Exam 36: Clinical Decision Making

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 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.

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 receive priority for nursing intervention?

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?

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?

Which statements accurately reflect the distinction between nursing diagnoses arrived at as part of the nursing process and medical diagnoses? 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?

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?

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.

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

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?

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?

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?

A client with congestive heart failure (CHF)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?

The nurse is creating a four-column plan of care for a client.For which areas should the nurse prepare to document when creating this care plan? 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.

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 decides to use a standardized plan of care to address a client's health problems.Which criterion differentiates this plan of care from other types? Select all that apply.

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?

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.