Nokea
Which of the following are components of the definition of critical thinking? Select all that apply.
- A. Reasoned thinking
- B. Openness to alternatives
- C. Adherence to established guidelines
- D. Ability to reflect
- E. Loyalty to traditional approaches
- F. Desire to seek the truth
Correct Answer: A, B, D, F
Rationale: Critical thinking includes reasoned thinking (A), openness to alternatives (B), reflection (D), and seeking truth (F). Adherence to guidelines (C) and loyalty to tradition (E) limit the flexibility required for critical thinking.
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The nurse cares for a client immediately following a percutaneous coronary intervention (PCI). Upon sheath removal, the client develops bradycardia and hypotension. Which intervention would be the nurse’s priority?
- A. Assess bilateral pedal pulses
- B. Apply a sandbag to stabilize the site
- C. Administer prescribed bolus of intravenous (IV) fluids
- D. Elevate the head of the bed
Correct Answer: C
Rationale: Bradycardia and hypotension post-PCI sheath removal (D) suggest a vasovagal response or bleeding, requiring a fluid bolus (C) to stabilize circulation, per ACLS guidelines. Pulse assessment (A), sandbag application (B), and head elevation (D) are secondary or inappropriate.
The nurse is caring for assigned clients. The nurse should immediately follow-up on the client who
- A. is being treated for pneumonia and develops restlessness.
- B. is receiving intravenous fluids for influenza and dehydration and reports a headache.
- C. has a chest drainage system in place for a hemothorax and tidaling is present in the water seal chamber.
- D. is being treated for pleurisy and is experiencing inspiratory chest pressure.
Correct Answer: A
Rationale: Restlessness in pneumonia (A) may indicate hypoxia, requiring immediate follow-up. Headache with fluids (B), tidaling in chest tube (C), and pleurisy pain (D) are expected or less urgent.
The nurse in the emergency department is caring for a client who sustained multiple rib fractures and a nasal fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up?
- A. shallow respirations
- B. chest pain with repositioning
- C. bruising on the chest
- D. vomiting
Correct Answer: A
Rationale: Shallow respirations (A) in a client with rib fractures suggest impaired ventilation, risking hypoxia or pneumothorax, requiring immediate follow-up. Chest pain (B), bruising (C), and vomiting (D) are expected but less urgent.
The nurse is performing a verbal hand-off report for a client admitted to the medical-surgical unit. Which essential information should the nurse include in the report?
- A. Discontinued medications
- B. Involuntary admission status
- C. Food and mealtime preferences
- D. The presence of family at the bedside
Correct Answer: A, B
Rationale: Discontinued medications (A) prevent administration errors, and involuntary admission status (B) ensures legal and safety compliance, both critical for safe care transitions per ISBAR standards. Food preferences (C) and family presence (D) are less essential for immediate care continuity.
The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who
- A. has a closed-chest drainage system and has redness at the insertion site.
- B. is receiving treatment for ulcerative colitis and has had three bloody stools in the past hour.
- C. is being treated for a concussion and reports a headache rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.
Correct Answer: D
Rationale: Hypotension (100/58 mm Hg) in ischemic stroke (D) suggests hemodynamic instability, risking cerebral perfusion and requiring immediate follow-up. Redness at chest tube site (A), bloody stools in ulcerative colitis (B), and mild headache in concussion (C) are concerning but less immediately life-threatening.