NURS 121L-A | Medical-Surgical Nursing Practicum | Clinical Judgment
& Prioritization | 2026 Update WCU
1. A nurse is caring for four clients on a medical-surgical unit. Which client
should the nurse assess first?
A. A client who underwent an abdominal hysterectomy 6 hours ago and has a heart rate of 118 bpm.
B. A client with chronic obstructive pulmonary disease (COPD) with a pulse oximetry reading of 90% on 2L
oxygen.
C. A client with diabetes mellitus who has a pre-meal blood glucose level of 145 mg/dL.
D. A client with a history of heart failure who has 2+ pitting edema in the lower extremities.
Answer: A
Rationale: A heart rate of 118 bpm in a post-operative client (tachycardia) is a potential
sign of hemorrhage or shock and requires immediate assessment. The other clients are
relatively stable or within expected ranges for their chronic conditions.
2. The nurse is using the NCSBN Clinical Judgment Measurement Model to care
for a client with pneumonia. Which action by the nurse represents ‘Analyzing
Cues’?
A. Auscultating the client’s breath sounds and noting crackles in the right lower lobe.
B. Relating the client’s fever and productive cough to a potential infectious process in the lungs.
C. Administering a prescribed dose of intravenous antibiotics.
D. Checking the client’s oxygen saturation levels 30 minutes after starting oxygen therapy.
Answer: B
Rationale: Analyzing cues involves linking collected data (fever, cough) to a physiological
significance or potential diagnosis. Auscultating is ‘Recognizing Cues’, administering meds
is ‘Taking Action’, and checking saturation later is ‘Evaluating Outcomes’.
,3. A client with a potassium level of 2.8 mEq/L is scheduled for surgery. What is
the priority nursing action?
A. Document the finding in the medical record.
B. Notify the surgeon and anesthesiologist immediately.
C. Administer a potassium supplement as per the standing PRN order.
D. Encourage the client to eat a banana before being NPO.
Answer: B
Rationale: Hypokalemia (2.8 mEq/L) is life-threatening and can cause cardiac
dysrhythmias during anesthesia. The surgical team must be notified to stabilize the client
before proceeding. Bananas are insufficient and NPO status must be maintained.
4. Which task is most appropriate for the nurse to delegate to an unlicensed
assistive personnel (UAP)?
A. Measuring the intake and output for a client with a continuous bladder irrigation (CBI).
B. Assisting a stable client with a walker to the bathroom for the first time after surgery.
C. Applying a sterile dressing to a new pressure injury.
D. Obtaining vital signs on a client who just returned from the PACU.
Answer: A
Rationale: UAPs can perform routine tasks like measuring I&O. Assessing a client’s first
ambulation, performing sterile dressing changes, and taking initial post-op vitals require
the judgment and assessment skills of an RN.
5. A client with Type 1 Diabetes is found confused, diaphoretic, and shaky. What
is the nurse’s first action?
A. Administer the scheduled dose of glargine insulin.
B. Administer 15g of rapid-acting carbohydrates.
C. Call the healthcare provider to report the change in status.
D. Check the client’s capillary blood glucose level.
Answer: D
, Rationale: The client is showing signs of hypoglycemia. The first step is to confirm the
blood glucose level to guide intervention. If the client is severely symptomatic and a
monitor is unavailable, treating immediately is acceptable, but checking first is standard
practice.
6. A nurse is assessing a client with a chest tube. Which finding requires
immediate intervention?
A. Tidaling in the water seal chamber with respirations.
B. Intermittent bubbling in the suction control chamber.
C. Continuous bubbling in the water seal chamber.
D. Drainage of 50 mL of serosanguinous fluid over the last 4 hours.
Answer: C
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the
system. Tidaling is normal, and serosanguinous drainage of 50 mL in 4 hours is usually
acceptable. Intermittent bubbling in the water seal is normal for a pneumothorax, but
continuous bubbling is a leak.
7. The nurse is caring for a client with a suspected Pulmonary Embolism (PE).
Which diagnostic test is the gold standard for confirmation?
A. Chest X-ray
B. D-dimer assay
C. Arterial Blood Gas (ABG)
D. Computed Tomography Pulmonary Angiography (CTPA)
Answer: D
Rationale: CTPA is the preferred and most accurate diagnostic tool for confirming a PE. D-
dimer is used for screening but is non-specific. X-rays and ABGs help rule out other
conditions but do not confirm PE.
& Prioritization | 2026 Update WCU
1. A nurse is caring for four clients on a medical-surgical unit. Which client
should the nurse assess first?
A. A client who underwent an abdominal hysterectomy 6 hours ago and has a heart rate of 118 bpm.
B. A client with chronic obstructive pulmonary disease (COPD) with a pulse oximetry reading of 90% on 2L
oxygen.
C. A client with diabetes mellitus who has a pre-meal blood glucose level of 145 mg/dL.
D. A client with a history of heart failure who has 2+ pitting edema in the lower extremities.
Answer: A
Rationale: A heart rate of 118 bpm in a post-operative client (tachycardia) is a potential
sign of hemorrhage or shock and requires immediate assessment. The other clients are
relatively stable or within expected ranges for their chronic conditions.
2. The nurse is using the NCSBN Clinical Judgment Measurement Model to care
for a client with pneumonia. Which action by the nurse represents ‘Analyzing
Cues’?
A. Auscultating the client’s breath sounds and noting crackles in the right lower lobe.
B. Relating the client’s fever and productive cough to a potential infectious process in the lungs.
C. Administering a prescribed dose of intravenous antibiotics.
D. Checking the client’s oxygen saturation levels 30 minutes after starting oxygen therapy.
Answer: B
Rationale: Analyzing cues involves linking collected data (fever, cough) to a physiological
significance or potential diagnosis. Auscultating is ‘Recognizing Cues’, administering meds
is ‘Taking Action’, and checking saturation later is ‘Evaluating Outcomes’.
,3. A client with a potassium level of 2.8 mEq/L is scheduled for surgery. What is
the priority nursing action?
A. Document the finding in the medical record.
B. Notify the surgeon and anesthesiologist immediately.
C. Administer a potassium supplement as per the standing PRN order.
D. Encourage the client to eat a banana before being NPO.
Answer: B
Rationale: Hypokalemia (2.8 mEq/L) is life-threatening and can cause cardiac
dysrhythmias during anesthesia. The surgical team must be notified to stabilize the client
before proceeding. Bananas are insufficient and NPO status must be maintained.
4. Which task is most appropriate for the nurse to delegate to an unlicensed
assistive personnel (UAP)?
A. Measuring the intake and output for a client with a continuous bladder irrigation (CBI).
B. Assisting a stable client with a walker to the bathroom for the first time after surgery.
C. Applying a sterile dressing to a new pressure injury.
D. Obtaining vital signs on a client who just returned from the PACU.
Answer: A
Rationale: UAPs can perform routine tasks like measuring I&O. Assessing a client’s first
ambulation, performing sterile dressing changes, and taking initial post-op vitals require
the judgment and assessment skills of an RN.
5. A client with Type 1 Diabetes is found confused, diaphoretic, and shaky. What
is the nurse’s first action?
A. Administer the scheduled dose of glargine insulin.
B. Administer 15g of rapid-acting carbohydrates.
C. Call the healthcare provider to report the change in status.
D. Check the client’s capillary blood glucose level.
Answer: D
, Rationale: The client is showing signs of hypoglycemia. The first step is to confirm the
blood glucose level to guide intervention. If the client is severely symptomatic and a
monitor is unavailable, treating immediately is acceptable, but checking first is standard
practice.
6. A nurse is assessing a client with a chest tube. Which finding requires
immediate intervention?
A. Tidaling in the water seal chamber with respirations.
B. Intermittent bubbling in the suction control chamber.
C. Continuous bubbling in the water seal chamber.
D. Drainage of 50 mL of serosanguinous fluid over the last 4 hours.
Answer: C
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the
system. Tidaling is normal, and serosanguinous drainage of 50 mL in 4 hours is usually
acceptable. Intermittent bubbling in the water seal is normal for a pneumothorax, but
continuous bubbling is a leak.
7. The nurse is caring for a client with a suspected Pulmonary Embolism (PE).
Which diagnostic test is the gold standard for confirmation?
A. Chest X-ray
B. D-dimer assay
C. Arterial Blood Gas (ABG)
D. Computed Tomography Pulmonary Angiography (CTPA)
Answer: D
Rationale: CTPA is the preferred and most accurate diagnostic tool for confirming a PE. D-
dimer is used for screening but is non-specific. X-rays and ABGs help rule out other
conditions but do not confirm PE.
