Clinical Judgment
The nurse is assigned to care for four clients. In planning client rounds, which
client should the nurse assess first?
D. A client with asthma who requested a breathing treatment during the previous
shift.
A nursing graduate is attending an agency orientation regarding the nursing model of practice
implemented in the health care facility. The nurse is told that the nursing model is a team nursing
approach. The nurse determines that which scenario is characteristic of the team-based model of
nursing practice?
B) An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12
clients
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the
operative consent form because of sedation from opioid analgesics that have
been administered. The nurse should take which most appropriate action in the
care of this client?
D) Obtain a telephone consent from a family member, following agency policy.
The home care nurse is visiting an older client whose spouse died 6 months ago.
Which behaviors by the client indicates effective coping? Select all that apply.
B) Looking at old snapshots of family
C) Participating in a senior citizens program
D) Visiting the spouse's grave once a month
E) Decorating a wall with the spouse's pictures and awards received
The nurse employed in an emergency department is assigned to triage clients
coming to the emergency department for treatment on the evening shift. The
nurse should assign priority to which client?
A. A client complaining of muscle aches, a headache, and history of seizures
The nurse manager has implemented a change in the method of the nursing
delivery system from functional to team nursing. An assistive personnel (AP) is
resistant to the change and is not taking an active part in facilitating the process of
change. Which is the best approach in dealing with the AP?
C) Confront the AP to encourage verbalization of feelings regarding the change.
The nurse provides an educational session on client rights. Which statement by a
member of the session demonstrates the best understanding of the nurse's role
regarding ensuring that each client's rights are respected?
D) "Regardless of the client's condition, all nurses have the duty to value client
rights."
The visiting nurse observes that the older male client is confined by his daughter-in-law
to his room. When the nurse suggests that he walk to the den and join the family, he
says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is
the most important action for the nurse to take?
D) Suggest appropriate resources to the client and daughter-in-law, such as respite
care and a senior citizens center.
The clinic nurse prepares to perform a focused assessment on a client who is
complaining of symptoms of a cold, a cough, and lung congestion. Which should the
nurse include for this type of assessment? Select all that apply.
A. Auscultating lung sounds
B. Obtaining the client's temperature
D. Obtaining information about the client's respirations
F. Asking the client about a family history of any illness or disease
The registered nurse is planning the client assignments for the day. Which is
the most appropriate assignment for an assistive personnel (AP)?
C) A client who requires urine specimen collections
The nurse is acting in the role of client advocate in which situations? Select all
that apply.
A) Promoting client comfort.
C) Questioning primary health care provider prescriptions
D) Supporting a client decision regarding a health care choice
The nurse is performing an assessment on an older adult client. Which
assessment data would indicate a potential complication associated with the skin?
A) Crusting
The nurse has documented the following outcome goal in the care plan: “The
client will transfer from the bed to chair with 2-person assist”. The charge nurse
tells the nurse to add which missing element to complete the SMART goal?
C) Time
The nurse employed in a long-term care facility is planning assignments for the
clients on a nursing unit. The nurse needs to assign four clients and has a
licensed practical nurse (LPN) and 3 assistive personnel (APs) on a nursing team.
Which client would the nurse most appropriately assign to the LPN?
B) A client requiring abdominal wound irrigations and dressing changes every 3
hours
After initial assessment the nurse determines the need to place a restraint on a
client. The client refuses application of the restraint. What is the best nursing
action for this client?
B) Contact the primary health care provider (PHCP).
The home health nurse is visiting a client for the first time. While assessing the
client's medication history, it is noted that there are 19 prescriptions and several
over-the-counter medications that the client has been taking. Which intervention
should the nurse take first?
B) Determine whether there are medication duplications.
The nurse has just assisted a client back to bed after a fall. The nurse and primary
health care provider have assessed the client and have determined that the client
is not injured. After completing the occurrence report, the nurse should implement
which action next?
D) Document in the nurse's notes that an occurrence report was completed.
The nurse is preparing the client assignment. Which should be assigned to a
licensed practical nurse (LPN)?
B. Completing an admission assessment on a newly admitted client.
The nurse is working at a computer in the nurses' station when the charge nurse
from another nursing unit approaches and asks about the condition of the client in
room 432, stating, "The client is my neighbor and I want to check on her." The
nurse should make which most appropriate response?
A. "I'm sorry, I cannot tell you."
The long-term care nurse is performing assessments on several of the residents.
Which are normal age-related physiological changes the nurse should expect to
note? Select all that apply.
B) Decline in visual acuity
E) Increased susceptibility to urinary tract infections
F) Increased incidence of awakening after sleep onset