ACCURATE ANSWERS
(predicting and) managing potential complications correct answer Plan nursing
interventions to decrease the risk of predicted future complication
A diabetic patient's blood glucose reading is 48. Patient is confused drowsy
complaining of dizziness. Which intervention by the nurse will clinical judgment
step in responding in judgement? correct answer Administer 1 mg of glucagon by
order.
A nurse receives a health care provider order to meds, however the patient
refuses to take the meds and reports HX of side effects of this med. Which is the
best action will the nurse take? correct answer Call the HCP and explain what is
stated and request different meds
A patient admitted to surgical unit for a scheduled procedure during an admission
assessment the nurse palpates the irregular pulse. According to Tanners which
thinking is skilled as the nurse using. correct answer identifying signs and
symptoms
A patient with CHF is admitted into the hospital during the assessment the nurse
identifies mild SOB. The nurse uses which step of the nursing process to begin the
patient plan of care base on the identified problem. correct answer Nursing
diagnosis
A patient with ESLC is admitted to the unit for comfort care, vital signs are taken,
lung sounds. Congestion is noted. Which phase of the nursing process. What is
the nurse involved with these finding? correct answer Assessment
, A patient with SOB and pain in their chest with ambulating around the house.
Which will the nurse predict as potential complications for patient? correct
answer Falls, pain management, decreased oxygen
According to tanner model clinical judgement that analytical intuitive and
narrative to interpret the meaning of what is notice a patient with situation,
which factor best influences the nurses clinical reasoning patterns? correct
answer Experience
advance beginner correct answer A nurse who has had some level of experience
with the situation. This experience may only be observational in nature, but the
nurse is able to identify meaningful aspects or principles of nursing care.
- have no more than 2 years of experience
- past experience guides the actions
After receiving hands off notes from previous nurse, which patient would you see
first? correct answer A patient with pneumonia, SOB, O2 89%, and labor
respiration at rest
Assessing systematically and comprehensively correct answer Noticing data by
using a systematic method or an assessment tool.
Based on Tanners model which is the appropriate nursing action for a patient
presenting with poor skin turgor with tinting after experiencing diarrhea for 36
hours. correct answer Infuse an IV solution of 0.9 normal 70mL per order.
Before delegating a tasked the RN will ensure that which is done? correct answer
Consider the delegates ability