ATI Nurse Logic: Nursing Concepts

A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality? A. Placement of computer systems in restricted areas B. Installation of firewall software on each computer C. Ability of staff to access electronic health records of clients throughout the facility D. Occurrence of an automatic log-off after a period of inactivity

Ability of staff to access electronic health records of clients throughout the facility

A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests a referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles? A. Justice B. Autonomy C. Veracity D. Fidelity

Autonomy

A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching? A. Cue the client by providing picture cards that portray common needs B. Increase the volume of the voice when speaking to the client C. Encourage the client to limit hand gestures when communicating C. Vary the use of phrases and terminology in discussions

Cue the client by providing picture cards that portray common needs

A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take? A. Administer epinephrine (Adrenaline) B. Elevate the lower extremities C. Determine respiratory status D. Apply oxygen via non-rebreather mask

Determine respiratory status

A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting? Select all that apply. A. Dietician B. Physical therapist C. Hospice nurse D. Social worker E. Respiratory therapist

Dietician Physical therapist Social worker

A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires the nurse preceptor to intervene? A. Including in a client's nurses' note that an incident report was completed after a medication error B. Drawing horizontal lines through blank spaces left in the nurses' notes followed by a signature C. Refusing to chart the vital signs taken by another nurse on a client's graphic flow sheet D. Documenting the provider was contacted to clarify a questionable prescription

Including in a client's nurses' note that an incident report was completed after a medication error

A nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication? A. Speech pathologist B. Occupational therapist C. Social worker D. Respiratory therapist

Speech pathologist

A nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions? A. Prone with head of the bed flat B. Dorsal recumbent with head of the bed elevated to 15 degrees C. Supine with head of the bed elevated to 30 degrees D. Side-lying with head of the bed elevated to 45 degrees

Supine with head of the bed elevated to 30 degrees

A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first? A. Take an ABG specimen to the laboratory B. Transport a client to the radiology department for an x-ray C. Obtain a clean catch urine sample from a newly admitted client D. Pass fresh water to clients

Take an ABG specimen to the laboratory

A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching? A. "I will only be on this medication 4 to 6 months because it can lead to physical dependence." B. "I can have 1 to 2 alcoholic beverages each week." C. "I will need to stop taking Xanax two weeks before I can begin taking this medication." D. "I can have 6 to 8 ounces of grapefruit juice each day."

"I can have 1 to 2 alcoholic beverages each week."

A nurse is working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching? A. "I will have my husband wear a condom during intercourse." B. "I will check my temperature every 4 hours." C. "I will wipe from front to back after bowel movements." D. "I will notify my doctor if my baby moves fewer than 4 times in the 2 hours following each meal."

"I will have my husband wear a condom during intercourse."

A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching? A. "It is necessary to have written consent for invasive procedures." B. Implied consent is appropriate for some aspects of nursing care." C. "It is the responsibility of the provider to obtain express consent." D. "Informed consent should be obtained separately for each surgical procedure."

"It is the responsibility of the provider to obtain express consent."

A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate? A. "I know this must be difficult, but your mother will calm down soon." B. "Let's discuss some strategies you can use when this happens again." C. "Individuals near death are ready to let go toward the end." D. "Have you determined why she is crying and saying she is ready to die."

"Let's discuss some strategies you can use when this happens again."

A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized, she asks the nurse why she had to be transferred to a unit where her family will be unable to stay with her all the time. Which of the following responses is appropriate? A. "I know this must be frightening, but you are going to be fine." B. "Let's talk for a minute about your concerns." C. "You were transferred because it is in your best interest." D. "Why do you feel a family member should be with you?"

"Let's talk for a minute about your concerns."

A nurse is reinforcing teaching about transdermal nitroglycerin (Nitro-Dur) to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective? A. "I should leave the patch on for 16 to 20 hours each day." B. "I will apply a new patch in the same location each day." C. "The patch should be effective within an hour of being applied." D. "The medication is not absorbed as well when placed on the abdomen."

"The patch should be effective within an hour of being applied."

A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client? A. Acupuncture is loosely regulated by the federal government B. Acupuncture has been discredited by scientific research C. Acupuncture is though to be effective only as a placebo D. Acupuncture has been proven to reduce pain and increase function

Acupuncture has been proven to reduce pain and increase function

A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin? A. Provide a toy doctor's kit to play with B. Keep all syringes and needles out of sight until needed C. Use an approach that is firm but direct D. Allow the child to manipulate the medical equipment

Allow the child to manipulate the medical equipment

A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign? A. A preschooler with a hip spica cast who is being discharged today B. An infant scheduled for a surgical repair of a ventricular septal defect tomorrow C. A toddler with a fractured femur who has been in Bryant's traction for 5 days D. An adolescent who is 2 days postoperative following an appendectomy

An adolescent who is 2 days postoperative following an appendectomy

A nurse is caring for an older adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following? A. Celecoxib is contraindicated in clients taking valproic acid B. Celecoxib is contraindicated in older adults C. Celecoxib is contraindicated in clients with a seizure disorder D. Celecoxib is contraindicated in clients with an allergy to sulfonamide

Celecoxib is contraindicated in clients with an allergy to sulfonamide

A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors by the client best indicate to the nurse that teaching has been effective? A. Self-reporting the ability to perform the procedure B. Answering appropriately when questioned orally C. Responding accurately on a written examination D. Demonstrating independent performance of the procedure

Demonstrating independent performance of the procedure

A nurse in a local clinic is caring for a female client who is 35 years old. Which of the following screenings should the nurse recommend to the client? A. Mammogram every year to detect breast cancer B. Colonoscopy every 10 years to detect colon cancer C. Dermatologist evaluation every 3 years to detect skin cancer D. Complete eye examination every year to detect eye disorders

Dermatologist evaluation every 3 years to detect skin cancer

A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action? A. Inform the nurse manager B. Determine the client's condition C. Notify the provider D. Complete an incident report

Determine the client's condition

A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention? A. Painful swallowing B. Hoarse voice C. Difficulty breathing D. Blood-tinged sputum

Difficulty breathing

A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice? A. Assign a security guard to stay at the client's door B. Request a prescription from the provider for soft restraints C. Discuss the risks associated with leaving with the client D. Remove the telephone from the client's room

Discuss the risks associated with leaving with the client

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis? A. Increased appetite B. Elevated temperature C. Bradycardia D. Drowsiness

Elevated temperature

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication? A. Hyperkalemia B. Severe diarrhea C. Atelectasis D. Excessive vomiting

Excessive vomiting

A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following? A. Facial edema B. Urinary frequency C. Acid indigestion D. Breast leakage

Facial edema

A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client? A. Raising her voice when speaking to the client B. Asking the client open-ended questions C. Clarifying client statements with the family as needed D. Having the client use eye blinks to indicate yes or no

Having the client use eye blinks to indicate yes or no

A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects? A. Tachycardia B. Sternal retractions C. Hypoglycemia D. Hypothermia

Hypoglycemia

A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include? A. Medications will eliminate HIV in most clients B. Adolescents are at a lower risk for developing HIV C. Initial HIV symptoms are often similar to the flu D. Using condoms ensures the prevention of HIV during sexual intercourse

Initial HIV symptoms are often similar to the flu

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? A. Pupil dilaton B. Ataxia C. Lethargy D. Bradycardia

Lethargy

A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include in the teaching to place the client in which of the following positions? A. Lithotomy B. Dorsal recumbent C. Prone D. Lateral recumbent

Lithotomy

A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis and is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol? A. Loss of color discrimination B. Nausea and vomiting C. Red-orange discoloration to body fluids D. Edema of feet and hands

Loss of color discrimination

A nurse at a long-term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immoblie? A. Prospective audit B. Outcome audit C. Process audit D. Structure audit

Outcome audit

A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention? A. Blood glucose 150mg/dL B. Potassium 2.5 mEq/L C. Total protein 5.2 g/dL D. Urine specific gravity 1.040

Potassium 2.5 mEq/L

A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse's priority goal? A. Support the client's relationship with his caregivers B. Encourage the client to express his feelings C. Determine who is responsible for the abuse D. Protect the client from further abuse

Protect the client from further abuse

A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion? A. Reduced bleeding time B. Decreased plasma globulins C. Improved activity tolerance D. Increased immune functioning

Reduced bleeding time

A nurse is caring for a client who has nausea and a prescription for promethazine (Phenergan) 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule? A. Use a filter needle to administer to promethazine B. Expel air bubbles back into the ampule C. Set the ampule on a flat surface to withdraw the promethazine D. Break the ampule toward the body

Set the ampule on a flat surface two withdraw the promethazine

A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone teaching? A. States that pain is an 8 on a scale of 0 to 10 B. States that her partner should be given the information C. Expresses concern about the exercises causing pain when performed after surgery D. Expresses uncertainty about the benefits of the exercises

States that pain is an 8 on a scale of 0 to 10

A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first? A. Notify the provider B. Obtain a chest x-ray C. Flush the catheter D. Stop the infusion

Stop the infusion