Essential Nursing Practice Questions and Clinical Scenarios

Clinical Nursing Assessment and Intervention Scenarios

Hospice Care Assessment

A nurse assesses a hospice client. The assessment reveals BP 74/40, urine output 30 cc over 3 hours, poor skin turgor, skin cool to touch, respiratory rate 8 and irregular, and dysphagia. The nurse recognizes these combined assessment findings are signs of impending death.

Postoperative Care and Complications

• Pulmonary Prevention: A nurse is developing a plan of care for a postoperative client. To prevent pulmonary complications, the nurse should encourage the use of an incentive spirometer.
• Wound Healing: A nurse changing the dressing of a client 1 week postoperative following abdominal surgery notes serosanguineous drainage. The nurse should recognize this as a manifestation of possible dehiscence.

Diagnostic and Medication Review

• Metabolic Acidosis: A nurse reviewing arterial blood gas results for a client suspected of metabolic acidosis should expect to see a pH below 7.35.
• Potassium Calculation: A nurse preparing to administer 40 mEq of potassium chloride in 500 mL of 0.45% NaCl to infuse at 10 mEq/hr should set the IV pump to 125 mL/hr.
• Morphine Dosage: A nurse preparing to administer a 2 mg IV bolus of morphine sulfate (available as 10 mg/mL) should administer 0.2 mL per dose.

Nursing Procedures and Patient Safety

• Postmortem Care: Nursing interventions for a hospitalized patient should include:
  • Bathe the patient
  • Place the patient in an anatomical position
  • Remove the endotracheal tube
• Hearing Impairment: When admitting a client with partial hearing loss, the priority action by the nurse is to determine if the client uses hearing aids.
• Enema Administration: If a client questions a soap suds enema order, the appropriate nursing action is to check the client's medical record for the provider's prescription.
• Respiratory Assessment: A nurse in the PACU observing the absence of left-sided chest wall expansion in a client with an endotracheal (ET) tube should suspect movement of the ET tube into the right main bronchus.