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RN 3.0 Clinical Judgment Practice 2 Questions and Answers | Latest Version | 2025/2026 | Correct & Verified
A nurse is caring for a client who is experiencing chest pain. What is the first step the nurse should take?✔✔ The nurse should assess the client's vital signs and perform an ECG to evaluate for any potential cardiac issues.
A nurse is caring for a client with diabetes who reports feeling lightheaded and weak. What is the first action the nurse should take?✔✔ The nurse should check the client’s blood glucose level immediately to assess for hypoglycemia.
A nurse is providing care for a post-operative client who has a surgical wound that is showing signs of infection. What should the nurse do first?✔✔ The nurse should assess the wound for size, drainage, and any other signs of infection and notify the healthcare provider if necessary.
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A nurse is caring for a client who has recently had a stroke and is exhibiting signs of facial drooping and slurred speech. What is the nurse's priority action?✔✔ The nurse should notify the healthcare provider immediately and prepare for a potential CT scan to assess for a stroke.
A nurse is caring for a client who is receiving chemotherapy and complains of nausea. What is the nurse's priority action?✔✔ The nurse should administer prescribed antiemetic medication to alleviate the client's nausea.
A nurse is assessing a client’s respiratory status and notices shallow, rapid breathing. What should the nurse do next?✔✔ The nurse should assess the client’s oxygen saturation levels and administer supplemental oxygen if needed.
A nurse is caring for a client with a history of hypertension who suddenly develops a severe headache, blurry vision, and confusion. What is the nurse's first action?✔✔ The nurse should check the client’s blood pressure and notify the healthcare provider immediately if it is elevated.
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A nurse is caring for a client who has just undergone a hip replacement surgery. The nurse notes that the client’s leg is swollen and warm to the touch. What is the nurse's priority action?✔✔ The nurse should assess for signs of deep vein thrombosis (DVT) and notify the healthcare provider immediately if any are found.
A nurse is caring for a client who is receiving a blood transfusion. The client begins to exhibit chills, fever, and back pain. What should the nurse do immediately?✔✔ The nurse should stop the transfusion and assess the client’s vital signs, notifying the healthcare provider if necessary.
A nurse is caring for a client who is post-operative following a bowel surgery. The client begins to experience severe abdominal pain, nausea, and vomiting. What should the nurse do first?✔✔ The nurse should assess the client's abdomen for signs of distension or tenderness and notify the healthcare provider.
A nurse is providing care for a client with a recent head injury who is exhibiting signs of confusion and agitation. What is the nurse's priority intervention?✔✔ The nurse should perform a neurological assessment to evaluate the client’s level of consciousness and neurological function.
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