Clinical Judgement

The nurse working in a skilled nursing home is evaluating a client that has completed a 10-day course of antibiotics three days ago for pneumonia. What assessments will the nurse need to notify the healthcare provider about? Select all that apply. a. change in level of consciousness b. tympanic temperature 98.2°F (36.8°C) c. clear breath sounds d. cough with phlegm e. pulse oximetry reading of 96%

a. change in level of consciousness d. cough with phlegm A change in the level of consciousness and a cough with phlegm are abnormal assessments related to pneumonia. Clear breath sounds, pulse oximetry reading of 96%, and tympanic temperature 98.2°F (36.8°) are normal assessments indicating that the antibiotic may have helped manage the pneumonia symptoms.

A client is a primigravida in early labor. She tells the nurse that she is worried about pain control as her contractions are becoming stronger, and she asks the nurse about the use of narcotics. Which of the following is the nurse's appropriate response about the use of narcotics? Select all that apply. a. "Narcotics can decrease uterine activity." b. "Narcotics may prolong labor if given too early." c. "Narcotics are very effective in early labor." d. "Narcotics cause variable fetal heart rate accelerations." e. "Narcotics will require that the newborn is given naloxone upon birth."

a. "Narcotics can decrease uterine activity." b. "Narcotics may prolong labor if given too early." Narcotics may decrease uterine activity if given in early labor, thus slowing the progression of labor. Narcotics may cause decreased fetal heart rate variability. If the newborn experiences respiratory depression upon birth, naloxone may be warranted; however, this is not always required and other interventions may be appropriate.

A runner in a marathon who collapsed on the road is brought in with the following symptoms: sunken eyes, a body temperature of 37.8°C (100°F), and a report of dizziness while sitting to have his blood pressure taken (which subsides upon his lying down). Which treatment should be carried out first? a. Administer an electrolyte solution by mouth. b. Give him water by mouth. c. Establish IV access for the administration of vasoconstrictors. d. Bring down his body temperature with ice.

a. Administer an electrolyte solution by mouth. Fluid volume deficit results in postural hypotension (dizziness while upright) due to decreased blood volume. Sunken eyes and elevated temperature also point to a fluid volume deficit. The most important action to take is to replace fluid; however, pure water would be a mistake, since without accompanying electrolytes such as sodium, hyponatremia (water retention and a decrease in serum osmolality) could result. Thus, an oral electrolyte solution is recommended; in more severe cases an IV would be appropriate. Vasoconstrictors are not used to treat fluid volume deficit.

A nurse identifies a nursing diagnosis of spiritual distress for a patient based on assessment of which of the following? Select all that apply. a. Ambivalence b. Acceptance c. Peacefulness d. Anger e. Despair

a. Ambivalence d. Anger e. Despair Spiritually distressed patients may show despair, discouragement, ambivalence, detachment, anger, resentment, or fear. They may question the meaning of suffering or life and express a sense of emptiness.

A school-age client with hemophilia A has fallen and badly bruised his knee. Which action should the nurse do first to manage the client's hemarthrosis? a. Apply pressure and immobilize the joint. b. Apply cold packs to promote vasoconstriction. c. Use active range of motion to prevent immobility. d. Notify the health care provide (HCP) of the injury.

a. Apply pressure and immobilize the joint. Application of pressure and immobilization of the affected limb are the first priority. Pressure is required to stop the bleeding, and immobilization aids in reducing swelling and pain. Active range of motion is recommended after the bleeding is controlled. The application of cold packs can be helpful in diminishing swelling and pain. Cold packs will also promote vasoconstriction, which can help reduce the bleeding. The health care provider (HCP) should be informed of the bleeding episode after initial measures to control the bleeding are implemented.

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? a. Check the patency and amount of drainage from the NG tube. b. Irrigate the NG tube with water and give an analgesic as ordered. c. Administer an analgesic and antiemetic as ordered. d. Explain that nausea is common because the NG tube irritates the gag reflex.

a. 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. Then appropriate action can be taken if the tube is not patent. Giving an analgesic and antiemetic would alleviate the symptoms of pain and nausea, but would not correct the problem if the NG tube is not draining properly. Irrigations are done after assessment of patency. The gag reflex is triggered during insertion, but once in position does not cause nausea.

Two days after application of a cast to treat a fractured femur, the client reports severe, deep, and constant pain in the leg. What will the nurse suspect? a. Compartment syndrome. b. Chronic venous insufficiency. c. Infection d. Phlebitis

a. Compartment syndrome. Compartment syndrome refers to the compression of nerves, blood vessels, and muscle within a closed space. This leads to tissue death from lack of oxygenation.

Your client with end-stage renal disease is receiving 2 units of packed red blood cells for anemia (Hgb of 8.2 g/dL [82 g/L]). Twenty minutes into the first transfusion, the nurse observes the client has a flushed face, hives over upper body trunk, and is reporting pain in lower back. His vital signs include pulse rate of 110 and BP drop to 95/56. What is the nurse's priority action? a. Discontinue the transfusion and begin an infusion of normal saline. b. Slow the rate of the blood infusion to 50 mL/hour. c. Recheck the type of blood infusing with the chart documentation of client's blood type. d. Document the assessment as the only action.

a. Discontinue the transfusion and begin an infusion of normal saline. An immediate hemolytic reaction usually is caused by ABO incompatibility. The signs include flushing of the face, urticaria [hives], headache, pain in the lumbar area, chills, fever, chest pain, tachycardia, hypotension, and dyspnea. If any of these actions occur, the transfusion should be stopped immediately. Access to a vein should be maintained because it may be necessary to infuse IV solutions to ensure diuresis. Slowing the rate of the blood infusion will not correct this hemolytic reaction and will only worsen the client's condition. Of course, documentation after the above interventions are performed is vital. Rechecking the blood type infusing will not stop the hemolytic reaction. After corrective actions/interventions are taken, the blood bag is returned to the blood bank for further testing.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority? a. FHR b. signs of infection c. maternal comfort level d. fetal position

a. FHR When membranes rupture, the priority focus should be on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. Prolonged rupture can lead to an infection. Assessing the fetal position and maternal comfort are important but should not be the primary focus.

Which feature(s) indicates a carpopedal spasm in a client with hypoparathyroidism? a. Hand flexing inward b. Bulging forehead c. Moon face and buffalo hump d. Cardiac dysrhythmia

a. Hand flexing inward Carpopedal spasm is evidenced by the hand flexing inward. Cardiac dysrhythmia is a symptom of hyperparathyroidism. Moon face and buffalo hump are the symptoms of Cushing syndrome. A bulging forehead is a symptom of acromegaly.

Students are reviewing information about substance abuse and its effects on individuals and families. The students demonstrate understanding of this topic when they identify which of the following? a. Individuals with substance abuse often have difficulty using adaptive behaviors. b. Substance abuse is most frequently seen in outpatient settings. c. Individuals use substances to enhance their decision-making ability. d. Substance abuse applies primarily to the use of illegal drugs.

a. Individuals with substance abuse often have difficulty using adaptive behaviors. Substance abuse refers to the use of alcohol and illegally obtained, prescribed, or over-the-counter drugs alone or combined in ineffective attempts to cope with the pressures, strains, and burdens of life. Thus, individuals with substance abuse often have difficulty identifying and implementing adaptive behaviors. Substance abuse occurs in all settings. Individuals who abuse substances are unable to make healthy decisions and to solve problems effectively.

A 12-year-old child is scheduled for surgery to repair a fractured tibia. One hour prior to surgery, the nurse assesses that the child is febrile. What is the best action for the nurse to take? a. Inform the surgeon. b. Record the temperature c. Apply cool compress d. Administer an antipyretic.

a. Inform the surgeon. The surgeon must be informed immediately so the decision can be made whether to proceed with the surgery. A child scheduled for surgery in 1 hour would be NPO, so oral antipyretics would not be an option. Although cool compresses might relieve some discomfort, the priority is to notify the physician.

Which of the following musculoskeletal injuries is manifested by acromioclavicular joint pain? a. Rotator cuff tears b. Epicondylitis c. Heterotopic ossification d. Acute compartment syndrome

a. Rotator cuff tears Key assessment findings related to rotator cuff tears include acromioclavicular joint pain, limited range of motion, and muscle weakness. Epicondylitis (tennis elbow) is manifested by pain that usually radiates down the extensor surface of the forearm and generally is relieved with rest and avoidance of the aggravating activity. Heterotopic ossification is the abnormal formation of bone, near bones or in muscle, in response to soft tissue trauma after blunt trauma, fracture, or total joint replacement. Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? a. positioning the client on the side with the knees flexed b. encouraging frequent visits from family and friends c. administering frequent oral feedings d. administering an analgesic once per shift, as ordered, to prevent drug addiction

a. positioning the client on the side with the knees flexed The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin? a. vitamin k b. vitamin d c. vitamin e d. vitamin a

a. vitamin k Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Antibiotic therapy may interfere with synthesis of these substances, including vitamin K. Intestinal bacteria don't synthesize vitamins A, D, or E.

The nurse identifies the nursing diagnosis of deficient knowledge related to a new hearing aid for a client. After teaching a client about caring for his new hearing aid, the nurse determines that the outcome has been achieved when the client states which of the following? a "I should wash the receiver with soap and water once a week." b. "I need to keep my ear canal clean and dry." c. "I should insert the ear mold when it is wet." d. "I need to wipe the ear mold daily with a moist washcloth."

b. "I need to keep my ear canal clean and dry." The client demonstrates understanding of the care of a hearing aid when stating the need to keep the ear canal clean and dry. The ear mold is the only part of the hearing aid that can be washed frequently, that is daily with soap and water. It should be allowed to dry completely before it is snapped into the receiver or inserted into the ear.

The following nursing diagnoses are formulated with a client: constipation, acute pain, and caregiver role strain. During the planning phase of the nursing process, the nurse will prioritize the diagnoses in what order? a. Caregiver role strain, constipation, acute pain b. Acute pain, constipation, caregiver role strain c. Constipation, acute pain, caregiver role strain d. Caregiver role strain, acute pain, constipation

b. Acute pain, constipation, caregiver role strain Using critical thinking skills involves a sound knowledge base that leads to the formulation of outcome-oriented activities and identification of client needs. Critical thinking enables accurate prioritization of care. In this case, easing the client's pain is the most important priority, followed by alleviating the constipation, and then addressing the caregiver issues.

After replacing a fentanyl 25 mcg patch for a client with chronic pain, what is the priority action by the nurse? a. Dissolve the used patch in water and dispose of in the sink. b. Fold the adhesive edges together of the used patch and flush down the toilet. c. Wrap the used patch in a nonsterile glove and place in the trash. d. Wrap the used patch in a nonsterile glove and place in a sharps container.

b. Fold the adhesive edges together of the used patch and flush down the toilet. A fentanyl transdermal patch is a controlled substance with a high risk for abuse. Federal law requires proper disposal of all controlled substances to prevent diversion and misuse. The recommended procedure for disposal of the used fentanyl patch is to fold the adhesive edges together and flush down the toilet to prevent the misuse of any remaining medication in the patch. The trash and the sharps container are not secure and therefore would not prevent the misuse of the medication remaining in the patch. The patch will not dissolve in water in a reasonable amount of time. The patch should be disposed of immediately.

During a disaster, the nurse triages a victim with a fractured wrist. Which color triage tag should the nurse apply? a. Yellow b. Green c. Black d. Red

b. 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. A black triage tag (priority 4, or expectant) indicates injuries that are extensive; chances of survival are unlikely even with definitive care.

The nurse reviews a client's history and notes that the client has a history of hyperparathyroidism. The nurse would identify that this client most likely would be at risk for which of the following? a. Fistula b. Kidney stones c. Neurogenic bladder d. Chronic renal failure

b. Kidney stones A client with hyperparathyroidism is at risk for kidney stones. The client with diabetes mellitus is a risk factor for developing chronic renal failure and neurogenic bladder. A client with radiation to the pelvis is at risk for urinary tract fistula.

The student nurse is discussing the plan of care for a child admitted to the hospital for treatment of an infection. Which action should be taken first? a. Initiate antibiotic therapy. b. Obtain blood cultures. c. Initiate intravenous therapy. d. Obtain urine specimen for analysis.

b. Obtain blood cultures. When treating a child suspected of having an infection, the blood cultures must be obtained first. The administration of antibiotics may impact the culture's results. A urine specimen may be obtained but is not the priority action. Intravenous fluids will likely be included in the plan of care but are not the priority action.

Morton neuroma is exhibited by which clinical manifestation? a. Longitudinal arch of the foot is diminished b. Swelling of the third (lateral) branch of the median plantar nerve c. Inflammation of the foot-supporting fascia d. High arm and a fixed equinus deformity

b. Swelling of the third (lateral) branch of the median plantar nerve Morton neuroma is swelling of the third branch of the median plantar nerve. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. Flatfoot is a common disorder in which the longitudinal arch of the foot is diminished. Plantar fasciitis is an inflammation of the foot-supporting fascia.

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer: a. an acetaminophen suppository b. dantrolene sodium (Dantrium) c. potassium chloride d. verapamil (Isoptin)

b. dantrolene sodium (Dantrium) The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.

Which client statement would lead the nurse to suspect that the client is experiencing bacterial conjunctivitis? a. "My eyes hurt when I'm in the bright sunlight." b. "It feels like there is something stuck in my eye." c. "My eyelids were stuck together this morning." d. "My eyes feel like they are on fire."

c. "My eyelids were stuck together this morning." Burning, a sensation of a foreign body, and pain in bright light (photophobia) are signs and symptoms associated with any type of conjunctivitis. The drainage related to bacterial conjunctivitis is usually present in the morning, and the eyes may be difficult to open because of adhesions caused by the exudate.

Which child needs to be seen immediately in the physician's office? a. 8-month-old who is restless, irritable, and afebrile b. 4-month-old with a cough, elevated temperature and wetting eight diapers every 24 hours c. 10-month-old with a fever and petechiae who is grunting d. 2-month-old with a slight fever and irritability after getting immunizations the previous day

c. 10-month-old with a fever and petechiae who is grunting The presence of petechiae can indicate serious infection in an infant. Grunting is abnormal, indicating respiratory difficulty. The behavior of the 2-month-old is normal after immunizations. The 4-month-old needs to be watched but is adequately hydrated and the 8-month-old also needs to be watched. What the 8-month-old is experiencing is common in infants who are teething and is not indicative of illness.

A nurse on the telemetry unit is faced with various monitor rhythms. Which rhythm takes priority? a. A client's cardiac monitor suddenly reveals sinus tachycardia with isolated premature ventricular contractions. b. A client's monitor shows sinus tachycardia with frequent premature atrial contractions (PACs). c. A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. d. A client's monitor shows frequent paced beats with capture.

c. A client's cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation. The client whose cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation takes priority. This cardiac rhythm change may cause clots to shower from the atria, placing the client at risk for a stroke. The client whose cardiac monitor reveals sinus tachycardia with isolated premature ventricular contractions is not experiencing a life-threatening situation; therefore, does not take priority. Frequent paced beats with capture is a normal finding for a client with a pacemaker. Sinus tachycardia with premature atrial contractions is not a priority situation.

A client with acromegaly is admitted to the hospital with complaints of partial blindness that began suddenly. What does the nurse suspect is occurring with this client? a. Glaucoma b. Retinal detachment c. Pressure on the optic nerve d. Corneal abrasions

c. Pressure on the optic nerve Partial blindness may result from pressure on the optic nerve. Glaucoma does not occur suddenly, and the client did not report injury to suspect corneal abrasions or retinal detachment.

The nurse is assessing a client taking an anticoagulant. What nursing intervention is most appropriate for a client at risk for injury related to side effects of medication enoxaparin? a. Assess for clubbing of the fingers. b. Assess for hypokalemia. c. Report any incident of bloody urine, stools, or both. d. Administer calcium supplements.

c. Report any incident of bloody urine, stools, or both. The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both. Clients taking enoxaparin will not need to take calcium supplements or have potassium imbalances related to the medication. The clubbing of fingers may occur with chronic pulmonary diseases.

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: a. Mild TBI b. Moderate TBI c. Severe TBI d. Brain death

c. Severe TBI A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.

A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for: a. Respirations b. Urinary output c. Hypothermia d. Temperature

d. Temperature Common clinical manifestations of fever include anorexia, myalgia, arthralgia, headaches, and fatigue; thus, the nurse should assess the client's temperature.

A nurse is assigned to care for a client with dependent personality disorder. Which intervention should the nurse include in this client's care plan to promote independence? a. avoiding discussion of the client's feelings of helplessness b. spending long periods of unscheduled time with the client c. helping the client identify preferences, such as choosing which clothing to wear d. scheduling competitive activities so the client can test skills

c. helping the client identify preferences, such as choosing which clothing to wear Helping the client identify preferences promotes development of independent decision-making skills, which the client with dependent personality disorder lacks. To demonstrate availability during set times in a structured relationship, the nurse should spend scheduled, not unscheduled, time with the client and should set limits on the amount of time the nurse spends with the client. Activities in which the client can succeed would be more appropriate than competitive ones, which this client would find too threatening. To promote rapport and convey empathy, the nurse should acknowledge the client's helpless feelings, not avoid discussing them.

The nurse is caring for four clients. Select the client at risk for the development of a pulmonary embolism. a. A 32-year-old male with viral pneumonia b. A 36-year-old female smoker with an intrauterine device (IUD) c. An 80-year-old female client with diabetes d. A 62-year-old male who is postoperative for repair of a fractured femur

d. A 62-year-old male who is postoperative for repair of a fractured femur A client with surgery to the lower extremities is at higher risk for the development of deep vein thrombosis that could lead to a pulmonary embolism. There is increased risk for pulmonary embolism among users of oral contraceptives, particularly in women who smoke, but not with the use of IUD.

The nurse is helping a client who experiences frequent constipation select meal choices for the day. Which food should the nurse encourage the client to order? a. Applesauce b. Pop-Tart c. Bananas d. Bran cereal

d. Bran cereal To prevent constipation, the client should eat a diet with an adequate intake of high-fiber foods; therefore, the nurse should encourage the client to select bran cereal.

A nurse assesses that a patient is at increased risk for depression based on which of the following? a. Male gender b. Sporadic alcohol ingestion c. Supportive family d. Co-existing medical problems

d. Co-existing medical problems Risk factors for depression include a medical comorbidity, family history, stressful situations, female gender, prior episodes of depression, an onset before age 40 years, past suicide attempts, lack of support systems, history of physical or sexual abuse, and current substance abuse. Sporadic alcohol ingestion does not indicate substance abuse.

The nurse is caring for a client with a cerebral contusion who is moaning and reporting head pain. The family requests that aspirin be given to the client. What does the nurse do? Select all that apply. a. Explains that aspirin may cause pupil constriction. b. Explains that aspirin may cause the contusion to clot in his brain. c. Explains that aspirin may cause increased intracranial pressure. d. Explains that aspirin may increase the potential for further bleeding. e. Explains that aspirin may cause GI upset.

d. Explains that aspirin may increase the potential for further bleeding. e. Explains that aspirin may cause GI upset. Aspirin causes increased bleeding and GI upset. Aspirin does not cause the contusion to clot, cause pupil constriction, or cause increased intracranial pressure. The nurse may suggest other interventions for pain relief for the client if appropriate.

A client in the intensive care unit is receiving a blood transfusion. The client immediately developed a reddish-color urine flowing into the Foley bag. What is likely the cause of this red urine and what priority intervention should the nurse implement? a. Exposure to bacteria causing urinary tract infection with bleeding; contact health care provider for antibiotic prescription. b. Trauma to the urethra can cause blood in the urine; increase the fluid intake by increasing IV flow rate. c. Myoglobinuria causes urine color change and is associated with muscle destruction; call the health care provider immediately. d. Hemoglobinuria indicating an acute hemolytic reaction; the transfusion must be stopped immediately.

d. Hemoglobinuria indicating an acute hemolytic reaction; the transfusion must be stopped immediately. The onset of red urine during or shortly after a blood transfusion may represent hemoglobinuria indicating an acute hemolytic reaction. The priority of the nurse is to stop the transfusion, then call the laboratory and the health care provider. Myoglobinuria causes urine color change, usually brown in color, and is associated with muscle destruction. There is no indication that this occurred recently but if it occurs, the health care provider should be notified. Trauma with insertion of a catheter would cause bleeding at the time of the insertion and would not be associated with a blood transfusion. Severe kidney infections can cause bleeding but this would have been evident prior to hanging/infusing the blood.

A client is admitted to the neurologic intensive care unit for an intracranial hemorrhage. Which medication prescription should the nurse question for this client? a. famotidine b. ondansetron c. morphine d. enoxaparin

d. enoxaparin The nurse should question the prescription for enoxaparin for this client. Enoxaparin is a low-molecular weight heparin, and is an anticoagulant, which causes increased bleeding and impaired clotting, and would cause further complications in the client with bleeding in the brain. Famotidine is a common peptic ulcer prevention agent, and is often given to intensive care unit clients to help prevent gastric ulcers due to the stress of hospital admission. Ondansetron is a common antiemetic, and would be appropriate for this client to treat or prevent nausea and vomiting, because vomiting increases intracranial pressure. Morphine is a narcotic pain reliever, and would be an appropriate analgesic medication for the client with an intracranial hemorrhage.