**THE NEXUS NURSING DECISIONS
DRILL BOOK: 2026 CLINICAL JUDGMENT
FORCE**
A 68-year-old male with a history of heart failure is admitted with shortness of breath. He has 3+ pitting
edema in both lower extremities and crackles halfway up his lung fields. Which intervention should the
nurse implement first?
A) Administer furosemide 40 mg IV push as ordered
B) Place the patient in high-Fowler’s position
C) Restrict oral fluids to 1500 mL per day
D) Obtain a stat serum potassium level
---
💫RATIONALE✔️✔️: Positioning is always the priority to maximize ventilation and oxygenation before
pharmacological or diagnostic interventions. High-Fowler’s reduces venous return and relieves
pulmonary congestion.
💫ANSWER✔️✔️: B) Place the patient in high-Fowler’s position
A nurse is caring for a client receiving a continuous heparin infusion. Which laboratory value requires
immediate intervention?
A) aPTT of 65 seconds
B) Platelet count of 80,000/mm³
C) INR of 1.2
D) Hemoglobin of 12.5 g/dL
---
💫RATIONALE✔️✔️: Heparin-induced thrombocytopenia (HIT) is a life-threatening reaction. A drop in
platelets to below 150,000 or a 50% reduction mandates stopping heparin immediately.
💫ANSWER✔️✔️: B) Platelet count of 80,000/mm³
,The charge nurse is assigning staff for a medical-surgical unit. Which patient should be assigned to the
RN rather than the LPN?
A) Patient with diabetes requiring daily insulin sliding scale
B) Patient with a stable tracheostomy needing routine suctioning q4h
C) Patient with new-onset chest pain and unstable vital signs
D) Patient with a urinary tract infection receiving oral antibiotics
---
💫RATIONALE✔️✔️: Unstable or newly symptomatic patients require initial assessment and complex
decision-making by an RN. LPNs cannot independently assess unstable patients or initiate the nursing
process.
💫ANSWER✔️✔️: C) Patient with new-onset chest pain and unstable vital signs
A postpartum nurse is assessing a woman 2 hours after vaginal delivery. The fundus is boggy and
displaced to the right, and lochia is heavy with large clots. What is the nurse’s priority action?
A) Massage the fundus firmly
B) Assist the mother to empty her bladder
C) Administer oxytocin as ordered
D) Notify the healthcare provider stat
---
💫RATIONALE✔️✔️: A displaced boggy fundus indicates a full bladder preventing uterine contraction.
Emptying the bladder allows the uterus to contract and reduces bleeding.
💫ANSWER✔️✔️: B) Assist the mother to empty her bladder
A nurse is preparing to administer digoxin to a 6-month-old infant with heart failure. The apical heart
rate is 100 bpm. What should the nurse do?
A) Administer the medication as ordered
B) Hold the dose and notify the provider
C) Give half the dose and recheck in 30 minutes
D) Check the blood pressure before administration
---
, 💫RATIONALE✔️✔️: For infants, digoxin is held if the apical heart rate is below 110 bpm (or 90-100
depending on protocol). Bradycardia is a sign of digoxin toxicity.
💫ANSWER✔️✔️: B) Hold the dose and notify the provider
A client with major depressive disorder refuses to get out of bed or eat breakfast. Which nursing
statement is most therapeutic?
A) "You need to eat to keep up your strength."
B) "I will sit here with you for a few minutes."
C) "Why won't you eat? Your family is worried."
D) "If you don't eat, you'll need a feeding tube."
---
💫RATIONALE✔️✔️: Offering presence without demands demonstrates acceptance and reduces isolation.
It avoids judgment, "why" questions, or threats that increase power struggles.
💫ANSWER✔️✔️: B) "I will sit here with you for a few minutes."
A nurse is teaching a patient with new-onset type 1 diabetes about sick day rules. Which statement by
the patient indicates understanding?
A) "I should stop my insulin if I vomit more than twice."
B) "I will check my blood glucose every 2-4 hours when ill."
C) "I only need to check for ketones if my sugar is over 300."
D) "Clear liquids like apple juice are best if I can't eat."
---
💫RATIONALE✔️✔️: Frequent glucose monitoring (q2-4h) during illness prevents DKA. Insulin should
never be stopped; ketones should be checked with any illness or glucose >240.
💫ANSWER✔️✔️: B) "I will check my blood glucose every 2-4 hours when ill."
Which client is at highest risk for developing a pressure injury?
A) 45-year-old post-op day 2 ambulating with assistance
B) 80-year-old incontinent with limited mobility after hip fracture
C) 60-year-old with diabetic neuropathy wearing well-fitted shoes
DRILL BOOK: 2026 CLINICAL JUDGMENT
FORCE**
A 68-year-old male with a history of heart failure is admitted with shortness of breath. He has 3+ pitting
edema in both lower extremities and crackles halfway up his lung fields. Which intervention should the
nurse implement first?
A) Administer furosemide 40 mg IV push as ordered
B) Place the patient in high-Fowler’s position
C) Restrict oral fluids to 1500 mL per day
D) Obtain a stat serum potassium level
---
💫RATIONALE✔️✔️: Positioning is always the priority to maximize ventilation and oxygenation before
pharmacological or diagnostic interventions. High-Fowler’s reduces venous return and relieves
pulmonary congestion.
💫ANSWER✔️✔️: B) Place the patient in high-Fowler’s position
A nurse is caring for a client receiving a continuous heparin infusion. Which laboratory value requires
immediate intervention?
A) aPTT of 65 seconds
B) Platelet count of 80,000/mm³
C) INR of 1.2
D) Hemoglobin of 12.5 g/dL
---
💫RATIONALE✔️✔️: Heparin-induced thrombocytopenia (HIT) is a life-threatening reaction. A drop in
platelets to below 150,000 or a 50% reduction mandates stopping heparin immediately.
💫ANSWER✔️✔️: B) Platelet count of 80,000/mm³
,The charge nurse is assigning staff for a medical-surgical unit. Which patient should be assigned to the
RN rather than the LPN?
A) Patient with diabetes requiring daily insulin sliding scale
B) Patient with a stable tracheostomy needing routine suctioning q4h
C) Patient with new-onset chest pain and unstable vital signs
D) Patient with a urinary tract infection receiving oral antibiotics
---
💫RATIONALE✔️✔️: Unstable or newly symptomatic patients require initial assessment and complex
decision-making by an RN. LPNs cannot independently assess unstable patients or initiate the nursing
process.
💫ANSWER✔️✔️: C) Patient with new-onset chest pain and unstable vital signs
A postpartum nurse is assessing a woman 2 hours after vaginal delivery. The fundus is boggy and
displaced to the right, and lochia is heavy with large clots. What is the nurse’s priority action?
A) Massage the fundus firmly
B) Assist the mother to empty her bladder
C) Administer oxytocin as ordered
D) Notify the healthcare provider stat
---
💫RATIONALE✔️✔️: A displaced boggy fundus indicates a full bladder preventing uterine contraction.
Emptying the bladder allows the uterus to contract and reduces bleeding.
💫ANSWER✔️✔️: B) Assist the mother to empty her bladder
A nurse is preparing to administer digoxin to a 6-month-old infant with heart failure. The apical heart
rate is 100 bpm. What should the nurse do?
A) Administer the medication as ordered
B) Hold the dose and notify the provider
C) Give half the dose and recheck in 30 minutes
D) Check the blood pressure before administration
---
, 💫RATIONALE✔️✔️: For infants, digoxin is held if the apical heart rate is below 110 bpm (or 90-100
depending on protocol). Bradycardia is a sign of digoxin toxicity.
💫ANSWER✔️✔️: B) Hold the dose and notify the provider
A client with major depressive disorder refuses to get out of bed or eat breakfast. Which nursing
statement is most therapeutic?
A) "You need to eat to keep up your strength."
B) "I will sit here with you for a few minutes."
C) "Why won't you eat? Your family is worried."
D) "If you don't eat, you'll need a feeding tube."
---
💫RATIONALE✔️✔️: Offering presence without demands demonstrates acceptance and reduces isolation.
It avoids judgment, "why" questions, or threats that increase power struggles.
💫ANSWER✔️✔️: B) "I will sit here with you for a few minutes."
A nurse is teaching a patient with new-onset type 1 diabetes about sick day rules. Which statement by
the patient indicates understanding?
A) "I should stop my insulin if I vomit more than twice."
B) "I will check my blood glucose every 2-4 hours when ill."
C) "I only need to check for ketones if my sugar is over 300."
D) "Clear liquids like apple juice are best if I can't eat."
---
💫RATIONALE✔️✔️: Frequent glucose monitoring (q2-4h) during illness prevents DKA. Insulin should
never be stopped; ketones should be checked with any illness or glucose >240.
💫ANSWER✔️✔️: B) "I will check my blood glucose every 2-4 hours when ill."
Which client is at highest risk for developing a pressure injury?
A) 45-year-old post-op day 2 ambulating with assistance
B) 80-year-old incontinent with limited mobility after hip fracture
C) 60-year-old with diabetic neuropathy wearing well-fitted shoes
