Critical Thinking Flashcards
Your client voices pain, what action would you take?
o Ask objective question, When/how much painful/where/how/how long
o Check client hx
o Check Pressure
o Report to the nurse STAT
o Follow nurse’s directions
o Report and record
Your client voices pain to the rectum after a bowel movement, you note frank red blood. What
action would you take?
o Ask objective question, when start this pain, how severe
o Check client hx : hemorrhoid
o Pressure the rectum and check conscious
o Report to the nurse STAT
o Report and record
o Check the temperature before washing client
Your client voices pain to both legs upon standing. What action would you take?
o Turning back to the bed, wheelchair, chair
o When/how much painful/where/how/how long
o Don’t be rush
o Report and record
Partial bed bath: While assisting the client they voice they are getting short of breath. What action would you take?
o Stop partial bed bath and cover client
o Change the high Fowler position (lower : 15-30/ semi : 30-45 / high 45-90 (but we are in
45-60 in reality), orthopneic position : Sitting up (ortho) and leaning over a table to breathe
o Follow the care plan
Partial bed bath: While assisting the client with a partial bed bath the client becomes increasingly
anxious voicing “are we almost done?” “can you hurry up?” What action would you take next?
o Stop and cover
o Ask client “are you uncomfortable? Do you want me to come back later?”
o If client said yes. Leave call bell. Record and report
o If client said no. Give them time and ask again “are you okay? Would you like to continue?”
Then do
o Record and report
Dx UTI: Your client voices increased episodes of incontinence. What action do you take?
o Ask other symptoms (ask feeling_moderate or severe/ color/odour/ consistency of the urine)
o Note for the urine input and output
o Check fluid intake
o Report and record
Hx Seizures: You note while repositioning client that they begin to have convulsions. What action
do you take?
o Stop repositioning
o Stand by, airway check
o Check for unsafe object around it
o Recovery position
o At least 3 min, if it’s over, hit the call bell
Dx COVID/Asthma: Your client complains of chest pain, what action would you take?
o HOB up to high-fowler position
o Ask how are they feeling?
o Orthopneic position
o Ask them where is the pain? Scale rom 1-10 the pain? When they exhale or inhale is it hurt?
o Check care plan and MAR
o Record and report
Dx hyperglycemia: Your client voices weakness and appears confused (can’t remember what day
it is or his last name), what action would you take?
o Check the care plans & MAR
o Ask the client’s feeling
o Report and record to the nurse
Dx MRSA: While providing client care you notice the clients dressing on her elbow has come off
and there is drainage all over the bed. What action would you take?
o Get gauze and cover the elbow
o Transfer the client to a chair
o Changing occupied bed
o Report and record
Dx. Osteoporosis with severe pain and already took medication
check with the nurse which temp.
pack can apply, how much time
Mouth Care: While providing mouth care you note the client has a lot of secretions. What action
do you take?
o In this case is maybe unconscious
o Use toothies to clean and tongue depression to prevented chocking
o Record and report
Denture care: When assisting the client to remove their dentures you notice the client’s gums
have white patches and bleeding. What action would you take?
o Stop removing it and Ask the client “ your gum is painful? How much? When it started?”
o Observation of white patches : size, swollen, bleeding countinuous or light
o Report to the nurse and record
Complete bed bath: You note the clients skin becomes really warm to touch. What action would
you take?
o Check the temperature, skin condition
o Check the care plan
o Record and report
Partial bed bath: While assisting the client with their partial bed bath they become agitated both
verbally and physically, pushing your hand away. What action would you take?
o Cover towel
o Step away (to respect their personal space)
o Ask what happen? How are they feeling? > I can com back later, do you need some time
to settle down
o Report to the nurse
o Record
partial bed bath: You note client was incontinent of urine and was unaware, what action would
you take?
o Cover towel
o Provide bed pan
o Put continence pad beneath
o Check the observation of urine (color, odor)
o Ask any pain/ have you been done this before?
o Be calm and soft
o report and record