Critical Thinking/Clinical
Reasoning/Clinical Judgment: Rapid
Response/Clinical Emergencies
Questions and Answers.
A nurse in a rehabilitation facility is performing the role of a case manager for a group of clients.
Which of the following actions should the nurse take? - Answer Ensure clients receive
optimal care in a cost-effective manner.
The responsibility of the case manager is to ensure clients receive optimal care in a cost-
effective manner. A nurse often fulfills the role of case manager.
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
should the nurse attend to first? - Answer client who has received nitroglycerin sublingual
for chest pain and requires a 12-lead EKG
first action the nurse should take when using the airway, breathing, circulation approach to
client care is to obtain a 12-lead EKG for the client who is experiencing chest pain
A nurse is planning care for four clients. Which of the following tasks should the nurse delegate
to a licensed practical nurse (LPN)? - Answer perform a wet-to-dry dressing change for a
client who has a pressure ulcer.
A nurse is planning care for a client who is experiencing residual effects from an ischemic stroke.
The nurse should request a consultation with which of the following members of the
interprofessional care team first? - Answer Speech therapist
A nurse is managing the care for a client who has recent unexplained weight loss and a low
serum albumin level. Which of the following members of the interprofessional care team should
the nurse consult? - Answer registered dietitian
nurse should consult a registered dietitian who will design a therapeutic diet, which will provide
the client with needed nutrition to correct weight and protein loss
, A nurse is providing a transfer report to an inpatient rehabilitation facility for a client who has
atrial fibrillation. Which of the following pieces of information is the priority for the nurse to
include in the report? - Answer "Today's INR is 2.0."
The greatest risk to this client is injury from bleeding, due to an increased INR as a result of
receiving anticoagulant therapy for atrial fibrillation; therefore, this is the priority piece of
information the nurse should include in the transfer report.
A nurse is speaking with the provider about a client who has had a change in mental status since
admission. Which of the following statements by the nurse demonstrates the use of assertive
communication? - Answer "I am concerned about the client's rapid change in mental status."
This statement by the nurse is demonstrating the use of an "I" statement, which is a form of
assertive communication. The use of the "I" statement by the nurse encourages discussion
about the client with the provider and emphasizes the importance of working together for the
benefit of the client.
A nurse is teaching a newly licensed nurse about telephone reporting using the SBAR acronym.
Which of the following responses by the newly licensed nurse indicates an understanding of the
teaching? - Answer s stands for situation
identify that "S" stands for the "situation" of the client when providing a telephone report using
the SBAR acronym
A nurse is preparing to provide a hand-off report for a group of clients to the oncoming nurse.
Which of the following information should the nurse include in the report? - Answer "Mr.
Jones had pain medication last at 1800."
The nurse should include critical data related to the client's care, such as when the client last
received a PRN pain medication, when providing a hand-off report.
A nurse is providing a hand-off report to another nurse for a client who is newly admitted and
has Crohn's disease. Which of the following information is the priority for the nurse to include in
the report? - Answer Hgb 6.8 g/dL
The greatest risk to this client is injury from bleeding; therefore, this is the priority piece of
information the nurse should include in the hand-off report.
A nurse in a PACU is caring for a client who is postoperative following an abdominal
hysterectomy. Which of the following actions should the nurse take first? - Answer Place the
client in a side-lying position.
Reasoning/Clinical Judgment: Rapid
Response/Clinical Emergencies
Questions and Answers.
A nurse in a rehabilitation facility is performing the role of a case manager for a group of clients.
Which of the following actions should the nurse take? - Answer Ensure clients receive
optimal care in a cost-effective manner.
The responsibility of the case manager is to ensure clients receive optimal care in a cost-
effective manner. A nurse often fulfills the role of case manager.
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
should the nurse attend to first? - Answer client who has received nitroglycerin sublingual
for chest pain and requires a 12-lead EKG
first action the nurse should take when using the airway, breathing, circulation approach to
client care is to obtain a 12-lead EKG for the client who is experiencing chest pain
A nurse is planning care for four clients. Which of the following tasks should the nurse delegate
to a licensed practical nurse (LPN)? - Answer perform a wet-to-dry dressing change for a
client who has a pressure ulcer.
A nurse is planning care for a client who is experiencing residual effects from an ischemic stroke.
The nurse should request a consultation with which of the following members of the
interprofessional care team first? - Answer Speech therapist
A nurse is managing the care for a client who has recent unexplained weight loss and a low
serum albumin level. Which of the following members of the interprofessional care team should
the nurse consult? - Answer registered dietitian
nurse should consult a registered dietitian who will design a therapeutic diet, which will provide
the client with needed nutrition to correct weight and protein loss
, A nurse is providing a transfer report to an inpatient rehabilitation facility for a client who has
atrial fibrillation. Which of the following pieces of information is the priority for the nurse to
include in the report? - Answer "Today's INR is 2.0."
The greatest risk to this client is injury from bleeding, due to an increased INR as a result of
receiving anticoagulant therapy for atrial fibrillation; therefore, this is the priority piece of
information the nurse should include in the transfer report.
A nurse is speaking with the provider about a client who has had a change in mental status since
admission. Which of the following statements by the nurse demonstrates the use of assertive
communication? - Answer "I am concerned about the client's rapid change in mental status."
This statement by the nurse is demonstrating the use of an "I" statement, which is a form of
assertive communication. The use of the "I" statement by the nurse encourages discussion
about the client with the provider and emphasizes the importance of working together for the
benefit of the client.
A nurse is teaching a newly licensed nurse about telephone reporting using the SBAR acronym.
Which of the following responses by the newly licensed nurse indicates an understanding of the
teaching? - Answer s stands for situation
identify that "S" stands for the "situation" of the client when providing a telephone report using
the SBAR acronym
A nurse is preparing to provide a hand-off report for a group of clients to the oncoming nurse.
Which of the following information should the nurse include in the report? - Answer "Mr.
Jones had pain medication last at 1800."
The nurse should include critical data related to the client's care, such as when the client last
received a PRN pain medication, when providing a hand-off report.
A nurse is providing a hand-off report to another nurse for a client who is newly admitted and
has Crohn's disease. Which of the following information is the priority for the nurse to include in
the report? - Answer Hgb 6.8 g/dL
The greatest risk to this client is injury from bleeding; therefore, this is the priority piece of
information the nurse should include in the hand-off report.
A nurse in a PACU is caring for a client who is postoperative following an abdominal
hysterectomy. Which of the following actions should the nurse take first? - Answer Place the
client in a side-lying position.
