Med-Surg Exam 1 ch 1,2,3,15,16,17
The nurse is caring for a group of patients on a medical-
surgical unit. The licensed practical nurse/licensed vocational
nurse (LPN/LVN) assesses the patient experiencing a low
blood glucose first. Which process was needed to make this
decision? - ANS-Application of clinical judgment
The LPN/LVN enters the room of a patient who is angry and yells, "I asked 5 minutes ago for my
pain medication. You're so worthless!" Which action by the nurse demonstrates intellectual
integrity? - ANS-Refusing to share details of the interaction with colleagues
The nurse is collecting data on a patient. Which data is considered cues? - ANS-Respiratory
rate of 26 per minute
Which items are a part of "generate solutions" when using the clinical judgment process? -
ANS-Reposition the patient.
The nurse is prioritizing care based on Maslow's hierarchy of needs. Which need does the nurse
identify as having the highest priority? - ANS-Poor sleep habits
The nurse is using the clinical judgment process to provide care to a patient experiencing
nausea.
During the process of generating solutions, the patient begins to vomit. What should the nurse
do
next? - ANS-Identify and analyze the new cues presented.
While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes
serosanguineous
drainage on the dressing. Which phase of clinical judgment does this represent? - ANS-Identify
cues
The nurse is caring for a patient using the nursing process. Which step should the nurse take
first? - ANS-Assessment
The nurse hears the patient groan when getting out of bed and asks if there is pain, using a pain
scale. This describes which step of the clinical judgment process? - ANS-Identify and analyze
cues
The nurse is evaluating outcomes for a patient with difficult breathing from asthma. Which
, determines a positive outcome after the delivery of medication? - ANS-The patient can walk to
the restroom without reporting shortness of breath.
The nurse is speaking with a patient about a new medication. The patient asks the nurse a
question
that the nurse cannot answer confidently, and the nurse says, "I'm not sure, but I'll find out for
you." What is the nurse practicing? - ANS-Intellectual humility
The nurse is evaluating outcomes for a patient who is dehydrated. Which outcome should the
nurse
use to guide this patient's care? - ANS-The patient's intake is 3,000 mL daily.
Which statement is a part of the CUS acronym? - ANS-I am concerned!
Why are only 23% of new nurses practice-ready upon graduation from nursing school? -
ANS-They are unable to recognize a change in a patient's condition.
Which factors lead to failure to rescue events? - ANS-Poor staffing
Which critical thinking trait is demonstrated when the LPN/LVN is unsure of how to perform a
dressing change and asks the RN for assistance? - ANS-Intellectual humility
Which action should the nurse take after identifying and analyzing cues in a clinical situation? -
ANS-Prioritize hypotheses
The LPN/LVN asks a patient who received 2 mg of morphine IV 30 minutes ago to rate their
pain.
Which step of the clinical judgment process is the nurse using? - ANS-Identify and analyze
cues
The LPN/LVN is assisting the RN in generating solutions for a patient. Which is an example of a
collaborative action? - ANS-Requesting a dietitian consultation
What is the purpose of clinical judgment? - ANS-It determines what the nurse does after
thinking about a problem.
A nurse notes that a patient's blood glucose is low and properly treats the symptoms. The nurse
continues to monitor for symptoms of low blood glucose throughout the remainder of the shift.
What is the nurse practicing by this action? - ANS-Vigilance
The LPN/LVN is caring for a patient who begins to exhibit shortness of breath and chest pain.
Which action should the nurse take after notifying the RN? - ANS-Identify and analyze
additional cues
The nurse is caring for a group of patients on a medical-
surgical unit. The licensed practical nurse/licensed vocational
nurse (LPN/LVN) assesses the patient experiencing a low
blood glucose first. Which process was needed to make this
decision? - ANS-Application of clinical judgment
The LPN/LVN enters the room of a patient who is angry and yells, "I asked 5 minutes ago for my
pain medication. You're so worthless!" Which action by the nurse demonstrates intellectual
integrity? - ANS-Refusing to share details of the interaction with colleagues
The nurse is collecting data on a patient. Which data is considered cues? - ANS-Respiratory
rate of 26 per minute
Which items are a part of "generate solutions" when using the clinical judgment process? -
ANS-Reposition the patient.
The nurse is prioritizing care based on Maslow's hierarchy of needs. Which need does the nurse
identify as having the highest priority? - ANS-Poor sleep habits
The nurse is using the clinical judgment process to provide care to a patient experiencing
nausea.
During the process of generating solutions, the patient begins to vomit. What should the nurse
do
next? - ANS-Identify and analyze the new cues presented.
While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes
serosanguineous
drainage on the dressing. Which phase of clinical judgment does this represent? - ANS-Identify
cues
The nurse is caring for a patient using the nursing process. Which step should the nurse take
first? - ANS-Assessment
The nurse hears the patient groan when getting out of bed and asks if there is pain, using a pain
scale. This describes which step of the clinical judgment process? - ANS-Identify and analyze
cues
The nurse is evaluating outcomes for a patient with difficult breathing from asthma. Which
, determines a positive outcome after the delivery of medication? - ANS-The patient can walk to
the restroom without reporting shortness of breath.
The nurse is speaking with a patient about a new medication. The patient asks the nurse a
question
that the nurse cannot answer confidently, and the nurse says, "I'm not sure, but I'll find out for
you." What is the nurse practicing? - ANS-Intellectual humility
The nurse is evaluating outcomes for a patient who is dehydrated. Which outcome should the
nurse
use to guide this patient's care? - ANS-The patient's intake is 3,000 mL daily.
Which statement is a part of the CUS acronym? - ANS-I am concerned!
Why are only 23% of new nurses practice-ready upon graduation from nursing school? -
ANS-They are unable to recognize a change in a patient's condition.
Which factors lead to failure to rescue events? - ANS-Poor staffing
Which critical thinking trait is demonstrated when the LPN/LVN is unsure of how to perform a
dressing change and asks the RN for assistance? - ANS-Intellectual humility
Which action should the nurse take after identifying and analyzing cues in a clinical situation? -
ANS-Prioritize hypotheses
The LPN/LVN asks a patient who received 2 mg of morphine IV 30 minutes ago to rate their
pain.
Which step of the clinical judgment process is the nurse using? - ANS-Identify and analyze
cues
The LPN/LVN is assisting the RN in generating solutions for a patient. Which is an example of a
collaborative action? - ANS-Requesting a dietitian consultation
What is the purpose of clinical judgment? - ANS-It determines what the nurse does after
thinking about a problem.
A nurse notes that a patient's blood glucose is low and properly treats the symptoms. The nurse
continues to monitor for symptoms of low blood glucose throughout the remainder of the shift.
What is the nurse practicing by this action? - ANS-Vigilance
The LPN/LVN is caring for a patient who begins to exhibit shortness of breath and chest pain.
Which action should the nurse take after notifying the RN? - ANS-Identify and analyze
additional cues
