,Q1 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A patient receiving continuous heparin infusion has an aPTT of 98 seconds
(therapeutic range 60-80 seconds) and new hematuria. Which action should the
nurse anticipate implementing first?
A. Administer vitamin K 10 mg IV push
B. Stop the heparin infusion and prepare to administer protamine sulfate CORRECT
C. Continue the infusion and recheck aPTT in 4 hours
D. Transfuse fresh frozen plasma and maintain the infusion
RATIONALE: An aPTT of 98 seconds with bleeding indicates supratherapeutic heparin
anticoagulation; the priority is to stop the infusion and administer the antidote protamine sulfate.
Vitamin K reverses warfarin, not heparin; continuing the infusion risks hemorrhage; FFP is not
first-line for heparin reversal.
Q2 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A patient with major depressive disorder is started on sertraline. Which statement
by the patient indicates a need for further teaching?
A. "I should report any worsening mood or suicidal thoughts immediately."
B. "I can stop the medication once I feel better." CORRECT
C. "It may take several weeks before I notice improvement."
D. "I should avoid alcohol while taking this medication."
RATIONALE: SSRIs must be tapered gradually; abrupt discontinuation can cause discontinuation
syndrome and relapse. Reporting worsening mood, understanding delayed onset, and avoiding
alcohol are correct. Option B reflects a common misconception requiring correction.
Page 2
,Q3 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A nurse is evaluating a community health program aimed at reducing
hypertension. Which outcome measure best reflects the program's effectiveness
at the population level?
A. Percentage of participants who attended all education sessions
B. Mean systolic blood pressure reduction among participants at 6 months CORRECT
C. Number of educational pamphlets distributed
D. Participant satisfaction scores with the program
RATIONALE: Population-level effectiveness is best measured by clinical outcomes such as blood
pressure reduction, not process measures like attendance, distribution counts, or satisfaction.
Option B directly reflects improved health status.
Q4 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A patient with type 1 diabetes has a blood glucose of 42 mg/dL and is
unresponsive. After establishing unresponsiveness, which action should the
nurse take next?
A. Administer 15 g oral glucose gel
B. Administer glucagon 1 mg IM CORRECT
C. Start an IV and administer regular insulin
D. Recheck blood glucose in 15 minutes
RATIONALE: For severe hypoglycemia with unresponsiveness, IM glucagon is the immediate
intervention when IV access is unavailable. Oral glucose is unsafe in an unresponsive patient;
insulin would worsen hypoglycemia; rechecking delays treatment.
Page 3
, Q5 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A nurse is caring for a client with a new colostomy. Which finding requires
immediate intervention?
A. Stoma is beefy red and moist
B. Stoma is dusky and cyanotic CORRECT
C. Small amount of serosanguineous drainage on the dressing
D. Client reports passing flatus through the colostomy
RATIONALE: A dusky or cyanotic stoma indicates compromised perfusion and possible necrosis,
requiring immediate evaluation. A beefy red, moist stoma is normal; serosanguineous drainage is
expected initially; passing flatus indicates return of bowel function.
Q6 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A nurse manager is reviewing staffing for the next shift. Which task is appropriate
to delegate to a nursing assistant (UAP)?
A. Administering a PRN analgesic to a postoperative client
B. Reinforcing teaching about a new medication with a client
C. Measuring and recording intake and output for a client with heart failure CORRECT
D. Assessing a client's incision for signs of infection
RATIONALE: Measuring and recording intake/output is a routine, non-invasive task within UAP
scope. Medication administration, teaching, and assessment require a licensed nurse. Delegation
must follow the five rights of delegation and state nurse practice acts.
Page 4
NURSING INTERVENTIONS
A patient receiving continuous heparin infusion has an aPTT of 98 seconds
(therapeutic range 60-80 seconds) and new hematuria. Which action should the
nurse anticipate implementing first?
A. Administer vitamin K 10 mg IV push
B. Stop the heparin infusion and prepare to administer protamine sulfate CORRECT
C. Continue the infusion and recheck aPTT in 4 hours
D. Transfuse fresh frozen plasma and maintain the infusion
RATIONALE: An aPTT of 98 seconds with bleeding indicates supratherapeutic heparin
anticoagulation; the priority is to stop the infusion and administer the antidote protamine sulfate.
Vitamin K reverses warfarin, not heparin; continuing the infusion risks hemorrhage; FFP is not
first-line for heparin reversal.
Q2 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A patient with major depressive disorder is started on sertraline. Which statement
by the patient indicates a need for further teaching?
A. "I should report any worsening mood or suicidal thoughts immediately."
B. "I can stop the medication once I feel better." CORRECT
C. "It may take several weeks before I notice improvement."
D. "I should avoid alcohol while taking this medication."
RATIONALE: SSRIs must be tapered gradually; abrupt discontinuation can cause discontinuation
syndrome and relapse. Reporting worsening mood, understanding delayed onset, and avoiding
alcohol are correct. Option B reflects a common misconception requiring correction.
Page 2
,Q3 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A nurse is evaluating a community health program aimed at reducing
hypertension. Which outcome measure best reflects the program's effectiveness
at the population level?
A. Percentage of participants who attended all education sessions
B. Mean systolic blood pressure reduction among participants at 6 months CORRECT
C. Number of educational pamphlets distributed
D. Participant satisfaction scores with the program
RATIONALE: Population-level effectiveness is best measured by clinical outcomes such as blood
pressure reduction, not process measures like attendance, distribution counts, or satisfaction.
Option B directly reflects improved health status.
Q4 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A patient with type 1 diabetes has a blood glucose of 42 mg/dL and is
unresponsive. After establishing unresponsiveness, which action should the
nurse take next?
A. Administer 15 g oral glucose gel
B. Administer glucagon 1 mg IM CORRECT
C. Start an IV and administer regular insulin
D. Recheck blood glucose in 15 minutes
RATIONALE: For severe hypoglycemia with unresponsiveness, IM glucagon is the immediate
intervention when IV access is unavailable. Oral glucose is unsafe in an unresponsive patient;
insulin would worsen hypoglycemia; rechecking delays treatment.
Page 3
, Q5 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A nurse is caring for a client with a new colostomy. Which finding requires
immediate intervention?
A. Stoma is beefy red and moist
B. Stoma is dusky and cyanotic CORRECT
C. Small amount of serosanguineous drainage on the dressing
D. Client reports passing flatus through the colostomy
RATIONALE: A dusky or cyanotic stoma indicates compromised perfusion and possible necrosis,
requiring immediate evaluation. A beefy red, moist stoma is normal; serosanguineous drainage is
expected initially; passing flatus indicates return of bowel function.
Q6 APPLY THE CLINICAL JUDGMENT MODEL TO PRIORITIZE SAFE, EVIDENCE-BASED
NURSING INTERVENTIONS
A nurse manager is reviewing staffing for the next shift. Which task is appropriate
to delegate to a nursing assistant (UAP)?
A. Administering a PRN analgesic to a postoperative client
B. Reinforcing teaching about a new medication with a client
C. Measuring and recording intake and output for a client with heart failure CORRECT
D. Assessing a client's incision for signs of infection
RATIONALE: Measuring and recording intake/output is a routine, non-invasive task within UAP
scope. Medication administration, teaching, and assessment require a licensed nurse. Delegation
must follow the five rights of delegation and state nurse practice acts.
Page 4
