Clinical Judgement
Who's Next
Labs & Diagnostics
Name That Finding
Med-Surg Mayhem
100
A patient with CHF has new crackles, 3+ leg edema, a 5 lb weight gain, and increasing shortness of breath. What should the nurse suspect, and what is the priority nursing intervention?
What is worsening fluid overload, prioritize respiratory assessment and oxygenation. High Fowler's position and increase oxygen per protocol while notifying the provider.
100
Which client should the nurse assess first?
A. New colostomy with 30 mL bloody drainage
B. Patient with chest pressure and diaphoresis
C. CHF patient requesting pain medication
D. Diabetic with glucose 70
What is B. Patient with chest pressure and diaphoresis
100
A patient has:
Sodium 132
Potassium 3.0
Which abnormality requires intervention first?
What is Potassium 3.0
100
What assessment finding is depicted below?
What is blanchable redness
100
A patient has absent bowel sounds 8 hours after abdominal surgery.
Expected or unexpected?
What is Expected.
200
A patient with pneumonia was receiving 2 L NC with an SpO@ of 95%. Two hours later, the patient requires 4 L NC to maintain an SpO2 of 91% What should concern the nurse most?
What is the increased oxygen requirement, which may indicate worsening respiratory status.
200
Which patient requires immediate assessment?
A. Patient with a potassium of 3.2 mEq/L
B. Patient with new onset atrial fibrillation and HR 139
C. Patient with a BP of 156/88 mmHg
D. Patient with a glucose of 68 mg/dL who is awake and asking for juice.
What is B. Patient with new onset atrial fibrillation and HR 139.
200
A patient's sodium is 122 mEq/L. Which assessment finding would be most concerning?
A. Increased thirst
B. Confusion
C. Dry skin
D. Muscle cramps
What is B. Confusion
Why? Significant hyponatremia can cause neurological changes, including confusion and seizures
200
What assessment finding is depicted below?
What is a normal appearing surgical site
200
An older adult who was alert earlier in the shift is now suddenly confused and attempting to climb out of bed. Expected or not expected?
What is not expected. Acute mental status change requires assessment for delirium and underlying causes.
300
You receive report on four patients. Who should you see first?
A. Patient with chronic back pain reporting pain 7/10
B . COPD patient whose SpO2 is 90% consistent with their documented baseline
C. Patient who is newly confused with RR 30 and HR 118
D. High fall risk patient requesting assistance to the bathroom.
What is C. The patient has multiple new abnormal findings suggesting possible clinical deterioration.
300
You are assigned to four patients.
Who is highest priority?
- Potassium 6.7
- Hemoglobin 8.6
- Blood glucose 310
- WBC 15,000
What is Potassium 6.7
300
Troponin rises from 0.03 to 2.8.
What does this indicate?
What is Acute myocardial injury.
300
What assessment finding is depicted below?
What is an example of a medical device pressure injury from an oximetry probe.
300
A patient with SIADH is most likely to have what electrolyte abnormality?
What is Hyponatremia.
400
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.
400
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%
400
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
400
Name the assessment finding below:
What is hand with phlebitis
400
A patient's urine output drops to 15ml/hr for three consecutive hours
What is not expected.
500
You enter a patient's room and find them unresponsive and not breathing normally. What should you do first?
What is assess for responsivenss and breathing/pulse according to BLS. Immediately activate emergency response.
500
Which postoperative patient is MOST concerning?
A. Temp 100.6
B. RR 8 after hydromorphone
C. Incision pain 8/10
D. WBC 11,500
What is B. RR 8 after hydromorphone
500
A patient has:
Lactate 4.0
What assessment finding is expected?
What is severe sepsis.
500
What assessment finding is depicted below?
What is unilateral leg swelling
500
A patient receiving TPN accidentally has the infusion stopped for 2 hours.
What complication should the nurse monitor for?
What is Hypoglycemia.