Pearson Module 36 - Clinical Decision Making Questions and Correct Answers

A nurse receives a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first? A) The client who needs assistance with activities of daily living B) The client who needs help ambulating to the bathroom C) The client with a pain rating of 3/10 D) The client experiencing shortness of breath Answer: D Explanation: The nurse begins by assessing the client who is at the greatest risk, who in this case is the client having trouble breathing. The risk for the client with mild pain is not as severe as that for the client with dyspnea. The nurse can delegate the ambulation of a client to a nursing assistive individual. The nurse can also delegate assisting a client who needs help with a bath. Page Ref: 2481, 2533 A client with congestive heart failure (CHF) is having difficulty breathing. Before leaving the room, the nurse ensures the client has an overbed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? A) Delegating a task B) Priority setting C) Conflict resolution D) Critical thinking Answer: D Explanation: After assessing the client, the nurse sets goals for and with the client. To arrive at the goal, the nurse uses critical thinking to make the decision to provide the client with optimum ability to breathe. Delegating involves giving the task to another team member. There is no conflict in this decision. Conflict resolution usually involves a compromise that affects two sides that are in disagreement. Priority setting involves deciding which task to perform first. Page Ref: A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a rating scale of 1 to 10. The nurse decides to give the pain medication now. What does this nurse's action exemplify? A) Meeting a client goal B) Time management skills C) Prioritizing the client's care D) Responding to a change in the client's condition Answer: D Explanation: Each client has a plan of care, but it is the nurse who constantly evaluates the client for changes that the nurse responds to, if needed. Prioritizing involves choosing tasks in order of importance. Time management is completing the assigned tasks in the given time frame by organizing and using efficiency. The goal has not been met if the client is experiencing pain. Page Ref: 2481, 2533