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 D

Explanation

A. Stage IV: Stage IV ulcers involve full-thickness skin loss with exposed bone, tendon, or muscle. Since this ulcer is shallow and pink without slough, it is not Stage IV.

B. Stage I: Stage I ulcers are intact skin with non-blanchable erythema. Since the ulcer is open, it is not Stage I.

C. Stage III: Stage III ulcers have full-thickness tissue loss, possibly exposing subcutaneous fat. The given description lacks fat exposure or depth, ruling out Stage III.

D. Stage II: Stage II pressure ulcers involve partial-thickness skin loss with a shallow open wound, pink/red wound bed, and no slough. The given description matches Stage II.

A. "If I develop atelectasis, I will need a chest tube to drain excess fluid." B. "Hyperventilation will open up my alveoli, preventing atelectasis.” C. "Atelectasis affects only those with chronic conditions such as emphysema." D. "It is important to do breathing exercises every hour to prevent atelectasis."

Correct Answer is D

Explanation

A. "If I develop atelectasis, I will need a chest tube to drain excess fluid." Atelectasis is alveolar collapse, not fluid accumulation. Chest tubes are used for pneumothorax or pleural effusion, not for atelectasis.

B. "Hyperventilation will open up my alveoli, preventing atelectasis." Hyperventilation can cause respiratory alkalosis but does not effectively re-expand alveoli. Incentive spirometry and deep breathing are more effective.

C. "Atelectasis affects only those with chronic conditions such as emphysema." Atelectasis can affect anyone, especially postoperatively due to shallow breathing and reduced lung expansion. It is not exclusive to chronic conditions.

D. "It is important to do breathing exercises every hour to prevent atelectasis." Frequent deep breathing exercises, coughing, and incentive spirometry are essential for preventing atelectasis, especially after surgery.

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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

The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?

Correct Answer is D

Explanation

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?

Correct Answer is D

Explanation

A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?

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