Nursing Clinical Judgement Practicum Q & A w/ Rationales, Exams of Nursing

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NURSING 4590

Nursing Clinical

Judgement Practicum

Q & A w/ Rationales

1. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is experiencing an acute exacerbation. The nurse notices that the patient's oxygen saturation is 88% on room air. What is the most appropriate action for the nurse to take? a) Administer oxygen via nasal cannula at 2 L/min b) Administer oxygen via non-rebreather mask at 15 L/min c) Administer oxygen via simple face mask at 6 L/min d) Administer oxygen via venturi mask at 24% Rationale: The correct answer is d. A venturi mask delivers a precise concentration of oxygen and is preferred for patients with COPD who are at risk of carbon dioxide retention. A nasal cannula, a non-rebreather mask, and a simple face mask deliver variable concentrations of oxygen and may cause oxygen toxicity or hypercapnia in patients with COPD.
2. A nurse is conducting a health history interview with a patient who has a history of hypertension, diabetes mellitus, and hyperlipidemia. The nurse asks the patient about his medication adherence and lifestyle modifications. The patient states that he sometimes forgets to take his medications and that he does not follow a specific diet or exercise regimen. What is the best response by the nurse? a) "It is important to take your medications as prescribed and to make some changes in your diet and physical activity to prevent complications from your chronic conditions." b) "You should not skip your medications or eat unhealthy

injection site. It involves pulling the skin laterally before inserting the needle and releasing it after withdrawing the needle. Option a is correct for administering an intramuscular injection, but it is not the next step after cleansing the skin. Option b is no longer recommended for intramuscular injections because it does not prevent tissue damage and may increase bleeding and pain. Option d is also not recommended for intramuscular injections because it may increase absorption rate and cause tissue damage.

4. A nurse is evaluating a patient's fluid balance after receiving intravenous fluid therapy for dehydration. The nurse measures the patient's intake and output, vital signs, weight, and serum electrolyte levels. Which of these findings indicates that the patient's fluid balance has improved? a) Decreased urine output and increased urine specific gravity b) Increased blood pressure and decreased pulse rate c) Decreased body weight and increased serum sodium level d) Increased skin turgor and decreased serum osmolality Rationale: The correct answer is d. Increased skin turgor and decreased serum osmolality indicate that the patient's hydration status has improved and that there is less solute concentration in the blood. Option a indicates that the patient is still dehydrated and has concentrated urine. Option b indicates that the patient has fluid overload and increased vascular volume. Option c indicates that the patient has lost weight due to fluid loss and has

hypernatremia.

5. A nurse is caring for a patient who has undergone a total hip replacement surgery. The nurse instructs the patient on how to prevent dislocation of the new prosthesis. Which of these statements by the patient indicates a need for further teaching? a) "I will use a raised toilet seat and a shower chair when I go to the bathroom." b) "I will keep a pillow between my legs when I sleep or lie down." c) "I will avoid crossing my legs or bending my hip more than 90 degrees." d) "I will turn from side to side every 2 hours when I am in bed." Rationale: The correct answer is d. This statement indicates a need for further teaching because turning from side to side may cause dislocation of the new prosthesis. The patient should avoid twisting or rotating the affected hip and should maintain abduction and alignment of the leg. Options a, b, and c are correct statements that indicate understanding of how to prevent dislocation of the new prosthesis.

Answer: B Rationale: Effective utilization of nursing clinical judgement requires recognizing any abnormal findings and reporting them to the registered nurse promptly. This ensures that appropriate interventions can be initiated in a timely manner.

3. During a nursing shift, a patient's condition deteriorates suddenly. The nurse utilizes clinical judgement to determine the appropriate immediate action. What action should the nurse take? A. Continue with the planned care interventions for the patient. B. Call the healthcare provider to inform about the change in patient's condition. C. Perform a comprehensive assessment of the patient's vital signs. D. Initiate cardiopulmonary resuscitation (CPR). Answer: D Rationale: When a patient's condition deteriorates suddenly, initiating CPR is the most appropriate immediate action. This intervention addresses the patient's immediate life-threatening situation and requires prioritization.
4. A nursing student is assigned to administer medications to a group of patients. Which action by the student demonstrates effective utilization of nursing clinical judgement?

A. Administering medications without referring to a medication reference guide. B. Verifying the patient's allergies before administering medication. C. Administering medications in the order they were received from the pharmacy. D. Asking the patient if they have any concerns prior to medication administration. Answer: B Rationale: Effective utilization of nursing clinical judgement includes verifying patient allergies before administering medications to prevent potential adverse reactions. Essential safety measures should be consistently applied.

5. A nurse is planning care for a patient who requires postoperative pain management. How should the nurse utilize clinical judgement when selecting the appropriate pain management intervention? A. Consulting the patient's family members for their opinion on pain management. B. Assessing the patient's pain level using a standardized pain scale. C. Following the same pain management plan as for other postoperative patients. D. Administering a specific pain medication preferred by the healthcare provider. Answer: B

C. Reassuring the patient that the distress will resolve with time. D. Documenting the patient's respiratory patterns in the electronic health record. Answer: A Rationale: When a patient is experiencing acute respiratory distress, administering supplemental oxygen is an appropriate intervention that can be initiated by the nurse without waiting for provider orders. Swift action is necessary to address the patient's respiratory distress.

8. A nursing student is observing a registered nurse providing wound care to a patient. Which action by the student demonstrates effective utilization of nursing clinical judgement? A. Criticizing the registered nurse's choice of dressing material. B. Asking the registered nurse about the rationale for the chosen dressing. C. Suggesting alternative wound care approaches to the registered nurse. D. Taking over the wound care process without informing the registered nurse. Answer: B Rationale: Effective utilization of nursing clinical judgement involves seeking further understanding and rationale for the care interventions being observed. The student should ask the registered nurse about the rationale

behind the chosen dressing to enhance their learning.

9. A nurse is caring for a patient who requires frequent repositioning to prevent pressure ulcers. Which action demonstrates effective utilization of nursing clinical judgement? A. Repositioning the patient every four hours based on the unit's policy. B. Following the repositioning schedule of other patients on the unit. C. Assessing the patient's skin integrity and repositioning accordingly. D. Documenting the repositioning tasks in the patient's care plan. Answer: C Rationale: Effective utilization of nursing clinical judgement requires assessing the patient's skin integrity and repositioning interventions accordingly. Individual patient assessments ensure appropriate and customized care.
10. A nursing student is caring for a patient with diabetes who is experiencing hyperglycemia. Which action demonstrates effective utilization of nursing clinical judgement? A. Administering insulin without checking the patient's blood glucose level. B. Providing the patient with educational materials on glucose monitoring. C. Reviewing the patient's blood glucose logs with the

12. A nursing student is conducting a health assessment on a patient. Which action by the student demonstrates effective utilization of nursing clinical judgement? A. Asking the patient to rate their pain on a scale of 1-10. B. Documenting the patient's medical history as reported by the patient. C. Checking the patient's radiology reports to gather information. D. Communicating with the healthcare provider about abnormal findings. Answer: D Rationale: Effective utilization of nursing clinical judgement involves recognizing abnormal findings and effectively communicating them to the healthcare provider. Collaboration with the provider ensures appropriate interventions and continuity of care.
13. A nurse is assessing a patient's response to pain medications. When utilizing clinical judgement, what would be the nurse's priority action? A. Evaluating the patient's vital signs for any signs of distress. B. Consulting with the patient's family regarding their observations. C. Administering another dose of pain medication if the pain persists. D. Documenting the patient's pain rating in the electronic health record.

Answer: A Rationale: Utilizing nursing clinical judgement involves assessing the patient's response to medication and promptly evaluating vital signs for any potential adverse effects, such as respiratory distress or decreased blood pressure indicating an allergic reaction.

14. A nursing student is providing discharge education to a patient. What action demonstrates effective utilization of nursing clinical judgement? A. Providing the patient with a standard discharge packet. B. Assessing the patient's understanding of the educational materials. C. Recommending additional community resources to the patient. D. Documenting the discharge education in the patient's chart. Answer: B Rationale: Effective utilization of nursing clinical judgement involves assessing the patient's understanding of the discharge education. This ensures that the patient comprehends the provided information and can actively participate in their post-discharge care.
15. A nurse is caring for a patient with a complex medical history. Which action demonstrates effective utilization of nursing clinical judgement? A. Discussing the patient's case with colleagues during break time.

irrigation and dressing change to address the signs of infection and inflammation, which are essential for promoting wound healing and preventing further complications. A 40-year-old male patient is admitted with chest pain and shortness of breath. The nurse suspects acute myocardial infarction (MI). Which assessment finding is most indicative of an MI? A. Decreased blood pressure B. Presence of diaphoresis C. Elevated temperature D. Increased respiratory rate Answer: B Rationale: The presence of diaphoresis is a classic symptom of an acute MI and indicates sympathetic nervous system activation, which is a critical assessment finding in suspected MI. A postoperative patient reports sudden shortness of breath and chest pain. The nurse notes tachycardia and decreased oxygen saturation. What is the priority action? A. Administering pain medication B. Notifying the healthcare provider C. Initiating oxygen therapy D. Performing a focused respiratory assessment Answer: B Rationale: In this scenario, the priority action is to notify the healthcare provider to ensure prompt evaluation and management of the patient's sudden onset of dyspnea, chest

pain, and deteriorating respiratory status. A 30-year-old female patient is prescribed a new medication. The nurse notes that the patient has a known allergy to the prescribed medication. What is the appropriate nursing action? A. Administering the medication and observing for allergic reactions B. Notifying the healthcare provider about the allergy C. Documenting the allergy in the patient's chart D. Recommending an alternative medication Answer: B Rationale: The appropriate nursing action is to notify the healthcare provider about the patient's known allergy to the prescribed medication to prevent potential harm and ensure the prescription of a safe alternative. A 70-year-old patient with chronic obstructive pulmonary disease (COPD) presents with increased dyspnea and wheezing. The nurse auscultates decreased breath sounds. What is the priority nursing intervention? A. Administering a bronchodilator medication B. Notifying the healthcare provider C. Initiating oxygen therapy D. Performing chest physiotherapy Answer: C Rationale: The priority intervention is to initiate oxygen therapy to address the patient's increased dyspnea and decreased breath sounds, which indicate worsening respiratory status and the need for immediate oxygen

and support the management of suspected sepsis pending further diagnostic confirmation and treatment. A 45-year-old patient with a history of cirrhosis presents with abdominal distention and increasing ascites. The nurse observes signs of hepatic encephalopathy. What is the priority nursing intervention? A. Administering lactulose as prescribed B. Notifying the healthcare provider about the signs of encephalopathy C. Initiating paracentesis to drain ascitic fluid D. Monitoring the patient's serum ammonia levels Answer: A Rationale: The priority intervention is to administer lactulose as prescribed to manage hepatic encephalopathy by promoting the excretion of ammonia and reducing its neurotoxic effects. A 55-year-old patient is scheduled for a cardiac catheterization procedure. The nurse notes that the patient has not fasted as per the pre-procedure guidelines. What is the appropriate nursing action? A. Proceeding with the scheduled procedure B. Notifying the healthcare provider about the patient's non-compliance C. Educating the patient about the importance of fasting D. Rescheduling the procedure as per fasting requirements Answer: B Rationale: The appropriate nursing action is to notify the

healthcare provider about the patient's non-compliance with fasting guidelines to ensure a review of the procedural readiness and potential modifications to the plan based on the patient's status. A 25-year-old patient is prescribed a new opioid pain medication following a surgical procedure. The nurse assesses the patient's respiratory rate and notes a significant decrease. What is the priority nursing action? A. Administering naloxone to reverse opioid effects B. Notifying the healthcare provider about the respiratory depression C. Monitoring the patient's pain intensity D. Educating the patient about opioid side effects Answer: A Rationale: The priority nursing action is to administer naloxone to reverse opioid effects and address the respiratory depression, which is a potentially life- threatening complication of opioid medication. A 35-year-old patient with a history of heart failure is prescribed a diuretic medication. The nurse notes that the patient has gained 3 kg in 2 days and reports increased dyspnea. What is the priority nursing intervention? A. Administering the prescribed diuretic medication B. Notifying the healthcare provider about the weight gain and dyspnea C. Restricting the patient's fluid intake D. Monitoring the patient's blood pressure Answer: B