NURS 2539 CLINICAL DECISION MAKING/CLINICAL JUDGEMENT

CLINICAL DECISION MAKING/ CLINICAL JUDGEMENT Question 1 After learning that a roommate is HIV-positive, a client asks a nurse about moving to another room on the psychiatric unit because he no longer feels "safe." What should the nurse do first? Question 2 See full question 1m 3s A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which of the following would the highest priority goal in planning nursing interventions? Question 3 See full question 28s The nurse starts an infusion of tissue plasminogen activase (tPA) for a client with a cerebrovascular accident (CVA). What are the priority nursing interventions during treatment with this medication? Question 4 See full question 31s A client is a gravida 2 para 1 and is currently 12 weeks gestation. She states that she drank beer throughout her last pregnancy. The client asks the nurse if it is okay to have a few drinks during this current pregnancy. Which of the following responses by the nurse would be most appropriate? Question 5 See full question 26s A nurse is caring for a client posttranssphenoidal hypophysectomy and notes a watery discharge from the client's nose. Which of the following is the appropriate action for the nurse to take? Question 6 See full question 31s A client is admitted to the telemetry unit following a ST segment-elevation myocardial infarction (STEMI). The electrocardiogram (EKG) tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse should take? Question 7 See full question 26s The nurse is caring for a client in labor and notes late decelerations on the external fetal monitoring strip. Which of the following actions will the nurse include in the client's plan of care? Select all that apply. Question 8 See full question 24s A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which of the following is the appropriate nursing intervention? Question 9 See full question 1m 13s Which client admitted to the emergency department should the nurse see first? A client: Question 10 See full question 23s A client has been in early labor, with contractions ever 10 to 12 minutes, for the past 12 hours with no progression. What medication should the nurse anticipate to help stimulate this client’s uterine contractions? Question 1 See full question 24s When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently? Question 2 See full question 29s A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action should the nurse take? Question 3 See full question 24s A nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first: Question 4 See full question 1m 5s A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: Question 5 See full question 27s In the early postoperative period, the nurse notes a bright red, 3" × 5" (7.6 cm x 12.7 cm) area of drainage on the client's abdominal laparotomy dressing. What should be the nurse's first action in response to this observation? Question 6 See full question 30s The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine? Question 7 See full question 27s Three weeks after an infant receives a spica cast, the mother calls the nurse because the infant’s toes are swollen and cool to the touch. What should the nurse instruct the mother to do? Question 8 See full question 44s The nurse is calculating the digoxin dose for a pediatric client who weighs 11.36 kg. The dose for the client is 30 mcg/kg. How many mcg will the client receive? Record your answer using one decimal place. Question 9 See full question 30s A 74-year-old client receiving fluphenazine decanoate therapy develops pseudoparkinsonism, and is ordered amantadine hydrochloride. With the addition of this medication, the client reports feeling dizzy when standing. Which response by the nurse is best? Question 10 See full question 36s The nurse is assigned to care for four clients. Which client should the nurse assess first?