Adult Health Nursing III – Clinical Judgment
Practice Questions & Rationales
Question 1
The nurse reviews a provider's orders for a client admitted with acute
decompensated heart failure. Which order should the nurse question?
A) Furosemide 40 mg IV push
B) 0.9% normal saline at 125 mL/hr
C) Daily weights
D) Strict intake and output monitoring
Correct Answer: B) 0.9% normal saline at 125 mL/hr
Rationale: A rate of 125 mL/hr in acute decompensated heart failure would worsen
fluid overload. Fluid restriction and diuresis are priorities. The nurse should
question this order and advocate for a lower rate or restricted fluids.
Question 2
Which assessment finding in a client with a chest tube requires the nurse to act
immediately?
A) Serosanguineous drainage of 50 mL in the first hour
B) Tidaling in the water seal chamber with inspiration
C) Sudden onset of crepitus around the insertion site
D) Mild pain at the insertion site relieved by acetaminophen
,Correct Answer: C) Sudden onset of crepitus around the insertion site
Rationale: Crepitus (subcutaneous emphysema) indicates air leakage into
subcutaneous tissue and may signal tube disconnection or pleural injury. This
requires immediate assessment and provider notification.
Question 3
The nurse is assigning clients on a medical-surgical unit. Which client should the
nurse assess first?
A) Client with COPD requesting a PRN bronchodilator
B) Client with a new tracheostomy who is coughing forcefully
C) Client with sepsis whose mean arterial pressure is 58 mm Hg
D) Client with a colostomy requesting pouch change assistance
Correct Answer: C) Client with sepsis whose mean arterial pressure is 58 mm Hg
Rationale: MAP below 65 mm Hg indicates inadequate organ perfusion and
impending shock. This client requires immediate assessment and intervention. The
other clients have stable or routine needs.
Question 4
A client with DKA is receiving an insulin infusion. The nurse notes the blood
glucose has dropped from 520 mg/dL to 280 mg/dL in one hour. Which action
should the nurse take?
,A) Continue the current infusion rate and recheck in 1 hour
B) Increase the infusion rate to maintain the drop
C) Notify the provider and anticipate decreasing the rate
D) Stop the infusion and administer dextrose 50%
Correct Answer: C) Notify the provider and anticipate decreasing the rate
Rationale: Blood glucose should decrease by 50-75 mg/dL per hour in DKA. A
drop of 240 mg/dL in one hour is too rapid and increases risk of cerebral edema.
The rate should be decreased and dextrose added.
Question 5
The nurse is evaluating a client with a new ileostomy. Which finding indicates the
need for further teaching?
A) The client states they will avoid nuts and seeds
B) The client states they will drink 2-3 liters of fluid daily
C) The client states they will take a laxative daily to regulate output
D) The client states they will chew food thoroughly
Correct Answer: C) The client states they will take a laxative daily to regulate
output
Rationale: Routine laxative use is not recommended for ileostomy clients and can
cause dehydration and electrolyte imbalances. Fluid intake, chewing food
thoroughly, and avoiding high-fiber foods are appropriate.
, Question 6
A client with a spinal cord injury develops a severe headache and diaphoresis
above the level of injury. The nurse checks the blood pressure and finds it is
220/110 mm Hg. Which action should the nurse take next?
A) Administer PRN antihypertensive medication
B) Place the client flat and check for bowel impaction
C) Sit the client upright and check the urinary catheter for kinks
D) Notify the provider and prepare for emergency surgery
Correct Answer: C) Sit the client upright and check the urinary catheter for kinks
Rationale: Autonomic dysreflexia requires immediate removal of the triggering
stimulus. Sitting the client upright reduces blood pressure. Checking the catheter
for kinks addresses the most common trigger (bladder distention).
Question 7
The nurse receives handoff report on four clients. Which client should the nurse see
first?
A) Client with acute pancreatitis reporting pain of 6/10
B) Client with liver cirrhosis who is confused and has asterixis
C) Client with a colostomy requesting help with pouch emptying
D) Client with chronic kidney disease awaiting dialysis
Correct Answer: B) Client with liver cirrhosis who is confused and has asterixis
Practice Questions & Rationales
Question 1
The nurse reviews a provider's orders for a client admitted with acute
decompensated heart failure. Which order should the nurse question?
A) Furosemide 40 mg IV push
B) 0.9% normal saline at 125 mL/hr
C) Daily weights
D) Strict intake and output monitoring
Correct Answer: B) 0.9% normal saline at 125 mL/hr
Rationale: A rate of 125 mL/hr in acute decompensated heart failure would worsen
fluid overload. Fluid restriction and diuresis are priorities. The nurse should
question this order and advocate for a lower rate or restricted fluids.
Question 2
Which assessment finding in a client with a chest tube requires the nurse to act
immediately?
A) Serosanguineous drainage of 50 mL in the first hour
B) Tidaling in the water seal chamber with inspiration
C) Sudden onset of crepitus around the insertion site
D) Mild pain at the insertion site relieved by acetaminophen
,Correct Answer: C) Sudden onset of crepitus around the insertion site
Rationale: Crepitus (subcutaneous emphysema) indicates air leakage into
subcutaneous tissue and may signal tube disconnection or pleural injury. This
requires immediate assessment and provider notification.
Question 3
The nurse is assigning clients on a medical-surgical unit. Which client should the
nurse assess first?
A) Client with COPD requesting a PRN bronchodilator
B) Client with a new tracheostomy who is coughing forcefully
C) Client with sepsis whose mean arterial pressure is 58 mm Hg
D) Client with a colostomy requesting pouch change assistance
Correct Answer: C) Client with sepsis whose mean arterial pressure is 58 mm Hg
Rationale: MAP below 65 mm Hg indicates inadequate organ perfusion and
impending shock. This client requires immediate assessment and intervention. The
other clients have stable or routine needs.
Question 4
A client with DKA is receiving an insulin infusion. The nurse notes the blood
glucose has dropped from 520 mg/dL to 280 mg/dL in one hour. Which action
should the nurse take?
,A) Continue the current infusion rate and recheck in 1 hour
B) Increase the infusion rate to maintain the drop
C) Notify the provider and anticipate decreasing the rate
D) Stop the infusion and administer dextrose 50%
Correct Answer: C) Notify the provider and anticipate decreasing the rate
Rationale: Blood glucose should decrease by 50-75 mg/dL per hour in DKA. A
drop of 240 mg/dL in one hour is too rapid and increases risk of cerebral edema.
The rate should be decreased and dextrose added.
Question 5
The nurse is evaluating a client with a new ileostomy. Which finding indicates the
need for further teaching?
A) The client states they will avoid nuts and seeds
B) The client states they will drink 2-3 liters of fluid daily
C) The client states they will take a laxative daily to regulate output
D) The client states they will chew food thoroughly
Correct Answer: C) The client states they will take a laxative daily to regulate
output
Rationale: Routine laxative use is not recommended for ileostomy clients and can
cause dehydration and electrolyte imbalances. Fluid intake, chewing food
thoroughly, and avoiding high-fiber foods are appropriate.
, Question 6
A client with a spinal cord injury develops a severe headache and diaphoresis
above the level of injury. The nurse checks the blood pressure and finds it is
220/110 mm Hg. Which action should the nurse take next?
A) Administer PRN antihypertensive medication
B) Place the client flat and check for bowel impaction
C) Sit the client upright and check the urinary catheter for kinks
D) Notify the provider and prepare for emergency surgery
Correct Answer: C) Sit the client upright and check the urinary catheter for kinks
Rationale: Autonomic dysreflexia requires immediate removal of the triggering
stimulus. Sitting the client upright reduces blood pressure. Checking the catheter
for kinks addresses the most common trigger (bladder distention).
Question 7
The nurse receives handoff report on four clients. Which client should the nurse see
first?
A) Client with acute pancreatitis reporting pain of 6/10
B) Client with liver cirrhosis who is confused and has asterixis
C) Client with a colostomy requesting help with pouch emptying
D) Client with chronic kidney disease awaiting dialysis
Correct Answer: B) Client with liver cirrhosis who is confused and has asterixis
