CNO CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making

Question 1

During a head-to-toe assessment, a CNO-registered nurse notes that a client has unequal pupils. What is the nurse's priority action?

Accepted Answer

Notify the physician immediately as this may indicate a neurological emergency

Answer

Document the finding and continue the assessment

Answer

Administer prescribed pain medication

Answer

Reposition the client and reassess in one hour

Question 2

A nurse is assessing a client's pain using the PQRSTU framework. What does the 'U' stand for?

Accepted Answer

Understanding (what the client thinks is causing the pain)

Answer

Urgency

Answer

Unit of measurement

Answer

Usual pattern

Question 3

When assessing a client's lung sounds, the nurse hears crackles in the lower lobes bilaterally. This finding is most consistent with which condition?

Accepted Answer

Fluid accumulation such as pulmonary edema or pneumonia

Answer

Asthma

Answer

Pulmonary embolism

Answer

Pleural effusion without fluid

Question 4

According to CNO standards, when should a nurse perform a focused assessment rather than a comprehensive assessment?

Accepted Answer

When a client presents with a new or changing specific symptom or concern

Answer

On every client encounter regardless of status

Answer

Only during initial admission

Answer

Only when ordered by a physician

Question 5

A nurse uses clinical reasoning to determine that a post-operative client's increased heart rate and drop in blood pressure indicate possible internal bleeding. This is an example of which step in clinical decision making?

Accepted Answer

Interpretation and pattern recognition

Answer

Data collection

Answer

Implementation

Answer

Evaluation of outcomes

Question 6

When assessing a client's skin turgor, the nurse pinches the skin on the back of the hand and notes it returns slowly. This finding suggests:

Accepted Answer

Dehydration or decreased skin elasticity

Answer

Fluid overload

Answer

Normal hydration status

Answer

Allergic reaction