Which action should the nurse take when using critical thinking to make clinical decisions?

Reads and follows the health care provider's orders.

Accepts one established way to provide care.

Makes decisions based on intuition.

Consider what is important in any given situation.

Answer and Explanation

The Correct Answer is D

A. Reads and follows the health care provider's orders. While following provider orders is important, critical thinking requires assessing the situation and considering all relevant factors, rather than just following orders without analysis.

B. Accepts one established way to provide care. Critical thinking involves evaluating different approaches and adapting to individual patient needs rather than rigidly adhering to a single method.

C. Makes decisions based on intuition. While intuition can be helpful, evidence-based practice and clinical reasoning should guide decision-making, not just intuition alone.

D. Consider what is important in any given situation. Critical thinking involves analyzing the situation, prioritizing information, and making decisions based on what is most important for patient safety and care.

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Correct Answer is C

Explanation

A. Assess the pedal pulses for a full minute. Pedal pulses assess circulation to the lower extremities and are not related to confirming an irregular heart rate.

B. Assess the apical pulse with a Doppler device. A Doppler is not typically necessary to assess the apical pulse unless pulses are difficult to detect due to poor circulation.

C. Assess the apical pulse for a full minute. When an irregular radial pulse is detected, the most accurate way to assess heart rate and rhythm is by auscultating the apical pulse for a full minute. This helps determine the presence of arrhythmias.

D. Assess the pedal pulses with a Doppler device. Checking pedal pulses with a Doppler is useful for assessing circulation in the lower extremities but does not help confirm an irregular heart rate.

A. Give the medication in the morning daily. B. Administer the medication 2 hours before exercise C. Administer the granules mixed with 20 ounces of water D. Give the medication at the onset of wheezing

Correct Answer is A

Explanation

A. Give the medication in the morning daily. Montelukast (a leukotriene receptor antagonist) is given once daily in the evening for long-term asthma control. If prescribed for allergic rhinitis, it can be given in the morning.

B. Administer the medication 2 hours before exercise. Montelukast is not a rescue medication but a maintenance drug. However, it can be prescribed for exercise-induced bronchospasm and is taken at least 2 hours before exercise when used for that purpose.

C. Administer the granules mixed with 20 ounces of water. Montelukast granules should be mixed with a small amount of soft food (e.g., applesauce, mashed carrots) or breast milk/formula but not a large volume of liquid.

D. Give the medication at the onset of wheezing. Montelukast is not a quick-relief medication and does not work immediately. Short-acting bronchodilators (e.g., albuterol) should be used for acute wheezing.

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Which action should the nurse take when using critical thinking to make clinical decisions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide to the client's parents on administering the medication?

Correct Answer is A

Explanation

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