COMPLETE ALL QUESTIONS AND CORRECT ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
The Chief Operational Officer (COO) interviews a nurse and asks, "Tell me about your practical
experiences in clinical decision making". Which example should the nurse give?
A. I palpated the right hip of the client, which appeared red and noted the warm feeling
B. I identified impaired skin integrity in a pressure ulcer form upon finding redness in the client's hip
C. I quickly offered a salt recipe to a client with a history of hypotension who suffered from light-
headedness and dizziness
D. I assessed weakness and hunger in a patient with a history of diabetes who suffers with light-
headedness and blurred vision - (answer)B.
Clinical decision making is a problem-solving activity that focuses on defining a problem and selecting an
appropriate action. So as a part of clinical decision making, the nurse identified impaired skin integrity in
a pressure ulcer form upon finding redness in the client's hip. Diagnostic reasoning and inference is an
analytical process that involves determining the client's health problems. An example is the nurse
palpating and observing a warm sensation in the client's right hip that has turned red. Another example
is a nurse who finds that a client who has hypotension history now feels light-headedness and dizziness.
A further example is a nurse who assesses symptoms of diabetes in a client who has a history of the
disease and now suffers blurred vision.
A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The
common client response the nurse expects to identify during this phase of burn recovery is an increase
in what?
A. Serum Sodium
B. Urinary output
C. Hematocrit Level
D. Serum Potassium - (answer)B.
As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum
sodium level (hypernatremia) is not a common response identified during the second (acute) phase of
burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the
second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn
recovery, potassium moves back into the cells, decreasing serum potassium.