Critical Thinking Nursing QUESTIONS AND ANSWERS 100 VERIFIED A GUARANTEED
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Course
Nursing
Institution
Nursing
Critical Thinking Nursing QUESTIONS AND ANSWERS 100% VERIFIED A+ GUARANTEED
The nurse prioritizes care for a client with diabetes mellitus using Maslow's hierarchy of needs. Which need is identified as the priority for this client?
A.
The nurse teaches the client proper home safety techn...
1). The nurse prioritizes care for a client with diabetes mellitus using maslow's hierarchy of
needs. which need is identified as the priority for this client?
a.
the nurse teaches the client proper home safety techniques to prevent diabetic wounds.
b.
the nurse teaches the client how to properly change dressings on the right-leg amputation
site.
c.
the client attends classes to deal with body image after amputation of the right leg.
d.
the client joins the local american diabetes association support group.
Ans: B
Rationale: When prioritizing care based on Maslow's hierarchy of needs, physiological
needs will come before safety, social, and esteem needs. Caring for an amputation site
is meeting a physiological need. Attending a class to deal with body-image issues
addresses an esteem need. Teaching the client about safety techniques to prevent
diabetic wounds addresses a safety need. Joining a support group meets an esteem
need.
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, 2). Which client should the nurse assess first after receiving the change-of-shift report?
a.
a client with hypertension with a blood pressure of 168/88 mmhg
b.
a client with a bowel obstruction who is complaining of nausea
c.
a client with heart failure who is complaining of shortness of breath
d.
a client with type 1 diabetes mellitus with blood glucose of 82 mg/dl
Ans: C
Rationale: Using the ABCs (airway, breathing, and circulation) as a guide, the nurse
should first assess the client with shortness of breath. This would take priority over a
client complaining of nausea, a client with an elevated (but not critically elevated) blood
pressure, and a client with a normal blood glucose reading.
3). The nurse is assessing a client's peripheral circulation after cardiac catheterization. which
finding is the highest priority?
a.
the femoral site is soft and free of hematoma or bleeding.
b.
the client's toes are warm and pink.
c.
the client is experiencing numbness in the toes.
d.
pulses are palpable and bounding.
Ans: C
Rationale: After cardiac catheterization, a finding that the client is experiencing
numbness may indicate a complication of the procedure, thus it would be the highest
priority. Warm and pink toes, palpable, bounding pulses, and a femoral site free of
hematoma and bleeding are all normal findings.
4). A client is admitted to the emergency department with a rash on the trunk and extremities.
the client reports difficulty breathing, chest tightness, and weakness. respirations are 24
breaths/min and even, pulse is 90 beats/min and thready, and blood pressure is 96/70
mmhg. the client reports a recent history of a urinary tract infection and having been on
sulfasalazine for the past 5 days. which is the priority nursing assessment for this client?
a.
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, urine discoloration
b.
gastrointestinal disturbances
c.
airway patency
d.
peripheral edema
Ans: C
Rationale: Using the ABCs (airway, breathing, and circulation) to establish priority nursing
interventions, the nurse would first establish airway patency based on the client's
symptoms of difficulty breathing. This would take priority over assessment for edema,
urine discoloration, and gastrointestinal disturbances.
5). The medical surgical nurse is planning the day immediately after receiving report. which
should be the primary nursing intervention when prioritizing care?
a.
ascertaining interventions
b.
assessing client situations
c.
assigning staff to clients
d.
analyzing collected data
Ans: B
Rationale: The first step when prioritizing care is assessment. Assessment is the
process of gathering information to make decisions. Assessment includes knowing
individual clients' health statuses to prepare for anticipated or unanticipated changes.
Ascertaining interventions would occur after the assessment. Analyzing collected data
would occur after an assessment. Assigning staff to clients would occur after knowing
the number and level of caregivers available to provide care.
6). The home care nurse is planning the order of clients for the day. which client should the
nurse prioritize as needing to be seen first?
a.
a client with daily dressing change, normally done at 0800 per client
preference
b.
a client being seen poststroke for rehabilitation and education about
poststroke care
c.
a newly diagnosed diabetic client who is administering morning insulin independently for
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, the first time
d.
a client requiring indwelling catheter change due to leakage
Ans: C
Rationale: A newly diagnosed client who is administering insulin independently for the
first time creates a time constraint. The nurse would see this client first to ensure that
the insulin is being administered properly. While client preferences are an important
consideration, the time constraint of the insulin would be a higher priority. A client being
seen poststroke for rehabilitation and education as well as a client with a leaking
indwelling catheter would also be lower priorities when planning the order of clients for
the day.
7). The nurse is prioritizing client care as low, medium, or high priority for the current
assignment. which client should the nurse identify as having a high-priority circumstance?
(select all that apply.)
a.
a client who is receiving warfarin (coumadin)
b.
a client with emphysema and a pulse oximeter reading of 88
c.
an extremely confused older client
d.
a client who is experiencing extreme bouts of diarrhea
e.
a client with congestive heart failure and shortness of breath
Ans: A
B
E
Rationale: High-priority circumstances include clients with a risk for bleeding, such as a
client receiving warfarin (Coumadin), clients with ineffective breathing patterns, and
clients with impaired gas exchange. A confused client and a client with diarrhea would
have medium-priority circumstances.
8). The nurse is planning the day on a general medical unit. which activity should the nurse
prioritize as "must do" and not advisable to be delegated to unlicensed assistive personnel
(uap)?
a.
collecting vital signs on assigned clients
b.
health teaching for a client being discharged poststroke
c.
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