A nurse is caring for a client who has a fever, cough, and shortness of breath. The nurse suspects that the client has pneumonia and orders a chest x-ray and blood cultures. Which of the following actions by the nurse demonstrate critical thinking?
The nurse compares the client's vital signs with the normal ranges.
The nurse asks the client about his medical history and allergies.
The nurse explains to the client the purpose and procedure of the tests.
The nurse administers an antipyretic medication to the client.
The nurse documents the client's condition and interventions in the chart.
The Correct Answer is C
Choice A:
Comparing the client's vital signs with the normal ranges is a basic nursing skill that does not require critical thinking. It is part of the assessment process, but it does not involve analysis, interpretation, or evaluation of the data. Therefore, this choice is incorrect.
Choice B:
Asking the client about his medical history and allergies is also a basic nursing skill that does not require critical thinking. It is part of the assessment process, but it does not involve analysis, interpretation, or evaluation of the data. Therefore, this choice is incorrect.
Choice C :
Explaining to the client the purpose and procedure of the tests is an example of critical thinking because it involves applying knowledge, skills, and attitudes to provide patient-centered care. The nurse uses critical thinking to determine what information the client needs to know, how to communicate it effectively, and how to evaluate the client's understanding. Therefore, this choice is correct.
Choice D :
Administering an antipyretic medication to the client is a standard nursing intervention that does not require critical thinking. It is part of the implementation process, but it does not involve analysis, interpretation, or evaluation of the data. Therefore, this choice is incorrect.
Choice E:
Documenting the client's condition and interventions in the chart is a legal and ethical responsibility of the nurse that does not require critical thinking. It is part of the communication process, but it does not involve analysis, interpretation, or evaluation of the data. Therefore, this choice is incorrect. Source:.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A:.
This statement does not indicate a lack of critical thinking because the nurse is planning to monitor the client's blood glucose level more frequently to evaluate the effectiveness of the insulin therapy. This is an appropriate nursing intervention for a client who has hyperglycemia.
Choice B :.
This statement does not indicate a lack of critical thinking because the nurse is checking the medication administration record to see if the client received his insulin as prescribed. This is an important step to identify any possible errors or omissions that could have contributed to the client's high blood glucose level.
Choice C:.
This statement indicates a lack of critical thinking because the nurse is increasing the insulin dose by 2 units as per the sliding scale protocol without considering other factors that could affect the client's blood glucose level, such as diet, exercise, stress, or infection. The nurse should not adjust the insulin dose without consulting the provider or following a specific protocol that takes into account the client's individual needs and goals.
Choice D:.
This statement does not indicate a lack of critical thinking because the nurse is asking the client if he ate anything that could have raised his blood sugar level. This is a relevant question to assess the client's dietary intake and adherence to the prescribed meal plan. The nurse should also educate the client about the importance of following a consistent carbohydrate diet and avoiding foods that can spike blood glucose levels.
Correct Answer is A
Explanation
Choice A :.
This statement reflects critical thinking because the nurse prioritizes the most important assessments for a client with multiple injuries and follows the ABC (airway, breathing, circulation) principle of trauma care. Assessing the level of consciousness, airway, breathing, and circulation is essential to determine the client's condition and plan appropriate interventions.
Choice B :.
This statement does not reflect critical thinking because the nurse expresses a hope rather than a fact or an action. Hoping for no internal injuries or organ damage does not help the nurse to provide effective care for the client. The nurse should focus on assessing the client's injuries and providing appropriate interventions based on the findings.
Choice C :.
This statement does not reflect critical thinking because the nurse wonders about irrelevant information that does not affect the client's care. The cause of the crash and the use of seat belt are not important for the nurse to know at this point. The nurse should focus on assessing the client's injuries and providing appropriate interventions based on the findings.
Choice D :.
This statement does not reflect critical thinking because the nurse jumps to a conclusion without assessing the client first. Calling the trauma surgeon and the neurologist right away may not be necessary or appropriate depending on the client's condition. The nurse should assess the client first and then consult with other health care professionals as needed.
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