Question 1

The nurse is prioritizing care for a client based upon nursing diagnoses.If following Maslow's hierarchy of needs,list the order in which the nurse should provide care to the client.

Accepted Answer

A)  Fatigue 
B)  Anxiety 
C)  Alteration in Perfusion 
D)  Self-Care Deficit 
E)  Deficient Knowledge 
F) Diarrhea

Question 2

The nurse manager is concerned that a staff nurse is having difficulty prioritizing client care needs.Which did the manager observe the nurse perform that caused these concerns? Select all that apply.

Accepted Answer

A)  Relying upon another nurse's assessment 
B)  Reviewing the medication administration record 
C)  Not completing an assessment 
D)  Doing easiest tasks first 
E)  Asking unlicensed assistive personnel to perform complicated care

Question 3

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?

Accepted Answer

A)  Discuss the plan with the physician. 
B)  Request that the client review the plan. 
C)  Request a review of the plan with the nurse's preceptor. 
D)  Place the plan on the client's chart.

Question 4

The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques.Upon completion of the class,what should the nurse expect the participants to do?

Accepted Answer

A)  Set goals for the next class session. 
B)  Pass a written test on how to bathe a newborn infant. 
C)  Review the major points of the class. 
D)  Provide a return demonstration of a bath on a newborn doll.

Question 5

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.

Accepted Answer

A)  Things that could have been done differently 
B)  Gut reactions to the situation 
C)  Things that were done well 
D)  Resources that were used at the time 
E)  Resources that were needed but not available

Question 6

The nurse is selected to participate on a committee to write critical pathways for a specific set of medical diagnoses.Which are advantages of using this approach when providing client care? Select all that apply.

Accepted Answer

A)  Link nursing diagnoses with specific assessment data 
B)  Sequence the care that is to be given on a particular day 
C)  Identify interventions, time frames, and expected outcomes 
D)  List medical treatments to be performed by other providers 
E)  Provide specific columns for diagnosis, interventions, and evaluation

Question 7

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?

Accepted Answer

A)  The client who needs assistance with activities of daily living. 
B)  The client who needs help ambulating to the bathroom. 
C)  The client with a pain rating of 3/10. 
D)  The client experiencing shortness of breath.

Question 8

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.

Accepted Answer

A)  Legend created identifying nursing process phases and client information categories 
B)  Lines drawn between assessment data and associated nursing diagnoses 
C)  Different colors used to represent the phases of the nursing process 
D)  A column entitled "evaluation" located on the outer edge of the document 
E)  A checklist located at the bottom of the document

Question 9

The nurse is prioritizing care needed for a group of clients according to urgency.Which care should the nurse identify as being medium priority? Select all that apply.

Accepted Answer

A)  Instructing on changing ostomy appliance 
B)  Performing passive range of motion every 4 hours 
C)  Removing splints and providing complete skin care every 2 hours 
D)  Administering 2 units of fresh frozen plasma 
E)  Performing endotracheal suction

Question 10

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?

Accepted Answer

A)  Examine the current interventions for pain relief. 
B)  Refer the client to social services. 
C)  Contact Meals on Wheels so that the client will eat. 
D)  Revise the goals in the current plan of care.

Question 11

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?

Accepted Answer

A)  Wake the child to choose a meal for dinner. 
B)  Order chicken nuggets because most children like this meal. 
C)  Ask the dietary worker to come back later. 
D)  Ask the parents to bring dinner from home for the client.

Question 12

The nurse is collecting data about a client's current health status.Which statement would assist in gathering subjective data about the client?

Accepted Answer

A)  "Your eyelid is red and swollen." 
B)  "Your skin appears to be dry and irritated." 
C)  "I see that you have bruises on your legs." 
D)  "Tell me why you have difficulty sleeping."

Question 13

A client with aspiration pneumonia is diaphoretic,pale,and taking gasping breaths.Which is the priority nursing action?

Accepted Answer

A)  Notify the healthcare provider. 
B)  Complete a thorough cardiopulmonary assessment. 
C)  Administer 10 L of oxygen per face mask. 
D)  Reposition the client to help with breathing.

Question 14

A client who has just been diagnosed with 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.

Accepted Answer

A)  "I should talk to the doctor about an exercise program." 
B)  "I don't need to watch my diet as long as I take my insulin." 
C)  "I need to limit the amount of fat in my diet." 
D)  "I should eat a candy bar when my energy is low." 
E)  "I will test my blood sugar before meals and at bedtime."

Question 15

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?

Accepted Answer

A)  Ask the client about readiness to walk. 
B)  Call for a wheelchair to start the process. 
C)  Conduct a breathing assessment. 
D)  Evaluate the client's level of pain.

Question 16

The nurse is preparing to provide care to a group of clients.Which specific areas should the nurse focus in order to prioritize the clients' care needs? Select all that apply.

Accepted Answer

A)  Asking if any clients have complex issues 
B)  Noting number of licensed staff assigned for the shift 
C)  Noting time when the attending physicians make rounds 
D)  Identifying clients with specific medication times 
E)  Noting which clients have particular safety needs

Exam 36: Clinical Decision Making