CLINICAL REASONING SUMMARY 2026
◉ A nurse is initiating a protective environment for a client who has
had an allogenic stem cell transplant. Which of the following
precautions should the nurse plan for this client?
a) make sure the clients room has at least six air exchanges per hour
b) make sure the client wears a mask when outside her room if there
is construction in the area
c) place the client in a private room with negative-pressure airflow
d) wear an N95 respirator when giving the client direct care.
Answer: b) make sure the client wears a mask when outside her
room if there is construction in the area
◉ A nurse is caring for a client who is postoperative and is
exhibiting signs of hemorrhagic stroke. The nurse notifies the
surgeon, who tells the nurse to continue to measure the clients vital
signs every 15 min and to report back in 1 hr. Which of the following
actions should the nurse take next?
a) document the providers statement in the medical record
b) complete an incident report
,c) consult the facility's risk manager
d) notify the nursing manager.
Answer: d) notify the nursing manager
◉ A nurse is planning to insert a peripheral IV catheter for an older
adult client. Which of the following actions should the nurse plan to
take?
a) insert the catheter at a 45º angle
b) place the clients arm in a dependent position
c) shave excess hair from the insertion site
d) initiate IV therapy in the veins of the hand.
Answer: b) place the clients arm in a dependent position
because the veins will dilate due to gravity
◉ A nurse is caring for a client who has dementia. Which of the
following interventions should the nurse take to minimize the risk
for injury to the client?
a) use a bed exit alarm system
b) raise four side rails while the client is in bed
c) apply one soft wrist restraint
, d) dim the lights in the clients room.
Answer: a) use a bed exit alarm system
◉ A nurse is caring for a client who has a terminal illness and is at
the end of life. The nurse should recognize that which of the
following statements by the client's partner indicates effective
coping?
a) "I am not worried because I still have hope that he will be okay"
b) "I am relying on support from our family during this time"
c) "We can plan our family reunion once he recovers and comes
home"
d) "We don't see any reason to start discussing funeral arrangements
right now".
Answer: b) "I am relying on support from our family during this
time"
◉ A nurse is administering 1 L of 0.9% sodium chloride to a client
who is postoperative and has fluid volume deficit. Which of the
following changes should the nurse identify as an indication that the
treatment was successful?
a) increase in hematocrit
b) increase in respiratory rate