Clinical Judgment
The nurse is using the clinical judgment process to provide care to a patient experiencing nausea. During the process of generating solutions, the patient begins to vomit. What should the nurse do next?
1. Take actions as prepared.
2. Evaluate outcomes of the solutions generated.
3. Identify and analyze the new cues presented.
4. Generate different solutions.
3. At any point in the cycle of clinical judgment, if a problem is encountered or something changes, the nurse should go back a step or two in the process and try again.
A nurse approaches a person in a restaurant who appears to be experiencing respiratory distress. Which action should the nurse perform first?
1. Diagnose the problem.
2. Assist the person to lie down.
3. Consider if the person can walk to a more private location.
4. Collect data about the person’s condition.
4. The first step in the nursing process is to collect data, and the patient should come first. This is identify and analyze cues.
The nurse has identified a clinical question. Which step of the EBP practice process should occur next?
1. Make it happen.
2. Measure outcomes before and after change.
3. Evaluate the practice change.
4. Search for and collect the most relevant evidence available.
4. This is Step 2 and should occur after the question is asked.
The LPN/LVN is contemplating whether delegation is appropriate. Which would help the LPN/LVN make this decision?
1. Patient’s bill of rights
2. Nurse practice act
3. Facility policy and procedure manual
4. The Joint Commission guidelines
2. The nurse practice act will provide guidelines for delegation.
The unlicensed assistive personnel (UAP) reports this information to the nurse. Which patient should the nurse see first?
1. A patient with a blood pressure of 80/54 mm Hg
2. A patient with respirations of 22 breaths/minute
3. A patient with a heart rate of 78 beats/minute
4. A patient with a urine output of 120 mL over 3 hours
1. This patient has a low blood pressure, which requires urgent action.
What is the purpose of clinical judgment?
1. It designates the orders written by the doctor.
2. It determines what the nurse does after thinking about a problem.
3. It establishes the jobs needing to be accomplished during a shift.
4. It is based on personal ethical beliefs.
2. Clinical judgment is based on good critical thinking and determines what the nurse DOES after thinking about a problem.
The nurse is caring for a patient who was in a motor vehicle accident and has significant trauma. The patient reports level 9 pain on a 0-to-10 scale. Which medication option provides the fastest relief?
1. Oral
2. Rectal
3. Intramuscular (IM)
4. IV
4. IV has the quickest onset of action.
A licensed practical nurse (LPN) working in a pediatric clinic is interested in improving patient outcomes for children with asthma by preventing the need for hospitalization. Which clinical question would best guide the nurse’s next steps?
1. How many patients with asthma have a pet dog or cat?
2. What is the monthly admission rate of patients with asthma to the hospital?
3. What patient education materials are available that address prevention of asthma attacks in pediatric patients?
4. How has the occurrence rate of asthma in children under the age of 5 changed since the clinic instituted a no smoking policy?
3. Asking a burning clinical question is the first step in the EBP process. It is important to include related factors in the question and to focus on nursing interventions and care. For this scenario, the nurse would focus on nursing care that affects patient outcomes for the specific patient population of interest. Patient education is a critical component of nursing care.
The nurse is caring for a patient with a peripheral IV catheter with an intermittent infusion. What action should the nurse take to help maintain patency of the cannula?
1. Slow the infusion to a minimum rate of administration.
2. Perform a regularly scheduled flush.
3. Obtain blood pressure readings from the arm where the IV is located.
4. Elevate the arm on pillows, above the heart.
2. A regular flush schedule helps maintain patency.
The nurse is evaluating a group of patients for their risk for dehydration. Which patient is the greatest concern?
1. A patient with congestive heart failure
2. A patient with end-stage kidney failure
3. A patient who received 6 liters of IV fluid
4. A patient who lost 2 liters of blood during surgery
4. This patient is at risk for hypovolemia.
The LPN/LVN is caring for a patient who begins to exhibit shortness of breath and chest pain. Which action should the nurse take after notifying the RN?
1. Take action
2. Identify and analyze additional cues
3. Evaluate outcomes
4. Generate solutions
2. More information needs to be gathered, so identify and analyze additional cues is the priority.
The nurse is having difficulty assessing the pain of a nonverbal patient. Which method should the nurse use first to determine the patient’s pain level?
1. Use the FACES scale.
2. Ask, “Are you hurting?”
3. Observe the patient’s facial expression.
4. Explain to the patient how to use a 0-to-10 pain scale, with 0 being no pain and 10 being the worst possible pain.
1. The FACES scale was developed for use in children and is also used when someone is nonverbal or cognitively impaired.
A group of nurses in a long-term care facility conducted a pilot study about implementing a team to turn patients every hour to prevent skin breakdown. The results proved the intervention to be a success and skin breakdown rates decreased. What step should the nurses take next to implement this process throughout the facility?
1. Educate individuals in the facility about implementing the change agency-wide.
2. Collect evidence to support implementation of a turn team.
3. Plan another pilot study to determine if implementing a turn team will reduce skin breakdown.
4. Propose the change to a policy and procedure committee.
1. Because turning a patient is an independent nursing intervention, a literature review has been conducted, and a pilot study has been implemented where results have been proved to be successful, the next step is to educate other nurses in the facility about how to implement the turn team.
A patient is receiving all fluids, food and medications via a percutaneous endoscopic gastrostomy (PEG) tube. The pharmacy sends a sustained-released opioid medication for pain control. What action should the nurse take?
1. Provide the medication orally for the patient to swallow.
2. Crush the medication and administer it through the tube.
3. Dissolve the medication in water and administer it through the tube.
4. Ask the physician to prescribe the medication as an elixir for tube administration.
4. The nurse should ask the physician to prescribe the medication as an elixir for tube administration because a time-release tablet should never be crushed.
The nurse is caring for a group of patients. Which finding requires reporting to the health-care provider (HCP)?
1. A patient with end-stage renal failure and 1+ pitting pedal edema
2. A patient who is crying about a recent diagnosis
3. A patient with abdominal cramping and hyperactive deep tendon reflexes
4. A patient who just received furosemide for hypervolemia and is excreting urine
3. This patient could have an electrolyte imbalance; the HCP should be notified.
While collecting data on a patient with end-stage kidney disease, the nurse discovers a body temperature of 102.6°F (39.2°C). Which action should the nurse take?
1. Provide additional blankets.
2. Assist to a side-lying position.
3. Encourage increased oral fluid intake.
4. Administer acetaminophen as prescribed.
4. For the terminally ill patient experiencing a fever, the nurse should provide acetaminophen, an antipyretic, as prescribed.
The nurse is using Chvostek sign to assess for hypocalcemia. Which statement correctly describes this test?
1. Inflate a blood pressure cuff around the upper arm for 4 minutes.
2. Apply pressure over the ulnar and radial arteries.
3. Tap the face just below and in front of the ear.
4. Forcefully dorsiflex the ankle when the knee is in an extended position.
3. This describes Chvostek sign.
The nurse is reviewing a proposal for changing the type of fall-resistant slippers that are used in a long-term care facility to reduce the number of patient fall injuries. How should this purposed change be studied?
1. Plan a pilot study.
2. Integrate the new slippers system-wide and monitor patient falls.
3. Perform a randomized clinical trial and cite it as evidence to support a change proposal.
4. Compare fall injuries with another long-term care facility in town.
1. A small pilot study is typically done before an institute-wide change is made.
The LPN/LVN is taking a history on a patient who is scheduled for surgery in which he was to remain NPO after midnight. The nurse asks the patient when he last had something to eat, to which the patient replies, “About 2 hours ago.” Which action should the nurse take?
1. Document the response and send the patient to surgery.
2. Notify the surgeon immediately.
3. Tell the patient to come back that afternoon.
4. Ask the patient what he ate; liquids are okay.
2. The patient was NPO after midnight but ate 2 hours before surgery. The surgeon should be notified, as the surgery may be rescheduled.
Upon entering a patient’s room, the licensed practical nurse/licensed vocational nurse (LPN/LVN) notes coolness of the skin at the IV site and a sluggish infusion rate. What should the nurse do first?
1. Stop the infusion.
2. Notify the physician.
3. Elevate the extremity.
4. When the infusion is complete, remove the tubing and send it to the laboratory for analysis.
1. The findings are consistent with infiltration and the IV fluid should be stopped immediately.
The nurse is caring for a patient with SLE. The nurse notes that the patient has foamy, “cola-colored” urine. Which action should the nurse take?
1. Notify the health-care provider (HCP).
2. Encourage the patient to increase fluid intake.
3. Prepare the patient for dialysis.
4. Instruct the patient to eat high-protein meals.
1. This is indicative of proteinuria and hematuria. The HCP should be notified immediately.
DAILY DOUBLE!!!
The nurse is reviewing the health history of a patient treated with doxorubicin (Adriamycin) for cancer. What complication should the nurse be aware of and monitor for?
1. Liver dysfunction
2. Lung disease
3. Kidney failure
4. Heart damage
4. Doxorubicin (Adriamycin) has been associated with permanent heart damage.
The nurse is teaching a group of students about implementing EBP to control pain. Which statement by a student best describes an understanding of evidence-based care?
1. I saw a commercial for pain medication that works well.
2. The patient has chronic pain and will need more medication.
3. We could give this patient morphine every 4 hours. It works for the other patient.
4. There are studies that prove nonpharmacological methods can relieve pain.
4. Basing care on studies demonstrates an understanding of evidence.
The nurse is caring for a patient exposed to cold whose toes are pale and blanched. Which action should the nurse take?
1. Vigorously rub the affected area to promote circulation.
2. Apply a tight, wet, and sterile dressing to the affected area.
3. Hold the toes with warm hands to rewarm them.
4. Elevate the foot at or above heart level.
3. The findings are consistent with frostnip and warming the affected area with a warm object, such as someone’s hands, is appropriate as they rewarm.
The nurse is caring for a group of patients. Which patient should the nurse see first?
1. A patient with allergic rhinitis reporting frequent sneezing
2. A patient who had an anaphylactic reaction 2 days ago
3. A patient who just received an influenza vaccination
4. A patient receiving chemotherapy with a temperature of 103°F (39.4°C)
4. This patient should be seen first because they are immunocompromised and have a high fever.