ATI Nurse Logic 2.0 ~ Testing and Remediation (Beginner Test)

A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait. A. Client shifts weight from crutches to the unaffected leg. B. Client aligns crutches on the stair. C. Client stands, bearing weight on unaffected leg. D. Client advances the unaffected leg between the crutches. E. Client transfers body weight to the crutches.

1. C. Client stands, bearing weight on unaffected leg. 2. E. Client transfers body weight to the crutches. 3. D. Client advances the unaffected leg between the crutches. 4. A. Client shifts weight from crutches to the unaffected leg. 5. B. Client aligns crutches on the stair. Rationale: To answer this item you should have started by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority-setting. Let's analyze the item together now.Scenario: A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Question: Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait.Person of Focus: The client who is learning to go up stairs using a modified 3-point crutch gait.Key Words: learning, sequence of actions, up stairs, modified 3-point crutch gait.So, the question is asking for the appropriate sequence of actions when going up stairs using a modified 3-point gait crutch. This is a drag and drop or ordered response item, which means the options were listed unordered in a box on the left side of the screen and had to be "dragged and dropped" into the box on the right side of the screen in the correct order. This is a priority setting item because the options had to be placed in rank order.

A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine 25 mg every 6 hours as needed. Available is diphenhydramine 12.5 mg/5 mL syrup. How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose?

2 teaspoons Rationale: 1. 12.5 mg/5 mL = 25 mg/x mL 2. 12.5x = 125 3. x = 10 mL 4. 1 teaspoon = 5 mL 5. x = 2 teaspoons

A nurse is examining a client's lymphatic system. Identify the site the nurse should palpate to assess the posterior cervical lymph nodes. A. A B. B C. C D. D

A. A Rationale: To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is examining a client's lymphatic system. Question: Identify the site the nurse should palpate to examine the posterior cervical lymph nodes. Person of Focus: The nurse who is examining the client's lymph system Key Words: lymphatic system, identify site, palpate, posterior cervical lymph nodes So, the question is asking the location the nurse should palpate to examine the posterior cervical lymph nodes. This is a Hot Spot item, which means an image is provided with "Hot Spots" indicated in various locations on the image. These Hot Spots indicate the options you have for answering the item. Next you should roll the cursor over the image to locate all of the Hot Spots and determine if each is probably correct, possibly correct, or probably incorrect. Then, you should click on one of the Hot Spots to select it as the correct option. This area, known as the posterior cervical, is correct. While facing the client, the nurse should use the pads of the middle three fingers to gently palpate the nodes in a circular motion and evaluate each for consistency, characteristics, mobility, warmth, and tenderness. This is the location of the posterior cervical lymph nodes, which are a group of lymph nodes located on the sides of the neck.

A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should be elicited over areas of consolidation during percussion? A. Dullness B. Hyperresonance C. Resonance D. Tympany

A. Dullness Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is performing a respiratory examination on a client who has pneumonia. Question: Which of the following sounds should be elicited over areas of consolidation during percussion? Person of Focus: The client who has pneumonia Key Words: respiratory examination, sounds, consolidation, during percussion So, the question is asking which of the sounds heard during percussion should be elicited over areas of consolidation. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distractors. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Dullness is correct. Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness. This is the sound that will be elicited during percussion over areas of consolidation. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is performing a respiratory examination on a client who has pneumonia. Qu

A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following? A. Mood B. Immunity C. Memory D. Vitality

A. Mood Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is a provider's office is caring for a client who has depression and is taking St. John's Wort. Question: The herbal supplement is thought to improve which of the following? Person of Focus: The client who is taking St. John's Wort Key Words: depression, St. John's Wort, improve So, the question is asking which of the characteristics is thought to improve by taking St. John's Wort. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Mood is correct. St. John's Wort is widely used in the U.S. and other countries as an herbal supplement for treating mild to moderate depression and to relieve depression-related anxiety. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is a provider's office is caring for a client who has depression and is taking St. John's Wort. Question: The herbal supplement is thought to improve

A nurse is caring for a client who is immobile and has developed a stage II pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer? A. Partial thickness skin loss B. Visible subcutaneous fat C. Non-blanchable redness D. Exposed muscle

A. Partial thickness skin loss Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is immobile and has developed a pressure ulcer. Question: Which of the following characteristics is associated with a stage II pressure ulcer? Person of Focus: The client who has developed a pressure ulcer Key Words: pressure ulcer, characteristics, stage II So, the question is asking which of the characteristics is associated with a stage II pressure ulcer. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Partial thickness skin loss is correct. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse

A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should include that the disease is transmitted in which of the following ways? A. Vector B. Airborne C. Vehicle D. Bloodborne

A. Vector Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. Question: The nurse should include that the disease is transmitted in which of the following ways? Person of Focus: The nurse who is reinforcing the teaching Key Words: Lyme disease, transmitted So, the question is asking which of the modes is how Lyme disease is transmitted. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Vector is correct. Vectors are arthropods, which carry and transmit certain illnesses. Examples of illnesses transmitted by vectors include malaria, which is transmitted by mosquitos, and Rocky Mountain spotted fever, which is transmitted by ticks. Lyme disease is transmitted by ixodid, or deer ticks, which is a vector. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who is n

A nurse is preparing to auscultate a client's heart. Which of the following positions is best for detecting a low-pitched diastolic murmur? A. A B. B C. C D. D

B. B Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to auscultate a client's heart. Question: Which of the following positions is best for detecting a low-pitched diastolic murmur? Person of Focus: The nurse who is preparing to auscultate the client's heart Key Words: auscultate, heart, positions, best, low-pitched diastolic murmur So, the question is asking the best position for detecting a low-pitched murmur. This is a graphic option item, which is similar to traditional multiple choice items except images are used in the options instead of text. The key word "best" in the question indicates this is a priority setting item, which means all four options are correct, but one is better than the others. In this item, all four positions can be used to auscultate the heart, but one position is the best for detecting low-pitched murmurs. Next you should review each option and determine which position is the best. This is the incorrect position. This image represents the supine position, which is appropriate for determining cardiac function at the various anatomical sites. While it can be possible to detect a low-pitched murmur in this position, there is another position that is best for detecting the presence of a low-pitched diastolic murmur. If you missed this item, your remediation should include an overview of cardiac examination techniques. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you

A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client's diet? (Select all that apply.) A. Cooked oatmeal B. Grape juice C. Applesauce D. Ice cream E. Smooth peanut butter

B. Grape juice D. Ice cream Rationale: A. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Cooked oatmeal is appropriate for a soft diet, but should not be included in a full liquid diet. B. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Grape juice is appropriate to include in both a clear liquid and a full liquid diet. C. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Applesauce is appropriate for a soft diet, but should not be included in a full liquid diet. D. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Ice cream is appropriate to include in a full liquid diet. E. A full liquid diet is comprised of liquids and foods that turn to liquid at room temperature and some foods at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Smooth

A nurse is caring for a client who is receiving vancomycin for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor? A. Respiratory depression B. Hearing loss C. Hypertension D. Bradycardia

B. Hearing loss Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is receiving vancomycin for a beta-hemolytic streptococci infection. Question: For which of the following adverse effects should the nurse monitor? Person of Focus: The client who is receiving vancomycin Key Words: laboratory values, indicates, nephrotoxicity So, the question is asking which finding the nurse should monitor for in a client who is receiving vancomycin. This was a positively worded, traditional multiple choice item, which means there were four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next, you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Respiratory depression is incorrect. Difficulty breathing and wheezing, not respiratory depression, are adverse effects of vancomycin. If you missed this item, your remediation should include an overview of the adverse effects of vancomycin. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is receiving vancomycin for a beta-hemolytic

A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury? A. Lock knees. B. Stand close to the client. C. Keep feet close together. D. Move client by twisting at the waist.

B. Stand close to the client. Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who needs assistance moving from the bed to a chair. Question: The nurse should take which of the following actions to prevent a lift injury? Person of Focus: The client who is being transferred from the bed to a chair Key Words: transfer, prevent, lift injury So, the question is asking which of the actions the nurse should take to prevent sustaining an injury when transferring a client from the bed to a chair. This is a positively worded, traditional multiple choice item, which means there will be four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Lock knees is incorrect. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should flex the knees instead of locking them. Flexing the knees increases the stability of the nurse. If you missed this item, your remediation should include an overview of body mechanics and appropriate transfer techniques. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positivel

A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading? A. Wrapping the cuff loosely around the arm B. Using a cuff that is too wide C. Leaving client's arm unsupported D. Taking client's blood pressure immediately after client sits down

B. Using a cuff that is too wide Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to measure the blood pressure of a client who has hypertension. Question: Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading? Person of Focus: The client who has hypertension and is having his blood pressure measured by the nurse Key Words: measure, blood pressure, inaccurately low reading So, the question is asking which of the actions can cause an inaccurately low reading. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Wrapping the cuff loosely around the arm is incorrect. Wrapping the cuff too loosely around the arm can result in a false high blood pressure reading. If you missed this item, your remediation should include an overview of factors that influence blood pressure readings. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priori

A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam preoperatively. Which of the following statements by the client indicates the medication has been effective? A. "I am wide awake now." B. "My mouth is very dry." C. "I feel very relaxed." D. "My heart is racing."

C. "I feel very relaxed." Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam preoperatively. Question: Which of the following statements by the client indicates the medication has been effective? Person of Focus: The client who received the preoperative dose of lorazepam Key Words: administers, lorazepam (Ativan), preoperatively, effective So, the question is asking which client statement indicates the medication has been effective. This was a positively worded, traditional multiple choice item, which means there were four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you have to review each option and determined if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. "I am wide awake now" is incorrect. Lorazepam is a benzodiazepine and does not cause the client to become more awake. Instead, lorazepam's effect on the CNS can cause drowsiness. This statement by the client does not indicate the medication has been effective. If you missed this item, your remediation should include an overview of lorazepam. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. A

A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following stages of grief? A. Anger B. Acceptance C. Bargaining D. Denial

C. Bargaining Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is scheduled for a biopsy of a tumor located in her left lower lobe. The client states, "I will quit smoking if the results don't come back positive for cancer." Question: This statement indicates the client is in which of the following stages of grief? Person of Focus: The client scheduled for the biopsy of a lung tumor Key Words: tumor, left lower lobe of lung, "I will quit if" So, the question is asking which of the stages of grief is client is in. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Anger is incorrect. Denial, anger, bargaining, and acceptance are all stages of the dying and grief process. The statement made by the client is not an example of anger. If you missed this item, your remediation should include an overview of the stages of grief. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priorit

A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take? A. Request prescription for iron supplement. B. Administer 4 oz of orange juice. C. Restrict fluid intake. D. Encourage bed rest.

C. Restrict fluid intake. Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse on a rehabilitation unit has just received report on a client who was admitted 3 days ago. Question: Upon review of the client's medical record, which of the following actions should the nurse take? Person of Focus: The nurse caring for the client who was admitted to the rehabilitation unit 3 days ago Key Words: review, medical record, actions This is a positively worded exhibit item presented as a traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review the additional data presented in each of the tabs to determine if each option is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Request prescription for iron supplement is incorrect. The client's hemoglobin level is within the expected reference range; therefore, requesting a prescription for an iron supplement is not an appropriate action by the nurse. If you missed this item, your remediation should include an overview of the clinical findings associated with fluid volume excess. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded,

A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While performing a respiratory examination, the nurse hears the sound in the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds? A. Rhonchi B. Crackles C. Stridor D. Wheezes

C. Stridor Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While performing a respiratory examination, the nurse hears the sound in the provided audio clip. Question: Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds? Person of Focus: The infant diagnosed with laryngotracheobronchitis Key Words: laryngotracheobronchitis, respiratory examination, hears, audio clip, breath sound So, the question is asking which of the manifestations the nurse hears when performing a respiratory assessment. This is an audio format item, which means you have to listen to the provided audio to determine the correct answer. There are four options; one which is correct, called the key, and three that are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Rhonchi is incorrect. Rhonchi are course rattling sounds that are similar to snoring. The breath sound on the audio clip is not an example of rhonchi. If you missed this item, your remediation should include an overview of auscultation sounds. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking.

A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle? A. 1/2 inch B. 5/8 inch C. 1 inch D. 1 1/2 inch

D. 1 1/2 inch Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Question: Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle? Person of Focus: The nurse who is preparing to administer an IM injection Key Words: IM injection, needle lengths, ventrogluteal muscle So, the question is asking which of the needle lengths is appropriate for administering an injection in the ventrogluteal muscle. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 1/2 inch is incorrect. A 1/2 inch needle is used for subcutaneous injections in adults; it is inappropriate to use for an IM injection. If you missed this item, your remediation should include an overview of administering IM injections. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparin

A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching? A. 1/2 cup of white rice B. 1 slice of wheat bread C. 1 cup of 2% milk D. 3/4 cup of canned tomato juice

D. 3/4 cup of canned tomato juice Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Question: Which of the following food or beverage selections by the client indicates a need for further teaching? Person of Focus: The client who has been taught about a 2,000 mg sodium-restricted diet Key Words: 2,000 mg sodium-restricted diet, selections, need for further teaching So, the question is asking which of nutritional selections is not appropriate for a client prescribed a 2,000 mg sodium-restricted diet. This is a negatively worded, traditional multiple choice item, which means there are four options. Of these options, three are accurate, called the distracters, and one is inaccurate, which is the key because the item is negatively worded. Because the question indicates there is only one correct answer, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 1/2 cup of white rice is incorrect. Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. A 1/2 cup of white rice contains approximately 5 mg of sodium; therefore, this food selection is appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet.If you missed this item, your remediation should include an overview of a 2,000 mg sodium-restricted diet, as well as sodium content of common fo

A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first? A. Percussion B. Palpation C. Auscultation D. Inspection

D. Inspection Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. Question: When examining the abdomen, which of the following techniques should the nurse perform first? Person of Focus: The client who is reporting abdominal discomfort Key Words: examining, techniques, first So, the question is asking which of the techniques the nurse should perform first when examining the abdomen. This is a positively worded, multiple choice item. The key word "first" in the question indicates this is a priority setting item, which means all four options are correct, but one takes priority over the others. In this item, all four techniques are performed when examining the abdomen, but one of the techniques should be performed before the others. Next you should review each option and determined which to perform first. Percussion is incorrect. Percussion is the third technique used while conducting an abdominal assessment on a client to discern the presence of tympany and dullness. It is performed to evaluate for the presence of gas in the intestines or fluid and masses in the abdominal cavity. If you missed this item, your remediation should include an overview of abdominal examination techniques. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it invol

A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client? A. Lithotomy B. Dorsal recumbent C. Prone D. Sims

D. Sims Rationale: A. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to administer a tap water enema to a client. Question: In which of the following positions should the nurse place the client? Person of Focus: The client who is being prepared for administration of an enema Key Words: tap water enema, positions So, the question is asking which of the positions the nurse should place the client to administer a tap water enema. This is a positively worded, traditional multiple choice item, which means there are be four options. Of these options, one is be correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Lithotomy is incorrect. The lithotomy position facilitates insertion of a vaginal speculum to examine the female genitalia and genital tract. The client should not be placed in this position to administer an enema. If you missed this item, your remediation should include an overview of procedural guidelines for administering cleansing enemas. B. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A n