Exam 36: Clinical Decision Making

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?

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 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 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.

The nurse is prioritizing care for a client with several problems. List the order in which the nurse should address the client's needs.

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 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?

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 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?

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?

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.

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 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?

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 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 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.

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 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?

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?

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?