Patient-Centered Nursing Q&A: Clinical
Decision-Making and Safety Essential
A nurse is assisting with the care of four clients. Which of the following clients is the priority for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 130 over 4hrs
- A client who has a permanent pacemaker with heart rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4 - ✔✔- A client who has chest tubes and an oxygen Sat
of 90%
Using the airway, breathing, and circulation approach to client care, the nurse should determine that the
priority finding is the client's oxygen saturation level, which is below the expected reference range of
95% to 100%. Therefore, the nurse should attend to this client first.
A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3. Which
of the following findings should the nurse expect?
- Vacalizes sound
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands - ✔✔Nonresponsive Commands
A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose state. The
GCS is a standardized tool that allows for the evaluation of a client's level of consciousness. The test is
divided into three sections that evaluate eye opening, motor response, and verbal response. The GCS
ranges from a high score of 15 (fully alert) to a low score of 3 (fully comatose).
,A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a closed chest
drainage system connected to low suction. For which of the following findings should the nurse notify
the charge nurse
- Fluctation of the water level in the water seal chamber
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber - ✔✔- Persistent bubbling in the water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the drainage system.
The nurse should notify the charge nurse of this finding.
A nurse is reinforcing teaching with a male client who has right sided hemiparesis about
preforming ADL's. Which of the following instructions should the nurse include in the teaching
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side - ✔✔Comb your hair with the unaffected arm
The nurse should instruct the client to brush their hair with the unaffected arm to reduce frustration and
increase independence and self-esteem.
A nurse is collecting data from a client and auscultates intermittent high-pitched sounds during
inspiration over the lower base of the lungs. The nurse should identify this finding as which of the
following lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction - ✔✔- Fine crackles
, Fine crackles are auscultated in the base of the lungs as air moves through airway secretions. Fine
crackles are intermittent, high-pitched sounds heard more often during inspiration.
A nurse is collecting data from a client who has coronary artery disease. Which of the following
manifestations should the nurse identify as an indication that the client has angina ( SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with rest - ✔✔- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with res
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
should the nurse plan to see first?
- A client who has diabetes mellitus with diaphoretic - ✔✔A client who has diabetes mellitus with
diaphoretic
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority action is to attend to a client who has diabetes mellitus and is diaphoretic. Diaphoresis is a
manifestation of hypoglycemia and can lead to decreased cerebral function. The nurse should check the
client's blood glucose and administer a fast-acting glucose as prescribed.
A nurse is collecting data from a client who has tuberculosis and started combination therapy
2months ago. Which of the following diagnostic results indicates that the client is adhering to the
medication regimen.
- A negative chest X-ray
- A negative sputum culture
-A negative tuberculin skin test
-A negative titer for cytomegalovirus - ✔✔A negative sputum culture
Tuberculosis is an infectious disease spread through airborne droplets. Sputum cultures are obtained to
both diagnose tuberculosis and to determine whether the medication treatment has been effective.
Decision-Making and Safety Essential
A nurse is assisting with the care of four clients. Which of the following clients is the priority for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 130 over 4hrs
- A client who has a permanent pacemaker with heart rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4 - ✔✔- A client who has chest tubes and an oxygen Sat
of 90%
Using the airway, breathing, and circulation approach to client care, the nurse should determine that the
priority finding is the client's oxygen saturation level, which is below the expected reference range of
95% to 100%. Therefore, the nurse should attend to this client first.
A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3. Which
of the following findings should the nurse expect?
- Vacalizes sound
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands - ✔✔Nonresponsive Commands
A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose state. The
GCS is a standardized tool that allows for the evaluation of a client's level of consciousness. The test is
divided into three sections that evaluate eye opening, motor response, and verbal response. The GCS
ranges from a high score of 15 (fully alert) to a low score of 3 (fully comatose).
,A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a closed chest
drainage system connected to low suction. For which of the following findings should the nurse notify
the charge nurse
- Fluctation of the water level in the water seal chamber
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber - ✔✔- Persistent bubbling in the water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the drainage system.
The nurse should notify the charge nurse of this finding.
A nurse is reinforcing teaching with a male client who has right sided hemiparesis about
preforming ADL's. Which of the following instructions should the nurse include in the teaching
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side - ✔✔Comb your hair with the unaffected arm
The nurse should instruct the client to brush their hair with the unaffected arm to reduce frustration and
increase independence and self-esteem.
A nurse is collecting data from a client and auscultates intermittent high-pitched sounds during
inspiration over the lower base of the lungs. The nurse should identify this finding as which of the
following lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction - ✔✔- Fine crackles
, Fine crackles are auscultated in the base of the lungs as air moves through airway secretions. Fine
crackles are intermittent, high-pitched sounds heard more often during inspiration.
A nurse is collecting data from a client who has coronary artery disease. Which of the following
manifestations should the nurse identify as an indication that the client has angina ( SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with rest - ✔✔- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with res
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
should the nurse plan to see first?
- A client who has diabetes mellitus with diaphoretic - ✔✔A client who has diabetes mellitus with
diaphoretic
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority action is to attend to a client who has diabetes mellitus and is diaphoretic. Diaphoresis is a
manifestation of hypoglycemia and can lead to decreased cerebral function. The nurse should check the
client's blood glucose and administer a fast-acting glucose as prescribed.
A nurse is collecting data from a client who has tuberculosis and started combination therapy
2months ago. Which of the following diagnostic results indicates that the client is adhering to the
medication regimen.
- A negative chest X-ray
- A negative sputum culture
-A negative tuberculin skin test
-A negative titer for cytomegalovirus - ✔✔A negative sputum culture
Tuberculosis is an infectious disease spread through airborne droplets. Sputum cultures are obtained to
both diagnose tuberculosis and to determine whether the medication treatment has been effective.
