CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making Flashcards
6 cards from real CNO practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making flashcards as text
During a head-to-toe assessment, a CNO-registered nurse notes that a client has unequal pupils. What is the nurse's priority action?
Answer: Notify the physician immediately as this may indicate a neurological emergency
Unequal pupils (anisocoria) can indicate a serious neurological condition such as increased intracranial pressure, requiring immediate physician notification.
A nurse is assessing a client's pain using the PQRSTU framework. What does the 'U' stand for?
Answer: Understanding (what the client thinks is causing the pain)
In the PQRSTU mnemonic, 'U' stands for Understanding — what the client believes is causing or contributing to their pain.
When assessing a client's lung sounds, the nurse hears crackles in the lower lobes bilaterally. This finding is most consistent with which condition?
Answer: Fluid accumulation such as pulmonary edema or pneumonia
Bilateral basal crackles are commonly associated with fluid in the alveoli, as seen in pulmonary edema or pneumonia.
According to CNO standards, when should a nurse perform a focused assessment rather than a comprehensive assessment?
Answer: When a client presents with a new or changing specific symptom or concern
A focused assessment is appropriate when evaluating a specific symptom or change in client condition, rather than performing a full head-to-toe review.
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?
Answer: Interpretation and pattern recognition
Recognizing that a cluster of vital sign changes points to a specific clinical problem is the interpretation and pattern recognition step of clinical decision making.
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:
Answer: Dehydration or decreased skin elasticity
Slow skin turgor return indicates decreased tissue fluid, which can be caused by dehydration or, in older adults, by reduced skin elasticity.
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