Question Set A: Cues, Clusters, and Hypotheses

Instruction strip

Work all six with a pen. Fill the reasoning ledger beside each item before you choose an answer. Do not turn the page until every ledger is complete.

Worked ledger example CUES USED: rising heart rate from own baseline, falling urine output, new confusion HYPOTHESIS: early sepsis, because vasodilation dropped perfusion pressure WHY NOT THE RUNNER-UP: hypovolemia does not explain the warm skin or the fever

Item 1. A client is on the first postoperative day after an open ventral hernia repair. Which charted finding is a cue rather than an expected finding?

1. Incisional pain rated 5 out of 10 that eases after the ordered analgesic.
2. Serosanguineous drainage staining a quarter-sized area of the dressing.
3. Absent bowel sounds in all four quadrants with a soft, non-distended abdomen at 12 hours after surgery.
4. Heart rate 112 beats per minute at rest, up from 78 on admission and 96 four hours ago.

CUES USED: ___ HYPOTHESIS: ___ WHY NOT THE RUNNER-UP: ___

Item 2. A 70-year-old client is on hospital day 2 for an exacerbation of heart failure and is receiving a loop diuretic. Select the four findings that require immediate follow-up.

1. Weight increased 4 pounds since yesterday morning.
2. Reports sleeping on two pillows at home and at present, unchanged.
3. New crackles at both lung bases with respirations 28 breaths per minute.
4. Oxygen saturation 88 percent on room air, down from 94 percent last evening.
5. Trace pedal edema, unchanged from admission.
6. Reports mild thirst and a dry mouth.
7. Serum potassium 2.9 mEq/L this morning, down from 3.8 on admission.
8. Voided 400 mL in the two hours after the morning diuretic dose.

CUES USED: ___ HYPOTHESIS: ___ WHY NOT THE RUNNER-UP: ___

Item 3. A 24-year-old client with type 1 diabetes arrives at the emergency department with deep, rapid respirations, a fruity odor on the breath, and a blood glucose of 448 mg/dL. Which hypothesis explains all three cues?

1. Hypoglycemia.
2. Diabetic ketoacidosis.
3. Hyperosmolar hyperglycemic state.
4. Panic attack with hyperventilation.

CUES USED: ___ HYPOTHESIS: ___ WHY NOT THE RUNNER-UP: ___

Item 4. A nurse's leading hypothesis for a client with three days of persistent vomiting is hypovolemia. Which findings would be expected to be present if that hypothesis is correct? Select all that apply.

1. Heart rate rising while blood pressure falls.
2. Urine output falling, with dark, concentrated urine.
3. Dry mucous membranes and a prolonged capillary refill time.
4. Jugular veins distended while the client sits upright.
5. Bounding peripheral pulses at all sites.
6. Blood pressure dropping when the client moves from lying to standing.

CUES USED: ___ HYPOTHESIS: ___ WHY NOT THE RUNNER-UP: ___

Item 5. At 0600 an 80-year-old client's blood pressure is 118/64 mm Hg. Every blood pressure charted from admission through last evening ran between 156/88 and 168/94 mm Hg, and no antihypertensive has been given. Which statement about the 0600 reading is correct?

1. It is not a cue, because the reading sits inside the published adult range.
2. It is a cue, because it is a marked change from this client's own established pattern with no treatment to explain it.
3. It is not a cue, because a single reading cannot establish a trend.
4. It is a cue only if the client also reports dizziness.

CUES USED: ___ HYPOTHESIS: ___ WHY NOT THE RUNNER-UP: ___

Item 6. A nurse assesses a client 4 hours after a total thyroidectomy who reports a tight sensation at the front of the neck and whose voice is hoarse and weaker than earlier. Place the reasoning moves in the order the nurse performs them.

1. Rank the candidate problems by how much of the picture each explains against what being wrong would cost.
2. Explain the cluster with candidate problems, including neck hematoma and airway edema.
3. Build the set of defensible actions for the ranked problem, including what is escalated to the surgeon.
4. Cluster the neck tightness, the voice change, and the dressing findings into the findings that matter.

CUES USED: ___ HYPOTHESIS: ___ WHY NOT THE RUNNER-UP: ___

Margin notewrite the ledger BEFORE you circle.

Rationales → BOOK 02 · P13.

TakeawayThe answer matters less than the ledger, because the ledger is what page 13 will grade.