Clinical Judgment
A nurse is caring for four clients. Which client should the nurse assess first?
A. COPD patient with SpO₂ 91% on 2 L NC
B. Stroke patient who now has unequal pupils
C. CHF patient with bilateral ankle edema
D. Diabetes patient with glucose of 188
B. Stroke patient who now has unequal pupils
Unequal pupils suggest increased intracranial pressure or neurological deterioration.
A nurse is caring for a client with heart failure who suddenly reports shortness of breath. Which nursing intervention should the nurse implement FIRST?
A. Administer furosemide.
B. Place the client in High Fowler's position.
C. Notify the provider.
D. Restrict fluids.
Answer:
B. Place the client in High Fowler's position.
Rationale:
Positioning the client upright improves lung expansion and decreases venous return, helping reduce pulmonary congestion.
A nurse is preparing to administer digoxin to a client with heart failure. Which assessment finding requires the nurse to hold the medication?
A. Apical pulse of 54/min
B. Blood pressure of 132/84 mm Hg
C. Respiratory rate of 18/min
D. Potassium level of 4.2 mEq/L
Answer:
A. Apical pulse of 54/min
Rationale:
Digoxin slows the heart rate. Hold the medication if the apical pulse is less than 60 beats/min.
Which task is appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
A. Reinforce discharge teaching
B. Obtain routine vital signs on a stable client
C. Assess pain following medication administration
D. Evaluate oxygen therapy
Answer:
B. Obtain routine vital signs on a stable client.
Rationale:
Routine tasks on stable clients can be delegated to the UAP.
A nurse notes that a client cannot shrug the right shoulder against resistance. Which cranial nerve is most likely affected?
A. CN VII
B. CN VIII
C. CN XI
D. CN XII
Answer:
C. CN XI
Rationale:
The accessory nerve controls shoulder shrug and head rotation.
A nurse is caring for a client who experienced a generalized tonic-clonic seizure lasting 2 minutes. Which assessment finding requires immediate intervention?
A. The client is sleepy.
B. The client is confused.
C. The client's oxygen saturation is 84%.
D. The client reports a headache.
Answer:
C. The client's oxygen saturation is 84%.
Rationale:
Airway and oxygenation are the priority following a seizure. An oxygen saturation of 84% requires immediate intervention.
A nurse is caring for a client receiving IV fluids. Which assessment finding indicates fluid volume overload?
A. Flat neck veins
B. Dry mucous membranes
C. Crackles in the lung bases
D. Blood pressure of 92/58 mm Hg
Answer:
C. Crackles in the lung bases
Rationale:
Crackles are an early sign of pulmonary fluid accumulation and fluid overload.
A client taking furosemide reports muscle cramps and weakness. Which electrolyte imbalance should the nurse suspect?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hyponatremia
Answer:
B. Hypokalemia
Rationale:
Loop diuretics increase potassium excretion, placing the client at risk for hypokalemia.
The nurse receives report on four clients. Which client should the nurse assess FIRST?
A. A client reporting pain rated 8/10
B. A client with new-onset confusion
C. A client with a blood glucose of 212 mg/dL
D. A client with a temperature of 100.5°F
Answer:
B. A client with new-onset confusion
Rationale:
Acute mental status changes may indicate hypoxia or neurological deterioration and require immediate assessment.
A nurse asks a client to stick out the tongue. The tongue deviates to the left. Which cranial nerve is impaired?
A. CN VII
B. CN IX
C. CN X
D. CN XII
Answer:
D. CN XII
Rationale:
The hypoglossal nerve controls tongue movement.
A client tells the nurse,
"This headache feels different from my usual migraines."
Which question is MOST important for the nurse to ask?
A. "Have you taken any pain medication?"
B. "Have you had surgery recently?"
C. "When did the headache begin?"
D. "What makes the headache feel better?"
Answer:
C. "When did the headache begin?"
Rationale:
A sudden onset headache may indicate a subarachnoid hemorrhage or stroke and requires immediate evaluation.
A client receiving a continuous heparin infusion has a platelet count of 72,000/mm³. Which action should the nurse anticipate?
A. Increase the heparin infusion.
B. Continue therapy as prescribed.
C. Discontinue the heparin and notify the provider.
D. Administer vitamin K.
Answer:
C. Discontinue the heparin and notify the provider.
Rationale:
A significant drop in platelet count while receiving heparin suggests heparin-induced thrombocytopenia (HIT).
A client taking warfarin has an INR of 5.8. Which action should the nurse take?
A. Administer the medication.
B. Hold the medication and notify the provider.
C. Give vitamin K immediately without an order.
D. Encourage foods high in vitamin K.
Answer:
B. Hold the medication and notify the provider.
Rationale:
An INR of 5.8 places the client at high risk for bleeding and requires provider notification.
Which client is appropriate for the LPN/LVN to care for?
A. A client admitted with chest pain
B. A postoperative client with unstable vital signs
C. A stable client receiving routine oral medications
D. A newly admitted client requiring assessment
Answer:
C. A stable client receiving routine oral medications
Rationale:
Stable clients with predictable outcomes are appropriate assignments for the LPN/LVN.
A nurse assessing a client with a head injury should recognize which finding as an early indication of increased intracranial pressure?
A. Bradycardia
B. Decreased level of consciousness
C. Widened pulse pressure
D. Fixed, dilated pupils
Answer:
B. Decreased level of consciousness
Rationale:
A change in level of consciousness is often the earliest sign of neurological deterioration.
A nurse is caring for a client receiving IV mannitol for increased intracranial pressure. Which finding indicates the medication is effective?
A. Increased urine specific gravity
B. Weight gain
C. Decreased headache and improved level of consciousness
D. Bradycardia
Answer:
C. Decreased headache and improved level of consciousness
Rationale:
Mannitol decreases cerebral edema, so improvement in neurological status indicates the medication is effective.
A client with COPD suddenly becomes restless and anxious. Which nursing action is the priority?
A. Administer morphine.
B. Increase oxygen to 10 L/min.
C. Assess oxygenation and respiratory status.
D. Encourage deep breathing exercises.
Answer:
C. Assess oxygenation and respiratory status.
Rationale:
Restlessness is often an early sign of hypoxia. The nurse should assess before implementing interventions.
A client receiving morphine becomes difficult to arouse. Which assessment should the nurse perform FIRST?
A. Blood pressure
B. Respiratory rate
C. Pain level
D. Temperature
Answer:
B. Respiratory rate
Rationale:
Respiratory depression is the most serious adverse effect of opioid medications.
The nurse reviews morning laboratory values. Which client should the nurse assess FIRST?
A. Potassium 2.9 mEq/L
B. Sodium 146 mEq/L
C. Hemoglobin 12.2 g/dL
D. Calcium 9.4 mg/dL
Answer:
A. Potassium 2.9 mEq/L
Rationale:
Severe hypokalemia can lead to life-threatening cardiac dysrhythmias.
A client receiving enteral feedings suddenly begins coughing. Which action should the nurse take FIRST?
A. Increase the feeding rate
B. Stop the feeding
C. Notify the provider
D. Administer oxygen
Answer:
B. Stop the feeding
Rationale:
Stopping the feeding reduces the risk of aspiration while the nurse assesses the client.
A client with increased intracranial pressure suddenly develops:
Which complication should the nurse suspect?
A. Hypovolemic shock
B. Septic shock
C. Cushing's Triad
D. Neurogenic shock
Answer:
C. Cushing's Triad
Rationale:
Bradycardia, hypertension, and irregular respirations are classic signs of increased intracranial pressure and impending brain herniation.
Which client assignment is most appropriate for the RN?
A. Stable diabetic client needing insulin administration
B. Stable pneumonia client needing routine vital signs
C. Postoperative client with new-onset confusion
D. Client being discharged home today
Answer:
C. Postoperative client with new-onset confusion
Rationale:
A sudden change in mental status is an unstable finding requiring assessment by the RN.
The nurse is preparing to administer regular insulin. The client's blood glucose is now 68 mg/dL. Which action should the nurse take?
A. Administer the insulin.
B. Hold the insulin and treat the hypoglycemia.
C. Recheck the glucose in one hour.
D. Notify dietary to bring lunch early.
B. Hold the insulin and treat the hypoglycemia.
Rationale:
Administering insulin would worsen hypoglycemia and place the client at risk for severe complications.
Which client is MOST unstable?
A. COPD client with SpO₂ 91% on prescribed oxygen
B. Stroke client with new slurred speech
C. Heart failure client with dependent edema
D. Diabetic client with blood glucose of 225 mg/dL
Answer:
B. Stroke client with new slurred speech
Rationale:
A new neurological deficit suggests an evolving stroke and requires immediate intervention.
A nurse discovers that the wrong medication was administered to a client. Which action should the nurse take FIRST?
A. Notify the provider
B. Complete an incident report
C. Assess the client
D. Notify the nurse manager
Answer:
C. Assess the client
Rationale:
The nurse's first priority is always the client's safety and condition.