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Nursing 354 Clinical Judgment Practice
Exam Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
___________________________________________________________________
1. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with chronic arthritis reporting pain of 6/10
B. A client with pneumonia who has a new oxygen saturation of 86%
C. A client awaiting discharge instructions
D. A client requesting assistance with bathing
Answer: A client with pneumonia who has a new oxygen saturation of 86%
Rationale: A new oxygen saturation of 86% indicates impaired oxygenation and
requires immediate assessment and intervention.
2. A nurse notices that a client's respiratory rate has increased from 18 to 30
breaths/minute. What should the nurse do first?
A. Document the finding
B. Notify the family
C. Assess the client's respiratory status
D. Administer the scheduled medication
Answer: Assess the client's respiratory status
,Rationale: The nurse should first collect additional assessment data to
determine the cause and severity of the change.
3. A client receiving an opioid analgesic becomes difficult to arouse and has
respirations of 8/minute. Which action is the priority?
A. Allow the client to sleep
B. Administer the next scheduled dose later
C. Assess airway and breathing
D. Offer oral fluids
Answer: Assess airway and breathing
Rationale: Decreased level of consciousness and respiratory depression indicate
a potential airway and breathing emergency.
4. Which finding best demonstrates that a nurse is using clinical judgment?
A. Following the same intervention for every client
B. Making decisions based only on one assessment finding
C. Integrating assessment findings to determine the most appropriate intervention
D. Waiting for another nurse to make all clinical decisions
Answer: Integrating assessment findings to determine the most appropriate
intervention
Rationale: Clinical judgment involves recognizing relevant information,
analyzing cues, prioritizing problems, taking action, and evaluating outcomes.
5. A postoperative client suddenly reports shortness of breath and chest
discomfort. Which action should the nurse take first?
A. Obtain a complete dietary history
B. Assess airway, breathing, and circulation
C. Encourage ambulation
D. Provide a snack
Answer: Assess airway, breathing, and circulation
,Rationale: Sudden respiratory symptoms may indicate a life-threatening
complication, so immediate assessment of airway, breathing, and circulation is
essential.
6. A nurse is reviewing laboratory results. Which finding requires the most
immediate attention?
A. Sodium 138 mEq/L
B. Potassium 6.4 mEq/L
C. Hemoglobin 13.8 g/dL
D. Glucose 98 mg/dL
Answer: Potassium 6.4 mEq/L
Rationale: Severe hyperkalemia can cause dangerous cardiac dysrhythmias and
requires prompt intervention.
7. A client with diabetes is confused, diaphoretic, and shaky. Which cue should
the nurse recognize as most significant?
A. Possible hypoglycemia
B. Possible hypercalcemia
C. Possible dehydration only
D. Possible hypertension
Answer: Possible hypoglycemia
Rationale: Confusion, diaphoresis, and shakiness are classic manifestations of
low blood glucose and require rapid assessment and treatment.
8. A nurse receives several assessment findings from a client. Which finding is
considered an abnormal cue?
A. Respiratory rate of 16/minute
B. Heart rate of 78/minute
C. New unilateral weakness
D. Oral temperature of 37°C (98.6°F)
Answer: New unilateral weakness
, Rationale: New unilateral weakness may indicate an acute neurologic event and
should be evaluated promptly.
9. A nurse is caring for a client with heart failure. Which finding indicates
worsening fluid retention?
A. Weight loss of 1 kg
B. Clear lung sounds
C. Increased ankle edema and rapid weight gain
D. Increased urine output
Answer: Increased ankle edema and rapid weight gain
Rationale: Rapid weight gain and peripheral edema are important cues of
increasing fluid retention in heart failure.
10.Which action best represents the "recognize cues" step of clinical
judgment?
A. Identifying an abnormal blood pressure reading
B. Selecting a treatment
C. Evaluating whether treatment worked
D. Delegating a task
Answer: Identifying an abnormal blood pressure reading
Rationale: Recognizing cues involves identifying relevant subjective and
objective information from the client's condition.
11.A client with a respiratory infection develops increasing confusion and a
blood pressure of 88/54 mmHg. What should the nurse suspect?
A. Improved oxygenation
B. Possible deterioration and impaired perfusion
C. Normal recovery
D. Mild anxiety only
Answer: Possible deterioration and impaired perfusion
Nursing 354 Clinical Judgment Practice
Exam Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
___________________________________________________________________
1. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with chronic arthritis reporting pain of 6/10
B. A client with pneumonia who has a new oxygen saturation of 86%
C. A client awaiting discharge instructions
D. A client requesting assistance with bathing
Answer: A client with pneumonia who has a new oxygen saturation of 86%
Rationale: A new oxygen saturation of 86% indicates impaired oxygenation and
requires immediate assessment and intervention.
2. A nurse notices that a client's respiratory rate has increased from 18 to 30
breaths/minute. What should the nurse do first?
A. Document the finding
B. Notify the family
C. Assess the client's respiratory status
D. Administer the scheduled medication
Answer: Assess the client's respiratory status
,Rationale: The nurse should first collect additional assessment data to
determine the cause and severity of the change.
3. A client receiving an opioid analgesic becomes difficult to arouse and has
respirations of 8/minute. Which action is the priority?
A. Allow the client to sleep
B. Administer the next scheduled dose later
C. Assess airway and breathing
D. Offer oral fluids
Answer: Assess airway and breathing
Rationale: Decreased level of consciousness and respiratory depression indicate
a potential airway and breathing emergency.
4. Which finding best demonstrates that a nurse is using clinical judgment?
A. Following the same intervention for every client
B. Making decisions based only on one assessment finding
C. Integrating assessment findings to determine the most appropriate intervention
D. Waiting for another nurse to make all clinical decisions
Answer: Integrating assessment findings to determine the most appropriate
intervention
Rationale: Clinical judgment involves recognizing relevant information,
analyzing cues, prioritizing problems, taking action, and evaluating outcomes.
5. A postoperative client suddenly reports shortness of breath and chest
discomfort. Which action should the nurse take first?
A. Obtain a complete dietary history
B. Assess airway, breathing, and circulation
C. Encourage ambulation
D. Provide a snack
Answer: Assess airway, breathing, and circulation
,Rationale: Sudden respiratory symptoms may indicate a life-threatening
complication, so immediate assessment of airway, breathing, and circulation is
essential.
6. A nurse is reviewing laboratory results. Which finding requires the most
immediate attention?
A. Sodium 138 mEq/L
B. Potassium 6.4 mEq/L
C. Hemoglobin 13.8 g/dL
D. Glucose 98 mg/dL
Answer: Potassium 6.4 mEq/L
Rationale: Severe hyperkalemia can cause dangerous cardiac dysrhythmias and
requires prompt intervention.
7. A client with diabetes is confused, diaphoretic, and shaky. Which cue should
the nurse recognize as most significant?
A. Possible hypoglycemia
B. Possible hypercalcemia
C. Possible dehydration only
D. Possible hypertension
Answer: Possible hypoglycemia
Rationale: Confusion, diaphoresis, and shakiness are classic manifestations of
low blood glucose and require rapid assessment and treatment.
8. A nurse receives several assessment findings from a client. Which finding is
considered an abnormal cue?
A. Respiratory rate of 16/minute
B. Heart rate of 78/minute
C. New unilateral weakness
D. Oral temperature of 37°C (98.6°F)
Answer: New unilateral weakness
, Rationale: New unilateral weakness may indicate an acute neurologic event and
should be evaluated promptly.
9. A nurse is caring for a client with heart failure. Which finding indicates
worsening fluid retention?
A. Weight loss of 1 kg
B. Clear lung sounds
C. Increased ankle edema and rapid weight gain
D. Increased urine output
Answer: Increased ankle edema and rapid weight gain
Rationale: Rapid weight gain and peripheral edema are important cues of
increasing fluid retention in heart failure.
10.Which action best represents the "recognize cues" step of clinical
judgment?
A. Identifying an abnormal blood pressure reading
B. Selecting a treatment
C. Evaluating whether treatment worked
D. Delegating a task
Answer: Identifying an abnormal blood pressure reading
Rationale: Recognizing cues involves identifying relevant subjective and
objective information from the client's condition.
11.A client with a respiratory infection develops increasing confusion and a
blood pressure of 88/54 mmHg. What should the nurse suspect?
A. Improved oxygenation
B. Possible deterioration and impaired perfusion
C. Normal recovery
D. Mild anxiety only
Answer: Possible deterioration and impaired perfusion
