the prescription is to contact the HCP who wrote the prescription.

A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do?

Discontinue the current solution, change the tubing, and hang a new bag of TPN solution. Explanation: IV fluids should not be infused for longer than 24 hours because of the risk of bacterial growth in the solution. The appropriate action for the nurse to take is to discontinue the current TPN solution, change the tubing, and hang a new bag of solution. Changing the filter does not decrease the risk of contamination. Notifying the HCP for a change in flow rate is not an acceptable solution.

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. Explanation: 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 nurse should not administer oxygen as there is no indication that the client is in need of oxygen at this time.

A nurse is working as pediatric case manager on the pediatric orthopedic unit. The nurse takes what action as most representative of the responsibilities in this role?

Ensuring the critical pathway related to care is followed. Explanation: Case managers follow a group of clients, ensuring that their care follows the appropriate critical pathway. These pathways contain a timeline designed to coordinate the multidisciplinary team toward a common goal of providing a short, safe, and healthy length of stay in the hospital. Case managers play an active role in discharge planning, but most often the primary nurse provides discharge teaching. Case managers often answer family questions, but this is not the primary role. Coordination of nursing care usually falls on the charge nurse.

A client hospitalized for a round of chemotherapy reports being very distressed at being unable to sleep because of a series of roommates who have been actively withdrawing from opioids. The nurse responds that they must accept clients who are detoxing from prescribed and illicit drugs. Which action should the nurse take?

Explore difficulties, identify solutions, and negotiate short-term aids. Explanation: The nurse should identify the conflict the client is experiencing and discuss specific areas that are problematic (such as sleep), and identify solutions and offer interim compromises where possible. It is not therapeutic to involve the physician, and inappropriate to suggest a transfer or written order to limit roommate assignments, which are the purview of nursing. Recommending the client sign out against medical advice is unethical since the client requires treatment.

When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first?

Hold the medication and report the information to the physician to ensure client safety. Explanation: The nurse should report the information to the physician because the client's safety may be endangered. The nurse shouldn't give the drug until clarifying the order with the physician. The fact that the client has taken the drug for several days doesn't guarantee that giving another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.

The nurse is caring for a client receiving a nitroglycerin infusion for a myocardial infarction. When titrating this infusion, for which adverse effect should the nurse monitor?

Hypotension Explanation: The nurse should monitor for hypotension, as nitroglycerin is a potent vasodilator. Often upward titration is limited by blood pressure. Tachycardia and diaphoresis may be present in this cardiac client, but these symptoms would not be caused by the medication. Confusion would not be an adverse reaction to nitroglycerin but would be an ominous finding of declining condition in this client.

A client presents with severe headache, blurred vision, anxiety and confusion. The client's blood pressure is 224/137 mm Hg. The family reports that the client has hypertension, but has not been taking the prescribed blood pressure medications. The nurse anticipates giving which medication?

Labetalol Explanation: This client is showing signs and symptoms of a hypertensive crisis, or hypertensive emergency, and the nurse should anticipate treatment/medications to lower the blood pressure. Labetalol is a beta-blocker medication given intravenously that is often a first-line treatment for hypertensive crisis. Norepinephrine is not indicated for this client as it is a vasopressor and increases blood pressure. Amiodarone is given for cardiac arrythmias and would not help lower blood pressure. Methotrexate is an antineoplastic medication used for treating various cancers and severe rheumatoid arthritis.

A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse's most important intervention?

Maintain the client on respiratory isolation Explanation: This client is showing signs and symptoms of active TB and, because of the productive cough, is highly contagious. He should be admitted to the hospital and placed in respiratory isolation. Three sputum cultures should be obtained to confirm the diagnosis.

The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on the leg. What should the nurse do first?

Notify the anesthesiologist of the prednisone administration. Explanation: The nurse should notify the anesthesiologist because supplemental prednisone suppresses the adrenal cortex's natural ability to produce increased corticosteroids in times of stress such as surgery. The anesthesiologist may need to prescribe supplemental steroid coverage during the perioperative period. The nurse should document the prednisone with current medications, but it is a priority to inform the anesthesiologist. Because the poison ivy is not in the surgical field, the surgeon does not need to be called regarding the skin disruption.

After receiving large doses of an ovulatory stimulant such as menotropins, a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. Based on this assessment, what should the nurse do next?

Notify the healthcare provider. Explanation: Ovarian hyperstimulation syndrome is caused by an excessive response to the medications used to produce eggs and make them grow. With the increased number of growing follicles, the estradiol levels are increased, leading to fluid leaks in the abdomen. There is increased vascular permeability that causes rapid accumulation of fluid in the peritoneal cavity, thorax, and pericardium. Some symptoms of the problem are an increased weight gain of 3 pounds or more over a 2-day period, shortness of breath, abdominal pain, dehydration, vomiting, and the production of blood clots. The healthcare provider should be notified as soon as possible. The woman may require hospitalization and a paracentesis. If the woman is not admitted to the hospital, the woman should be instructed to stop the medication, rest, and drink large amounts of electrolyte fluids.

The nurse discovers that a young client has been given a dose of morphine four times the dose prescribed. What is the priority action of the nurse?

Obtain naloxone and assess the need for administration. Explanation: Naloxone is an opioid antagonist that is given as an antidote for morphine. An antidote is an agent that neutralizes a poison or counteracts its effects. This would be an immediate priority for the nurse. Respiratory depression is a common side effect of opioids, and with a dosage error of this magnitude, it would be the priority to have naloxone ready to administer. Documentation of the error would happen after the client is treated and deemed stable. Emergency resuscitation equipment should be obtained after treating the client if indicated.

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. What should the nurse should do first?

Provide parenteral rehydration therapy as prescribed. Explanation: Initially, the extracellular fluid volume with isotonic IV fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is first necessary to rehydrate this client.

The nurse is ambulating a client. The client experiences chest pain after ambulating 50 feet. What is the nurse's priority intervention?

Sit the client down Explanation: The priority is to decrease oxygen consumption by sitting this client down. When the client's condition is stabilized, he can be returned to bed. An ECG can be obtained after the client is sitting down, and the ordered sublingual nitroglycerin could be administered.

The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the health care provider (HCP) immediately?

The stoma is dark red to purple. Explanation: A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.

The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure?

The student nurse irrigates the NG tube through the blue air vent port. Explanation: The student nurse would not want to instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease pressure that can build up into the stomach when suction is used. The student nurse should wear clean not sterile gloves because it is not a sterile procedure. The student nurse would disconnect the suction tubing in order to attach the syringe and can use gravity versus pushing the fluid in to instill it.

Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's post-procedure status. Which outcome is expected?

There is no bleeding at the aspiration site. Explanation: After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be prescribed. Signs of infection, such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be prescribed for pain, but if the client has pain longer than 24 hours, the nurse should assess the client for internal bleeding or increased pressure at the puncture site which may be the cause of the pain and should consult the health care provider (HCP).

A client who is homeless is admitted for treatment of a severe infection. The client reports, "I'm allergic to everything." The nurse reviews the client's medical records at that facility and learns that the client has extensive identified medication allergies. What is the best action for the nurse to take?

Use the drug allergy listing in the medical record as a starting point for a full allergy assessment. Explanation: It is helpful for the nurse to review the documented drug allergy listing and to use this as a basis for an assessment and discussion with the client. Drugs identified as contributing to an allergic reaction must be recognized and avoided as a serious risk to the client. It is poor practice not to pursue an allergy assessment simply because a client initially reports not being sure exactly what allergies are present; the client may respond well to prompting and an engaged interview. The goal of the nurse is to reach the most complete history and assessment possible with the client. Allergies can occur at any point in treatment, so the most recent allergies do not hold increased importance.

A client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride PO q.i.d. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client is also confused and incontinent, the nurse suspects neuroleptic malignant syndrome. What steps should the nurse take?

Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. Explanation: Neuroleptic malignant syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. The nurse should withhold the next dose, notify the physician, and continue to monitor the client's vital signs. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because additional fluid may further increase the client's fluid volume, elevating the blood pressure even more.

What is a priority for the nurse developing a plan with a client admitted to the hospital with an acute exacerbation of rheumatoid arthritis?

achieving a controlled level of pain and fatigue throughout the day. Explanation: Symptoms of rheumatoid arthritis include localized pain, stiffness, and decreased joint mobility after a period of rest, such as after sleeping. This can be more localized, which causes symptoms such as pain or stiffness. Lack of mobility over a period of time can increase the symptoms. Other answers are incorrect because they do not reflect management of care. Working on a positive self image is about self esteem. Always performing activities of daily living does not reflect promoting management; clients do not need to be independent. Accepting and working toward understanding is not about management.

The client visits the health care provider reporting a red, swollen, and painful right great toe and is subsequently diagnosed with gouty arthritis. Which drug does the nurse anticipate the healthcare provider to order?

allopurinol Explanation: Allopurinol is used to manage and prevent gout attacks and is also used for the treatment of calcium oxalate kidney stones. Phenytoin is used to treat and prevent seizures. Zaroxolyn is used to treat blood pressure and edema. Furosemide treats fluid retention and swelling caused by congestive heart failure, liver disease, and kidney disease.

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated?

applying an external fetal monitor and completing a physical assessment Explanation: Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile vaginal exam should never be done on a woman with a known or suspected placenta previa. Applying the external fetal monitor will allow the nurse to assess fetal status. A complete physical assessment of the client is indicated. A fundal height is used to monitor fetal growth during pregnancy but does not provide information related to vaginal bleeding.

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing?

decreased mental status Explanation: The client should be monitored closely for changes in mental status. Ammonia has a toxic effect on central nervous system tissue and produces an altered level of consciousness, marked by drowsiness and irritability. If this process is unchecked, the client may lapse into coma. Increasing ammonia levels are not detected by changes in blood pressure, urine output, or respirations.

The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which functions?

delegation Explanation: The professional nurse is responsible for delegating routine nursing measures to non-licensed personnel. The nurse needs to make the decision as to which aspects can be delegated and which clients need to be assessed and cared for by professional nurses. The definitions of the other terms do not pertain to this situation.*

A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively?

elevating the hand and wrapping it in a warm towel Explanation: Elevating the arm promotes venous drainage and reduces edema; applying warmth increases circulation and eases pain and edema. Ice application would relieve pain but not edema. An analgesic wouldn't correct the primary cause of the discomfort. Wrapping the arm above the hand would slow venous return and is contraindicated.

A client has been hospitalized with myxedema coma. What acid-base imbalance would be expected in this client?

respiratory acidosis Explanation: The client's respiratory drive is depressed, resulting in alveolar hypoventilation, progressive carbon dioxide retention, narcosis, and coma. These symptoms, along with cardiovascular collapse and shock, require aggressive and intensive therapy if the client is to survive.

A client has had a central venous pressure line inserted. The nurse should immediately report which sign to the health care provider?

sharp pain on the affected side Explanation: Sudden, sharp pain with breathing or coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected side, tachycardia, anxiety, and restlessness indicate a pneumothorax, which can be a complication of inserting a central venous pressure line. The other findings are within normal limits.

What is the most important action to take for a child with ineffective airway clearance?

suctioning the child's secretions Explanation: The most important goal is to maintain a patent airway. The child with ineffective airway clearance has secretions that can obstruct the airway. Reducing anxiety and administering medications will be necessary after the airway is secure. The child should not be allowed to eat or drink anything to prevent the risk of aspiration.

A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth?

umbilical cord prolapse Explanation: Indications for cesarean birth include umbilical cord prolapse, breech presentation, fetal distress, dystocia, previous cesarean birth, herpes simplex infection, condyloma acuminatum, placenta previa, abruptio placentae, and unsuccessful labor induction. Insufficient perineal stretching; rapid, progressive labor; and fetal prematurity aren't indications for cesarean birth.

A client has just begun treatment with busulfan, 4 mg by mouth daily, for chronic myelogenous leukemia. The client receives busulfan until their white blood cell (WBC) count falls to between 10,000/mm3 and 25,000/mm3. Then the drug is stopped. When should treatment resume?

when the WBC count rises to 50,000/mm3 Explanation: Busulfan treatment should resume when the WBC count rises to 50,000/mm3. Hair growth and anemia aren't appropriate markers for resuming busulfan treatment.

A client with chest pain doesn't respond to nitroglycerin. When the client is admitted to the emergency department, the healthcare team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

within 6 hours Explanation: For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Physicians initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 days.