NSG 3130 Nursing Concepts & Clinical Judgment Exam
Verified Questions & Answers | Galen College of Nursing
Question 1: A nurse is caring for a client with a history of heart failure who presents with acute
shortness of breath, bilateral crackles on auscultation, and an oxygen saturation of 88% on room air.
Which nursing action represents the priority clinical judgment decision using Maslow's Hierarchy of
Needs?
A. Administer a prescribed oral loop diuretic.
B. Place the client in High-Fowler’s position and apply supplemental oxygen.
C. Obtain a STAT chest X-ray and 12-lead ECG.
D. Educate the client on fluid restriction and daily weight monitoring.
CORRECT ANSWER: B. Place the client in High-Fowler’s position and apply supplemental oxygen.
Rationale: Applying the ABC (Airway, Breathing, Circulation) framework and Maslow's Hierarchy of
Needs, physiological oxygenation is the immediate priority. High-Fowler’s position decreases venous
return to the heart and expands chest volume, while supplemental oxygen rapidly addresses acute
hypoxemia before diagnostic or pharmacological interventions are carried out.
Question 2: According to Tanner’s Clinical Judgment Model, which cognitive process is the nurse
primarily engaged in when systematically gathering baseline vital signs, reviewing laboratory findings,
and reviewing the client's medical history upon admission?
A. Interpreting
B. Responding
C. Noticing
D. Reflecting-in-action
CORRECT ANSWER: C. Noticing
Rationale: Noticing is the initial step in Tanner’s Clinical Judgment Model. It involves collecting
comprehensive data, recognizing patterns, and identifying clinical cues that deviate from normal
parameters based on the nurse's background and expectations.
Question 3: A nurse evaluates a client's arterial blood gas (ABG) results: pH 7.28, PaCO2 52 mmHg, and
HCO3 24 mEq/L. Which acid-base imbalance does the nurse correctly interpret from these findings?
A. Uncompensated Metabolic Acidosis
,B. Uncompensated Respiratory Acidosis
C. Fully Compensated Respiratory Acidosis
D. Uncompensated Respiratory Alkalosis
CORRECT ANSWER: B. Uncompensated Respiratory Acidosis
Rationale: The pH (7.28) is below the normal range (7.35–7.45), indicating acidosis. The PaCO2 (52
mmHg) is above the normal range (35–45 mmHg), indicating a respiratory cause. The HCO3 (24 mEq/L) is
within normal limits (22–26 mEq/L), showing that renal compensation has not yet occurred. Therefore,
this represents uncompensated respiratory acidosis.
Question 4: A nurse is assessing a postoperative client who had an abdominal hysterectomy 12 hours
ago. The client reports severe lower abdominal pain rated 9 out of 10. Upon inspection, the nurse
notes that the surgical dressing is saturated with bright red blood. Which priority intervention
demonstrates sound nursing judgment?
A. Remove the saturated dressing immediately to inspect the incision line.
B. Reinforce the dressing with sterile gauze, assess vital signs, and notify the surgeon immediately.
C. Administer the prescribed IV push opioid analgesic and reassess in 30 minutes.
D. Document the finding as expected blood loss within the first 24 hours post-surgery.
CORRECT ANSWER: B. Reinforce the dressing with sterile gauze, assess vital signs, and notify the
surgeon immediately.
Rationale: Saturated bright red blood within 12 hours post-surgery indicates active hemorrhage, a clinical
emergency. Removing the initial dressing can disrupt clot formation. Reinforcing the dressing maintains
pressure while immediate hemodynamic assessment (vital signs) and surgeon notification are required
to address hemorrhage.
Question 5: A client with chronic kidney disease presents with a serum potassium level of 6.3 mEq/L.
The electrocardiogram (ECG) monitor displays tall, peaked T waves. Which order should the nurse
implement first?
A. Administer oral sodium polystyrene sulfonate (Kayexalate).
B. Administer IV Calcium Gluconate.
C. Obtain a repeat serum potassium draw.
D. Restrict dietary potassium intake.
CORRECT ANSWER: B. Administer IV Calcium Gluconate.
,Rationale: While sodium polystyrene sulfonate removes potassium from the body, IV Calcium Gluconate
acts immediately to stabilize the cardiac myocyte membrane, protecting the heart against life-
threatening dysrhythmias caused by severe hyperkalemia. Calcium gluconate is always the emergency
priority when ECG changes are present.
Question 6: The nurse is preparing to administer medications to four clients. Which client should the
nurse assess first using the safety and risk reduction priority principle?
A. A client receiving continuous enteral tube feedings who complains of nausea and abdominal
distension.
B. A client with diabetes mellitus requesting a bedtime snack whose blood glucose is 140 mg/dL.
C. A client post-appendectomy requesting pain medication prior to physical therapy.
D. A client with hypertension whose blood pressure is 138/84 mmHg.
CORRECT ANSWER: A. A client receiving continuous enteral tube feedings who complains of nausea
and abdominal distension.
Rationale: Nausea and abdominal distension during continuous tube feeding indicate gastric retention
and high risk for aspiration pneumonia, an immediate airway and safety hazard. The nurse must stop the
feed and assess residual volume to prevent aspiration.
Question 7: A client with type 1 diabetes mellitus is found confused, diaphoresis-soaked, and pale. The
bedside blood glucose meter reads 42 mg/dL. The client is awake but oriented only to person. Which
intervention is the most appropriate initial nursing response?
A. Administer 1 mg of IM Glucagon immediately.
B. Provide 15 grams of fast-acting oral carbohydrates such as 4 oz of fruit juice.
C. Administer 10 units of regular insulin subcutaneously.
D. Start an IV infusion of 0.9% Normal Saline at 125 mL/hr.
CORRECT ANSWER: B. Provide 15 grams of fast-acting oral carbohydrates such as 4 oz of fruit juice.
Rationale: Follow the "Rule of 15" for conscious hypoglycemia. Since the client is conscious and able to
swallow safely, 15 grams of simple fast-acting carbohydrates orally is the effective and least invasive
immediate treatment. IM Glucagon is reserved for unconscious clients or those unable to swallow safely.
Question 8: A nurse receives report on four clients in the medical-surgical unit. Which client requires
the nurse's immediate evaluation?
A. A client with COPD whose SpO2 is 90% on 2 L/min oxygen via nasal cannula.
B. A client 1 day post-op total hip replacement reporting surgical site pain rated 5/10.
, C. A client admitted with asthma who suddenly presents with a silent chest on auscultation and
decreased breath sounds.
D. A client with pneumonia who has a temperature of 101.2°F (38.4°C) and productive cough.
CORRECT ANSWER: C. A client admitted with asthma who suddenly presents with a silent chest on
auscultation and decreased breath sounds.
Rationale: A "silent chest" in an acute asthma client indicates complete airway constriction and absence
of airflow, signaling impending respiratory failure and cardiac arrest. This is a life-threatening airway
emergency overriding non-urgent pain, stable low SpO2 typical for COPD, or fever.
Question 9: A client is prescribed intravenous vancomycin 1g every 12 hours. Which laboratory
assessment parameter must the nurse review prior to administering the second dose to prevent organ
toxicity?
A. Serum Alanine Aminotransferase (ALT)
B. Serum Trough level and Creatinine
C. Prothrombin Time (PT/INR)
D. Serum Potassium and Magnesium
CORRECT ANSWER: B. Serum Trough level and Creatinine
Rationale: Vancomycin is nephrotoxic and ototoxic. Checking therapeutic trough levels ensures drug
efficacy without toxicity, and monitoring serum creatinine ensures proper renal clearance and detects
nephrotoxicity early.
Question 10: Which clinical situation demonstrates the nurse engaging in "Reflection-in-Action" within
Tanner’s Clinical Judgment framework?
A. The nurse discusses a complex patient care case with a supervisor after completing a shift.
B. The nurse notices an altered heart rhythm on a telemetry monitor and immediately reassesses the
client's radial pulse and blood pressure.
C. The nurse completes a journal entry describing a clinical mistake made during a dressing change.
D. The nurse attends an in-service educational session on new IV pump equipment.
CORRECT ANSWER: B. The nurse notices an altered heart rhythm on a telemetry monitor and
immediately reassesses the client's radial pulse and blood pressure.
Rationale: Reflection-in-action occurs during the care situation. It involves evaluating client responses
real-time, reassessing the clinical picture as changes occur, and modifying intervention strategy on the
spot. Discussing cases after the shift or writing in a journal represents reflection-about-action.
Verified Questions & Answers | Galen College of Nursing
Question 1: A nurse is caring for a client with a history of heart failure who presents with acute
shortness of breath, bilateral crackles on auscultation, and an oxygen saturation of 88% on room air.
Which nursing action represents the priority clinical judgment decision using Maslow's Hierarchy of
Needs?
A. Administer a prescribed oral loop diuretic.
B. Place the client in High-Fowler’s position and apply supplemental oxygen.
C. Obtain a STAT chest X-ray and 12-lead ECG.
D. Educate the client on fluid restriction and daily weight monitoring.
CORRECT ANSWER: B. Place the client in High-Fowler’s position and apply supplemental oxygen.
Rationale: Applying the ABC (Airway, Breathing, Circulation) framework and Maslow's Hierarchy of
Needs, physiological oxygenation is the immediate priority. High-Fowler’s position decreases venous
return to the heart and expands chest volume, while supplemental oxygen rapidly addresses acute
hypoxemia before diagnostic or pharmacological interventions are carried out.
Question 2: According to Tanner’s Clinical Judgment Model, which cognitive process is the nurse
primarily engaged in when systematically gathering baseline vital signs, reviewing laboratory findings,
and reviewing the client's medical history upon admission?
A. Interpreting
B. Responding
C. Noticing
D. Reflecting-in-action
CORRECT ANSWER: C. Noticing
Rationale: Noticing is the initial step in Tanner’s Clinical Judgment Model. It involves collecting
comprehensive data, recognizing patterns, and identifying clinical cues that deviate from normal
parameters based on the nurse's background and expectations.
Question 3: A nurse evaluates a client's arterial blood gas (ABG) results: pH 7.28, PaCO2 52 mmHg, and
HCO3 24 mEq/L. Which acid-base imbalance does the nurse correctly interpret from these findings?
A. Uncompensated Metabolic Acidosis
,B. Uncompensated Respiratory Acidosis
C. Fully Compensated Respiratory Acidosis
D. Uncompensated Respiratory Alkalosis
CORRECT ANSWER: B. Uncompensated Respiratory Acidosis
Rationale: The pH (7.28) is below the normal range (7.35–7.45), indicating acidosis. The PaCO2 (52
mmHg) is above the normal range (35–45 mmHg), indicating a respiratory cause. The HCO3 (24 mEq/L) is
within normal limits (22–26 mEq/L), showing that renal compensation has not yet occurred. Therefore,
this represents uncompensated respiratory acidosis.
Question 4: A nurse is assessing a postoperative client who had an abdominal hysterectomy 12 hours
ago. The client reports severe lower abdominal pain rated 9 out of 10. Upon inspection, the nurse
notes that the surgical dressing is saturated with bright red blood. Which priority intervention
demonstrates sound nursing judgment?
A. Remove the saturated dressing immediately to inspect the incision line.
B. Reinforce the dressing with sterile gauze, assess vital signs, and notify the surgeon immediately.
C. Administer the prescribed IV push opioid analgesic and reassess in 30 minutes.
D. Document the finding as expected blood loss within the first 24 hours post-surgery.
CORRECT ANSWER: B. Reinforce the dressing with sterile gauze, assess vital signs, and notify the
surgeon immediately.
Rationale: Saturated bright red blood within 12 hours post-surgery indicates active hemorrhage, a clinical
emergency. Removing the initial dressing can disrupt clot formation. Reinforcing the dressing maintains
pressure while immediate hemodynamic assessment (vital signs) and surgeon notification are required
to address hemorrhage.
Question 5: A client with chronic kidney disease presents with a serum potassium level of 6.3 mEq/L.
The electrocardiogram (ECG) monitor displays tall, peaked T waves. Which order should the nurse
implement first?
A. Administer oral sodium polystyrene sulfonate (Kayexalate).
B. Administer IV Calcium Gluconate.
C. Obtain a repeat serum potassium draw.
D. Restrict dietary potassium intake.
CORRECT ANSWER: B. Administer IV Calcium Gluconate.
,Rationale: While sodium polystyrene sulfonate removes potassium from the body, IV Calcium Gluconate
acts immediately to stabilize the cardiac myocyte membrane, protecting the heart against life-
threatening dysrhythmias caused by severe hyperkalemia. Calcium gluconate is always the emergency
priority when ECG changes are present.
Question 6: The nurse is preparing to administer medications to four clients. Which client should the
nurse assess first using the safety and risk reduction priority principle?
A. A client receiving continuous enteral tube feedings who complains of nausea and abdominal
distension.
B. A client with diabetes mellitus requesting a bedtime snack whose blood glucose is 140 mg/dL.
C. A client post-appendectomy requesting pain medication prior to physical therapy.
D. A client with hypertension whose blood pressure is 138/84 mmHg.
CORRECT ANSWER: A. A client receiving continuous enteral tube feedings who complains of nausea
and abdominal distension.
Rationale: Nausea and abdominal distension during continuous tube feeding indicate gastric retention
and high risk for aspiration pneumonia, an immediate airway and safety hazard. The nurse must stop the
feed and assess residual volume to prevent aspiration.
Question 7: A client with type 1 diabetes mellitus is found confused, diaphoresis-soaked, and pale. The
bedside blood glucose meter reads 42 mg/dL. The client is awake but oriented only to person. Which
intervention is the most appropriate initial nursing response?
A. Administer 1 mg of IM Glucagon immediately.
B. Provide 15 grams of fast-acting oral carbohydrates such as 4 oz of fruit juice.
C. Administer 10 units of regular insulin subcutaneously.
D. Start an IV infusion of 0.9% Normal Saline at 125 mL/hr.
CORRECT ANSWER: B. Provide 15 grams of fast-acting oral carbohydrates such as 4 oz of fruit juice.
Rationale: Follow the "Rule of 15" for conscious hypoglycemia. Since the client is conscious and able to
swallow safely, 15 grams of simple fast-acting carbohydrates orally is the effective and least invasive
immediate treatment. IM Glucagon is reserved for unconscious clients or those unable to swallow safely.
Question 8: A nurse receives report on four clients in the medical-surgical unit. Which client requires
the nurse's immediate evaluation?
A. A client with COPD whose SpO2 is 90% on 2 L/min oxygen via nasal cannula.
B. A client 1 day post-op total hip replacement reporting surgical site pain rated 5/10.
, C. A client admitted with asthma who suddenly presents with a silent chest on auscultation and
decreased breath sounds.
D. A client with pneumonia who has a temperature of 101.2°F (38.4°C) and productive cough.
CORRECT ANSWER: C. A client admitted with asthma who suddenly presents with a silent chest on
auscultation and decreased breath sounds.
Rationale: A "silent chest" in an acute asthma client indicates complete airway constriction and absence
of airflow, signaling impending respiratory failure and cardiac arrest. This is a life-threatening airway
emergency overriding non-urgent pain, stable low SpO2 typical for COPD, or fever.
Question 9: A client is prescribed intravenous vancomycin 1g every 12 hours. Which laboratory
assessment parameter must the nurse review prior to administering the second dose to prevent organ
toxicity?
A. Serum Alanine Aminotransferase (ALT)
B. Serum Trough level and Creatinine
C. Prothrombin Time (PT/INR)
D. Serum Potassium and Magnesium
CORRECT ANSWER: B. Serum Trough level and Creatinine
Rationale: Vancomycin is nephrotoxic and ototoxic. Checking therapeutic trough levels ensures drug
efficacy without toxicity, and monitoring serum creatinine ensures proper renal clearance and detects
nephrotoxicity early.
Question 10: Which clinical situation demonstrates the nurse engaging in "Reflection-in-Action" within
Tanner’s Clinical Judgment framework?
A. The nurse discusses a complex patient care case with a supervisor after completing a shift.
B. The nurse notices an altered heart rhythm on a telemetry monitor and immediately reassesses the
client's radial pulse and blood pressure.
C. The nurse completes a journal entry describing a clinical mistake made during a dressing change.
D. The nurse attends an in-service educational session on new IV pump equipment.
CORRECT ANSWER: B. The nurse notices an altered heart rhythm on a telemetry monitor and
immediately reassesses the client's radial pulse and blood pressure.
Rationale: Reflection-in-action occurs during the care situation. It involves evaluating client responses
real-time, reassessing the clinical picture as changes occur, and modifying intervention strategy on the
spot. Discussing cases after the shift or writing in a journal represents reflection-about-action.
