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Nursing

Nursing

Quiz 36 :

Clinical Decision Making

Quiz 36 :

Clinical Decision Making

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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?
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Multiple Choice
Answer:

Answer:

A

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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?
Free
Multiple Choice
Answer:

Answer:

C

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A client with congestive heart failure (CHF)is having difficulty breathing.Before leaving the room,the nurse ensures the client has an overbed table to lean on when awake if needed to ease breathing.Which technique did the nurse use to make this decision?
Free
Multiple Choice
Answer:

Answer:

D

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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?
Multiple Choice
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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?
Multiple Choice
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A client with aspiration pneumonia is diaphoretic,pale,and taking gasping breaths.Which is the priority nursing action?
Multiple Choice
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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?
Multiple Choice
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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?
Multiple Choice
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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?
Multiple Choice
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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.
Multiple Choice
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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?
Multiple Choice
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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?
Multiple Choice
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The nurse is collecting data about a client's current health status.Which statement would assist in gathering subjective data about the client?
Multiple Choice
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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.
Multiple Choice
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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?
Multiple Choice
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The nurse who uses clinical decision making to start CPR on a client is concerned about what other nursing concept?
Multiple Choice
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The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques.What goal will allow the nurse to best evaluate the mothers' learning?
Multiple Choice
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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?
Multiple Choice
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The urgent care clinic nurse is treating a client who is experiencing abdominal pain.The client states,"I think I ate tainted food last night." What should the nurse do after the client states that the food was tainted?
Multiple Choice
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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?
Multiple Choice
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