1. ABC = Does the question contain Airway, Breathing or Circulation and is it appropriate to the question being asked? Many questions are tricky because we are taught if there is an airway question chose it... however, if the question is asking about urination or something like that, would airway be the proper answer just because it is listed as an option? I would hope an instructor or NCLEX test maker would not include that type of question... except we know better.
The nurse identified the client problem “decreased cardiac output” for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care?
1. Monitor the client’s arterial blood gases.
2. Assess skin color and temperature.
3. Assess urinary output is >30 ml hour
4. Keep the client in the Trendelenburg position.
Page(s): 204, Med-Surge Success'' A Course Review Applying Critical Thinking to Test Taking by Ray A, Kathryn Caddenhead Colgrove and Hargrove-Huttel, F A Davis
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The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first?
1. Confirm that the ventilator settings are correct.
2. Verify that the ventilator alarms are functioning properly.
3. Assess the respiratory status and pulse oximeter reading.
4. Monitor the client’s arterial blood gas results.
Page(s): 207, Med-Surge Success'' A Course Review Applying Critical Thinking to Test Taking by Ray A, Kathryn Caddenhead Colgrove and Hargrove-Huttel, F A Davis
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2. Nursing Process- ADPIE... Is there a questions that asks what would you do first? ASSESS is always the first step in the nursing process. Usually these questions contain all of the steps or a few of the steps of the nursing process. Which we know all may be right, but we must assess before we take action.
Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment?
1. Assess the client’s bilateral lung sounds.
2. Obtain an order for a STAT chest x-ray.
3. Notify the health-care provider as soon as possible.
4. Document the findings in the client’s chart.
Page(s): 207, Med-Surge Success'' A Course Review Applying Critical Thinking to Test Taking by Ray A, Kathryn Caddenhead Colgrove and Hargrove-Huttel, F A Davis
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3. Maslow - Of course physiological needs come first, but generally if there is a Maslow question, it's about safety. Always err on the side of safe nursing practice and patient safety.
The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement?
1. Demonstrate the correct technique for giving a bed bath.
2. Encourage the UAP to put the bed in the lowest position.
3. Instruct the UAP to get another person to help with the bath.
4. Provide praise for performing the bath safely for the client and the UAP.
Page(s): 207, Med-Surge Success'' A Course Review Applying Critical Thinking to Test Taking by Ray A, Kathryn Caddenhead Colgrove and Hargrove-Huttel, F A Davis
. This material is protected by copyright.
That's it for now... back to studying I suppose!
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