ATI - NurseLogic Nursing Concepts Beginner

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 ? " I should leave the patch on for 16 to 20 hours each day . " " I will apply a new patch in the same location each day . " The patch should be effective within an hour of being applied . " " The medication is not absorbed as well when placed on the abdomen . "

" The patch should be effective within an hour of being applied . " Upon application of the patch the medication becomes effective within 20 to 60 minutes and lasts until the patch is removed The patch is worn for 12 to 14 hours each day for the medication to remain effective and prevent the development of tolerance The patch should be applied to a new location each day to prevent development of local irritation How to put results are attained when the patch is applied to the chest back abdomen or anterior thigh

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 ? Lithotomy Dorsal recumbent Prone Lateral recumbent

Lithotomy The lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of the female genitalia the nurse should drape the client appropriately to minimize exposure and embarrassment Dorsal recumbent position can be used as an alternative to the supine position when assessing the head and neck lungs breasts axillae heart and abdomen The prone position is used to assess hip joint extension skin and buttocks The lateral recumbent position is used to detect heart murmurs when assessing the heart

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 ? I know this must be frightening , but you are going to be fine . " " Let's talk for a minute about your concerns . " You were transferred because it is in your best interest . " Why do you feel a family member should be with you ? "

" Let's talk for a minute about your concerns . Discussing the clients concerns and providing appropriate information will Lower the clients anxiety level and establish an environment of open communication

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 ? Placement of computer systems in restricted areas Installation of firewall software on each computer Ability of staff to access electronic health records of clients throughout the facility Occurrence of an automatic log - off after a period of inactivity

Ability of staff to access electronic health records of clients throughout the facility The ability of staff to access electronic health records of clients throughout the facility allows for viewing confidential information on clients the staff might not directly be involved in the care of the majority of staff should only be allowed to access the electronic health records of clients on the unit where they work

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 ? Acupuncture is loosely regulated by the federal government . Acupuncture has been discredited by scientific research . Acupuncture is thought to be effective only as a placebo Acupuncture has been proven to reduce pain and increase function .

Acupuncture has been proven to reduce pain and increase function . Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care the nurse should include this information in discussions with the client acupuncture has been proven to reduce pain and increase function among clients who have osteoarthritis through clinical research studies clinical research has also shown additional benefits of acupuncture such as improving memory and orientation among clients who have certain types of dementia

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 ? Justice Autonomy Veracity Fidelity

Autonomy Autonomy is respecting the clients right to make personal healthcare decisions whether or not the nurse believes those decisions are in the best interest of the client this is the ethical principle the nurse is illustrating by making the referral as requested

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 ? Celecoxib is contraindicated in clients taking valproic acid . Celecoxib is contraindicated in older adults . Celecoxib is contraindicated in clients with a seizure disorder . Celecoxib is contraindicated in clients with an allergy to sulfonamide .

Celecoxib is contraindicated in clients with an allergy to sulfonamide . Celecoxib (celebrex) is a non-steroidal anti inflammatory cox2 inhibitor which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults however it contains a sulfa molecule.

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 ? Self - reporting the ability to perform the procedure Answering appropriately when questioned orally Responding accurately on a written examination Demonstrating independent performance of the procedure

Demonstrating independent performance of the procedure Return demonstration is the best evaluation tool for cycle motor learning

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 ? Mammogram every year to detect breast cancer Colonoscopy every 10 years to detect colon cancer Dermatologist evaluation every 3 years to detect skin cancer Complete eye examination every year to detect eye disorders

Dermatologist evaluation every 3 years to detect skin cancer Men and women Between the ages of 20 and 40 should have a skin cancer screening I had dermatologist every three years points above the age of 40 should have annual evaluation's Clients ages 40 or below should have a complete eye examination every 3 to 5 years clients between the ages of 40 and 64 should have a complete eye exam every two years and clients older than 65 should complete an eye examination annually Men in women ages 50 and older should have a colonoscopy every 10 years Women ages 40 or older should have annual mammograms

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 ? Inform the nurse manager . Determine the client's condition . Notify the provider . Complete an incident report .

Determine the client's condition . Ensuring clients remain the top priority in the provision of care nurses are able to assist in achieving national patient safety goals preventing or minimizing injury. The client is the immediate concern Determining their condition is crucial to the delivery of safe, effective care

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

Difficulty breathing .

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 ? Raising her voice level when speaking to the client Asking the client open - ended questions Clarifying client statements with the family as needed Having the client use eye blinks to indicate yes or no

Having the client use eye blinks to indicate yes or no Having a client who has aphasia use eye blinks to indicate yes or no is an appropriate action this action reduces anxiety of the client allows for the appropriate communication and reduces the risk of miscommunication

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 ? Including in a client's nurses ' note that an incident report was completed after a medication error Drawing horizontal lines through blank spaces left in the nurses ' notes followed by a signature Refusing to chart the vital signs taken by another nurse on a client's graphic flow sheet 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 This is not an appropriate action and requires intervention from the nurse preceptor incident reports are completed for incidents that are considered to be a deviation from expected outcomes of routine care and are often Used in quality improvement programs for the facility on incident report should be completed for a medication error this report is not referred to nor does it become part of the client permanent record. Drawing horizontal lines through blank space is left in the nursing notes followed by signature is an appropriate action and does not need intervention from the nurse preceptor these horizontal lines through blank spaces prevent incorrect information being added by another individual.

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 ? Medications will eliminate HIV in most clients . Adolescents are at a lower risk for developing HIV . Initial HIV symptoms are often similar to the flu . Using condoms ensures the prevention of HIV during sexual intercourse

Initial HIV symptoms are often similar to the flu . Emphasize the concept of client education by determining information that is appropriate to include in an educational program client education is the provision of health related education to clients to facilitate the acquisition of new knowledge and skills adoption of new behaviors and modification of attitudes it is important that information provided and educational programs we both useful to a client and based on current evidence. HIV infection consists of three stages the client typically experiences flu-like symptoms in the first or primary infection stage then during the clinical latency stage the client is an asymptomatic the final stage is characterized by the development of AIDS which is when the client become symptomatic and has a severely compromised immune system. Do use of condoms reduces the risk of contracting HIV but does not ensure prevention condoms can break a leak and just as they are not fool proof at preventing pregnancy they are 100% effective in preventing the spread of

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 ? Loss of color discrimination Nausea and vomiting Red - orange discoloration to body fluids Edema of feet and hands .

Loss of color discrimination The most commonly reported toxic reaction to normal therapeutic doses of erhambutol Is ocular toxicity as evidenced by visual disturbances examples include changes of color vision especially red and green and loss of visual acuity. Should be stopped immediately if ocular toxicity develops

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 ? Blood glucose 150 mg / dL Potassium 2.5 mEq / L Total protein 5.2 g / dL Urine specific gravity 1.040

Potassium 2.5 mEq / L Hypokalemia Potassium level of 2.5 is a low the expected reference range hyperkalemia can lead to arrhythmias or cardiac arrest

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 ? Support the client's relationship with his caregivers . Encourage the client to express his feelings . Determine who is responsible for the abuse . Protect the client from further abuse .

Protect the client from further abuse . By intervening appropriately and acting as an advocate for clients who have an abused nurses can assist in preventing or minimizing physical injury to the client protecting the client from further abuse should be the nurses priority goal is failure to do so can result in additional harm to the client as well as hierarchy of needs states that if there is not a Physiological need Then safety needs must be considered first because the client has been hospitalized for three days physiological needs have most likely been taken care of therefore the nurse should act to keep the client safe from harm While it is important to encourage the client to express their feelings it is not the nurses priority goal

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 ? Use a filter needle to administer the promethazine . Expel air bubbles back into the ampule . Set the ampule on a flat surface to withdraw the promethazine . Break the ampule toward the body .

Set the ampule on a flat surface to withdraw the promethazine . To withdraw the medication the ampule can be set on a flat surface or held upside down tilted at a slight angle . after the ampule is broken The rim is considered contaminated and should not be touched with the needle. A filter needle should be used to withdraw the medication from the ampule but should be replaced with a regular needle before administering the medication to the client Air bubbles should be expelled by removing the needle from the actual and tapping the sides of the syringe then pulling back on the plunger and finally pushing the plunger up gently to remove the air Always break away from the body

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 ? Speech pathologist Occupational therapist Social worker Respiratory therapist

Speech pathologist Interdisciplinary collaboration is a partnership between multidisciplinary members of the healthcare team that maximize is the expertise of each team member to enhance team decision making as well as achieve continuity of care and positive client outcomes. Pathologist identifies clients at risk for aspiration and develops recommendations for therapy the speech pathologist should attend swallowing and a client who has had a cerebrovascular incident An occupational therapist works with clients who have limited functional abilities to develop skills that are necessary to complete activities of daily living

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 ? States that pain is an 8 on a scale of 0 to 10 States that her partner should be given the information Expresses concern about the exercises causing pain when performed after surgery Expresses uncertainty about the benefits of the exercises

States that pain is an 8 on a scale of 0 to 10 Deep breathing and coughing exercises help prevent postoperative respiratory complications a key principle of teaching and learning is to first determine ability to learn physical symptoms such as pain fatigue or anxiety can prevent the client from learning because of a reduced ability to focus on and participate in education