Clinical Judgment
A postoperative client is 6 hours post-op bowel resection. The nurse notes:
The nurse recognizes the client is likely developing
Hypovolemic Shock
A client taking warfarin has an INR of 5.8.
The nurse anticipates a provider order for ___________.
Vitamin K (phytonadione)
A client with severe preeclampsia begins seeing spots and complains of a worsening headache.
The nurse's priority action is to initiate ___________.
Seizure precautions
A client with left-sided heart failure develops worsening symptoms.
Name four assessment findings the nurse would expect.
A client with major depressive disorder states, "My family would be better off without me."
The nurse should identify this statement as a possible indicator of ___________.
Suicidal ideation
A client with COPD is receiving oxygen at 2 L/min via nasal cannula.
The client's oxygen saturation decreases from 92% to 84%, and the client becomes increasingly restless.
The nurse should prioritize assessing ___________.
Airway patency and respiratory status
(Or oxygenation/ventilation status)
A client receives IV morphine.
Thirty minutes later, respirations decrease from 16/min to 8/min.
The priority medication is ___________.
Naloxone
A postpartum client saturates a pad in 15 minutes.
The fundus is boggy and displaced to the right.
The nurse should immediately ___________.
Massage the fundus
(Also assess/empty bladder)
A client develops septic shock.
List three findings that indicate worsening tissue perfusion.
Any three:
A client with acute kidney injury has the following assessment findings:
The nurse determines the client is at highest risk for ___________.
Cardiac arrest
A laboring client suddenly reports severe abdominal pain.
The fetal monitor shows recurrent late decelerations and the uterus remains rigid between contractions.
The nurse suspects ___________.
Placental abruption
Before administering digoxin, the nurse notes the apical pulse is 52 beats/min.
The nurse should ___________.
Hold the medication and notify the provider
A newborn of a diabetic mother is jittery and difficult to arouse.
The nurse suspects neonatal ___________.
Hypoglycemia
A nurse reviews the laboratory results and assessment findings of a client with kidney failure.
Which findings are consistent with hyperkalemia
A client admitted with pancreatitis has received aggressive IV fluid replacement for the past 24 hours.
Current assessment findings include:
The nurse recognizes the client's condition is most likely complicated by ___________.
Fluid volume overload (pulmonary edema)
A client with heart failure develops:
The nurse recognizes these findings as
Acute pulmonary edema
A client receiving magnesium sulfate develops:
These findings indicate ___________.
Magnesium toxicity
The most common cause of postpartum hemorrhage is ___________.
Uterine atony
A nurse is caring for a client diagnosed with right-sided heart failure.
Which assessment findings would the nurse expect to observe?
A client receiving broad-spectrum antibiotics for 6 days develops:
The nurse suspects the client may have developed ___________.
Clostridioides difficile (C. diff) infection
Which client should be seen first?
The client with chest pain
A client prescribed furosemide has the following laboratory results:
The nurse should recognize the client is at greatest risk for developing ___________.
Cardiac dysrhythmias
A laboring client at 39 weeks has been receiving oxytocin for induction. The nurse notes the following:
The nurse recognizes the fetus is showing evidence of ___________.
Uteroplacental insufficiency with fetal distress (fetal hypoxia)
A nurse receives report on a client whose condition may be deteriorating.
Which findings indicate impaired tissue perfusion and require immediate follow-up?
A client diagnosed with schizophrenia suddenly stops talking, stares at the wall, and remains motionless in bed for several hours despite repeated attempts at interaction.
The nurse recognizes these behaviors as manifestations of ___________.
Catatonia