Clinical Judgment in Test Taking UPDATED ACTUAL Exam Questions and CORRECT Answers
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Clinical Judgment in Taking
Institution
Clinical Judgment In Taking
Clinical Judgment in Test Taking
UPDATED ACTUAL Exam Questions and
CORRECT Answers
Identify the two assessment findings that require immediate follow-up.
The nurse is caring for a 12-month-old child in the emergency department with suspected
acute epiglottis. The child has a fever (T 102.6 �...
Clinical Judgment in Test Taking
UPDATED ACTUAL Exam Questions and
CORRECT Answers
Identify the two assessment findings that require immediate follow-up.
The nurse is caring for a 12-month-old child in the emergency department with suspected
acute epiglottis. The child has a fever (T 102.6 °F [39.2 °C]), is drooling, and sitting upright
and leaning forward (tripod position). Other assessment findings include tachypnea,
substernal chest retractions, restlessness, and agitation. The child weighs 12.7 kg.
The caregiver confirms that the child is not vaccinated, has a history of eczema, and had a
ventricular septal defect repaired 6 months ago. No one in the immediate family has been
sick, and the child does not attend daycare. - CORRECT ANSWER✔✔- tachypnea
substernal chest retractions
The most likely cause of the child's condition is ________. - CORRECT ANSWER✔✔- not
vaccinated
The client is at highest risk of developing _______ leading to _______ caused by ________. -
CORRECT ANSWER✔✔- hypoxia
respiratory acidosis
respiratory obstruction
For each potential healthcare provider's prescription, indicate if the nurse anticipates or does
not anticipate the prescription.
Administer intravenous ceftriaxone 100 mg/kg now.
Administer albuterol 0.15 mg/kg via nebulizer now.
Initiate droplet precautions.
Encourage oral fluids to maintain hydration. - CORRECT ANSWER✔✔- Anticipated
Not Anticipated
Anticipated
Not Anticipated
For each nursing action, identify if the action is indicated or contraindicated.
, Obtain a throat culture.
Monitor oxygen saturation.
Place a nasal intubation set at the bedside.
Maintain the child in a supine position. - CORRECT ANSWER✔✔- Contraindicated
Indicated, Indicated, Contraindicated
Which assessment findings in the nurses' notes indicate that the client is not progressing as
expected? Select all that apply.
Stridor
Flat, soft anterior fontanelle
Skin color
Respiratory effort
Oxygen saturation
Temperature - CORRECT ANSWER✔✔- Stridor
Skin color
Respiratory effort
Oxygen Saturation
The nurse is caring for a client with a peripheral intravenous (PIV) site in the left hand and
notes pallor and edema at the site. The dressing is damp and the infusion is running slowly.
Which action should the nurse implement first?
Apply a warm compress
Restart the peripheral IV
Remove the peripheral IV
Elevate the extremity - CORRECT ANSWER✔✔- Remove the peripheral IV
The nurse is caring for a child who is hospitalized with respiratory syncytial virus (RSV).
Which protective items should the nurse assemble before entering the client's room? Select
all that apply.
Surgical mask
Face shield
Shoe protectors
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