Case-Based Clinical Judgment Practice
Medical-Surgical Nursing Clinical Judgment Practice 2026–2027 | Practice Resource
, Medical-Surgical Nursing Clinical Judgment
Practice 2026–2027
Case-Based Clinical Judgment Practice
Case-Based Questions 1–25
Question 1 — Acute Heart Failure
A 72-year-old client with a history of heart failure with reduced ejection fraction is admitted with
increasing dyspnea. The client is sitting upright, using accessory muscles, and has bilateral
crackles. Vital signs are BP 168/94 mm Hg, HR 112/min, RR 30/min, and SpO₂ 84% on room air.
Which action should the nurse take first?
A. Administer the prescribed IV furosemide
B. Apply oxygen and position the client upright
C. Obtain the client's daily weight
D. Restrict the client's oral fluid intake
Correct Answer: B. Apply oxygen and position the client upright
Detailed Rationale:
The client has manifestations of acute pulmonary congestion and impaired
oxygenation. The immediate priority is to improve ventilation and oxygenation.
Sitting upright decreases venous return and allows greater lung expansion,
while supplemental oxygen addresses hypoxemia. After stabilization, the nurse
should administer prescribed diuretics and continue the remaining
interventions.
Why the Other Options Are Incorrect:
• A. Administer the prescribed IV furosemide: Appropriate and likely necessary, but
oxygenation is the immediate priority in a client with an SpO₂ of 84%.
• C. Obtain the client's daily weight: Important for evaluating fluid status but does not
address the immediate respiratory compromise.
• D. Restrict oral fluid intake: May be part of the treatment plan but does not immediately
correct hypoxemia.
—
Question 2 — Acute Ischemic Stroke
A 68-year-old client suddenly develops right-sided weakness, facial drooping, and difficulty
speaking. The spouse reports that the client was last seen normal 45 minutes ago.
Medical-Surgical Nursing Clinical Judgment Practice 2026–2027 | Practice Resource
,Which action is the nurse's priority?
A. Give aspirin immediately
B. Obtain a blood glucose level and activate the stroke response
C. Place the client in Trendelenburg position
D. Administer oral fluids
Correct Answer: B. Obtain a blood glucose level and activate the stroke response
Detailed Rationale:
Sudden neurologic deficits suggest an acute stroke. Rapid assessment is
essential because some clients may be candidates for reperfusion therapy.
Hypoglycemia can mimic stroke, so point-of-care glucose testing is an important
immediate assessment. The stroke response should be activated without delay.
Why the Other Options Are Incorrect:
• A. Give aspirin immediately: Aspirin should not be given until intracranial hemorrhage has
been excluded by appropriate imaging.
• C. Place the client in Trendelenburg position: This does not treat the suspected stroke and
may compromise respiratory status.
• D. Administer oral fluids: A client with acute stroke may have dysphagia and aspiration risk;
oral intake should be withheld until swallowing is assessed.
—
Question 3 — Diabetic Ketoacidosis
A client with type 1 diabetes is admitted with diabetic ketoacidosis. The client is lethargic, has dry
mucous membranes, BP 92/58 mm Hg, HR 124/min, and deep rapid respirations. Laboratory
results show glucose 486 mg/dL and potassium 5.6 mEq/L.
Which prescription should the nurse implement first?
A. Start IV regular insulin
B. Begin isotonic IV fluid replacement
C. Administer IV potassium chloride
D. Give sodium bicarbonate routinely
Correct Answer: B. Begin isotonic IV fluid replacement
Detailed Rationale:
DKA causes profound osmotic diuresis and dehydration. The initial priority is
restoring circulating volume with isotonic IV fluids. Insulin is then
administered to stop ketone production and reduce glucose. Potassium must be
monitored closely because serum potassium can initially appear elevated despite
total-body potassium depletion.
Why the Other Options Are Incorrect:
• A. Start IV regular insulin: Insulin is essential, but initial fluid resuscitation is the priority in a
hypotensive, dehydrated client.
Medical-Surgical Nursing Clinical Judgment Practice 2026–2027 | Practice Resource
, • C. Administer IV potassium chloride: The potassium is already elevated; potassium
replacement would be unsafe at this time.
• D. Give sodium bicarbonate routinely: Bicarbonate is not routinely indicated and is
reserved for specific severe acidemia situations.
—
Question 4 — COPD Exacerbation
A client with COPD is admitted with increasing dyspnea and wheezing. The client's SpO₂ is 82% on
room air. The nurse applies oxygen as prescribed. After several minutes, the client becomes
increasingly drowsy.
Which assessment is most important?
A. Check the client's bowel sounds
B. Obtain an arterial blood gas
C. Measure the client's urine output
D. Assess pedal pulses
Correct Answer: B. Obtain an arterial blood gas
Detailed Rationale:
Increasing drowsiness in a client with COPD and respiratory distress may
indicate worsening hypercapnia and respiratory failure. An ABG provides
information about oxygenation, ventilation, and acid-base status. The nurse
should promptly evaluate for CO₂ retention and worsening
respiratory failure.
Why the Other Options Are Incorrect:
• A. Check bowel sounds: Not relevant to the acute deterioration.
• C. Measure urine output: Important for overall assessment but not the immediate concern.
• D. Assess pedal pulses: Does not address the client's acute change in respiratory status.
—
Question 5 — Pulmonary Embolism
A postoperative client suddenly reports sharp chest pain and severe shortness of breath. The
client is anxious, HR 126/min, RR 32/min, and SpO₂ 86%.
Which action should the nurse take first?
A. Encourage ambulation
B. Apply oxygen and notify the healthcare provider/rapid response team
C. Place the client flat in bed
D. Administer an oral anticoagulant
Correct Answer: B. Apply oxygen and notify the healthcare provider/rapid response team
Detailed Rationale:
The sudden onset of dyspnea, pleuritic chest pain, tachycardia, and hypoxemia
after surgery is concerning for pulmonary embolism. The nurse should
immediately support oxygenation and escalate care because pulmonary embolism
Medical-Surgical Nursing Clinical Judgment Practice 2026–2027 | Practice Resource
Medical-Surgical Nursing Clinical Judgment Practice 2026–2027 | Practice Resource
, Medical-Surgical Nursing Clinical Judgment
Practice 2026–2027
Case-Based Clinical Judgment Practice
Case-Based Questions 1–25
Question 1 — Acute Heart Failure
A 72-year-old client with a history of heart failure with reduced ejection fraction is admitted with
increasing dyspnea. The client is sitting upright, using accessory muscles, and has bilateral
crackles. Vital signs are BP 168/94 mm Hg, HR 112/min, RR 30/min, and SpO₂ 84% on room air.
Which action should the nurse take first?
A. Administer the prescribed IV furosemide
B. Apply oxygen and position the client upright
C. Obtain the client's daily weight
D. Restrict the client's oral fluid intake
Correct Answer: B. Apply oxygen and position the client upright
Detailed Rationale:
The client has manifestations of acute pulmonary congestion and impaired
oxygenation. The immediate priority is to improve ventilation and oxygenation.
Sitting upright decreases venous return and allows greater lung expansion,
while supplemental oxygen addresses hypoxemia. After stabilization, the nurse
should administer prescribed diuretics and continue the remaining
interventions.
Why the Other Options Are Incorrect:
• A. Administer the prescribed IV furosemide: Appropriate and likely necessary, but
oxygenation is the immediate priority in a client with an SpO₂ of 84%.
• C. Obtain the client's daily weight: Important for evaluating fluid status but does not
address the immediate respiratory compromise.
• D. Restrict oral fluid intake: May be part of the treatment plan but does not immediately
correct hypoxemia.
—
Question 2 — Acute Ischemic Stroke
A 68-year-old client suddenly develops right-sided weakness, facial drooping, and difficulty
speaking. The spouse reports that the client was last seen normal 45 minutes ago.
Medical-Surgical Nursing Clinical Judgment Practice 2026–2027 | Practice Resource
,Which action is the nurse's priority?
A. Give aspirin immediately
B. Obtain a blood glucose level and activate the stroke response
C. Place the client in Trendelenburg position
D. Administer oral fluids
Correct Answer: B. Obtain a blood glucose level and activate the stroke response
Detailed Rationale:
Sudden neurologic deficits suggest an acute stroke. Rapid assessment is
essential because some clients may be candidates for reperfusion therapy.
Hypoglycemia can mimic stroke, so point-of-care glucose testing is an important
immediate assessment. The stroke response should be activated without delay.
Why the Other Options Are Incorrect:
• A. Give aspirin immediately: Aspirin should not be given until intracranial hemorrhage has
been excluded by appropriate imaging.
• C. Place the client in Trendelenburg position: This does not treat the suspected stroke and
may compromise respiratory status.
• D. Administer oral fluids: A client with acute stroke may have dysphagia and aspiration risk;
oral intake should be withheld until swallowing is assessed.
—
Question 3 — Diabetic Ketoacidosis
A client with type 1 diabetes is admitted with diabetic ketoacidosis. The client is lethargic, has dry
mucous membranes, BP 92/58 mm Hg, HR 124/min, and deep rapid respirations. Laboratory
results show glucose 486 mg/dL and potassium 5.6 mEq/L.
Which prescription should the nurse implement first?
A. Start IV regular insulin
B. Begin isotonic IV fluid replacement
C. Administer IV potassium chloride
D. Give sodium bicarbonate routinely
Correct Answer: B. Begin isotonic IV fluid replacement
Detailed Rationale:
DKA causes profound osmotic diuresis and dehydration. The initial priority is
restoring circulating volume with isotonic IV fluids. Insulin is then
administered to stop ketone production and reduce glucose. Potassium must be
monitored closely because serum potassium can initially appear elevated despite
total-body potassium depletion.
Why the Other Options Are Incorrect:
• A. Start IV regular insulin: Insulin is essential, but initial fluid resuscitation is the priority in a
hypotensive, dehydrated client.
Medical-Surgical Nursing Clinical Judgment Practice 2026–2027 | Practice Resource
, • C. Administer IV potassium chloride: The potassium is already elevated; potassium
replacement would be unsafe at this time.
• D. Give sodium bicarbonate routinely: Bicarbonate is not routinely indicated and is
reserved for specific severe acidemia situations.
—
Question 4 — COPD Exacerbation
A client with COPD is admitted with increasing dyspnea and wheezing. The client's SpO₂ is 82% on
room air. The nurse applies oxygen as prescribed. After several minutes, the client becomes
increasingly drowsy.
Which assessment is most important?
A. Check the client's bowel sounds
B. Obtain an arterial blood gas
C. Measure the client's urine output
D. Assess pedal pulses
Correct Answer: B. Obtain an arterial blood gas
Detailed Rationale:
Increasing drowsiness in a client with COPD and respiratory distress may
indicate worsening hypercapnia and respiratory failure. An ABG provides
information about oxygenation, ventilation, and acid-base status. The nurse
should promptly evaluate for CO₂ retention and worsening
respiratory failure.
Why the Other Options Are Incorrect:
• A. Check bowel sounds: Not relevant to the acute deterioration.
• C. Measure urine output: Important for overall assessment but not the immediate concern.
• D. Assess pedal pulses: Does not address the client's acute change in respiratory status.
—
Question 5 — Pulmonary Embolism
A postoperative client suddenly reports sharp chest pain and severe shortness of breath. The
client is anxious, HR 126/min, RR 32/min, and SpO₂ 86%.
Which action should the nurse take first?
A. Encourage ambulation
B. Apply oxygen and notify the healthcare provider/rapid response team
C. Place the client flat in bed
D. Administer an oral anticoagulant
Correct Answer: B. Apply oxygen and notify the healthcare provider/rapid response team
Detailed Rationale:
The sudden onset of dyspnea, pleuritic chest pain, tachycardia, and hypoxemia
after surgery is concerning for pulmonary embolism. The nurse should
immediately support oxygenation and escalate care because pulmonary embolism
Medical-Surgical Nursing Clinical Judgment Practice 2026–2027 | Practice Resource
