Clinical Judgement
A client with heart failure suddenly reports increased dyspnea. Assessment reveals crackles halfway up both lung fields and SpO₂ 90% on 2 L nasal cannula.
What is the priority nursing intervention?
What is High Fowler's position and increase oxygen per protocol while notifying the RN/provider.
Which client should the nurse assess first?
A. New colostomy with 30 mL bloody drainage
B. Pneumonia patient with SpO₂ 90%
C. CHF patient requesting pain medication
D. Diabetic with glucose 212
What is B. Pneumonia patient with SpO₂ 90%
A patient has:
Sodium 132
Potassium 3.0
Which abnormality requires intervention first?
What is Potassium 3.0
Which medication should be held before surgery?
What is Anticoagulants (example: warfarin).
A patient has absent bowel sounds 8 hours after abdominal surgery.
Expected or unexpected?
What is Expected.
A postoperative patient reports calf pain. Assessment reveals unilateral swelling and warmth.
Which intervention is contraindicated?
What is Massaging the leg.
Which patient can safely be assigned to the LPN?
A. New GI bleed
B. New seizure admission
C. Fresh Coronary Artery Bypass Graft
D. Stable cellulitis receiving IV antibiotics
What is D. Stable cellulitis receiving IV antibiotics
ABGs:
pH 7.29
PaCO₂ 55
HCO₃ 25
Interpretation?
What is Uncompensated respiratory acidosis.
A patient taking digoxin has nausea, blurred yellow vision, and HR 48.
What should the nurse suspect?
What is Digoxin toxicity.
A patient suddenly develops severe tearing chest pain radiating to the back.
Priority diagnosis?
What is Aortic dissection.
A client receiving a continuous heparin infusion suddenly develops severe abdominal pain and hypotension.
What complication should the nurse suspect?
What is Internal hemorrhage.
Four patients arrive simultaneously.
Who is highest priority?
What is Potassium 6.7
Troponin rises from 0.03 to 2.8.
What does this indicate?
What is Acute myocardial injury.
A patient receives lisinopril.
Which adverse effect requires immediate notification?
What is Angioedema.
A patient with SIADH is most likely to have what electrolyte abnormality?
What is Hyponatremia.
A client with COPD becomes increasingly lethargic after oxygen is increased from 2 L to 6 L.
What is the most likely explanation?
What is CO₂ retention causing respiratory depression.
Who should the nurse reassess FIRST after interventions?
A. Morphine given 30 minutes ago
B. IV antibiotic started
C. Insulin given for glucose 380
D. Oxygen increased for SpO₂ 84%
What is D. Oxygen increased for SpO₂ 84%
Which laboratory result places the patient at greatest risk for bleeding?
A. Platelets 32,000
B. Sodium 129
C. Potassium 5.6
D. Hemoglobin 10
What is A. Platelets 32,000
Which medication requires an independent double-check before administration?
What is Insulin.
Which patient is at greatest risk for developing compartment syndrome?
What is A patient with a newly casted extremity who reports severe pain unrelieved by opioids.
A patient admitted with pancreatitis develops:
What complication is occurring?
What is Hypovolemic shock.
Which postoperative patient is MOST concerning?
A. Temp 100.6
B. RR 10 after hydromorphone
C. Incision pain 8/10
D. WBC 11,500
What is B. RR 10 after hydromorphone
A patient has:
Calcium 6.9
What assessment finding is expected?
What is Positive Trousseau's or Chvostek's sign, muscle spasms/tetany.
A patient receiving vancomycin develops flushing of the face and neck during infusion.
The nurse suspects:
What is Red Man Syndrome due to rapid infusion.
A patient receiving TPN accidentally has the infusion stopped for 2 hours.
What complication should the nurse monitor for?
What is Hypoglycemia.