Knowledge and Clinical Judgment Beginning Test

A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements by the client indicated a need for further teaching?

"I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities."

A nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribed ciprofloxacin (Cipro) 250 mg PO two times daily. The amount available is 100 mg/tablet. How many tablets should the nurse administer with each dose?

2.5 250 mg x 1 tablet/100mg = x tablets; x=2.5 tablets.

A Nurse is providing discharge education to parents of preschooler who is prescribed tylenol 300mg every 4hr as needed. The liquid suspension that has been prescribed provides 120 mg/5mL. How many teaspoons should the nurse teach the parents to administer per dose?

2.5 tsp. 300 mg x 5 mL/120 mg = x mL; x= 12.5 mL; 1 tsp = 5 mL; 5 mL/1 tsp= 12.5 mL/x; 5x= 12.5; x= 2.5 tsp.

A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions?

Away from the body.

Which of the following solutions should the nurse use to clean a blood spill that occurred while inserting a catheter?

Bleach Chlorine is a disinfectant that is effective against bacteria, tuberculosis, spores, fungi, and viruses, and is specifically recommended for cleaning blood spills. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. Chlorine should be used to clean the spill.

When collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take?

Cover the area with a transparent wound barrier.

A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status?

Deep reddish-colored tongue

A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider?

Dimpling of the tissue in the upper outer quadrant

A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates a breach of confidentiality and requires intervention by the nurse preceptor?

Discussing changes in a client's plan of care with his friend who is a nurse on another unit.

A Nurse is caring for a patient with rheumatoid arthritis and is prescribed Prednisone. Which of the following indicates the client is experiencing an adverse effect?

Hyperglycemia Hyperglycemia, an elevated blood glucose level, is an adverse effect of dexamethasone. Both hyperglycemia and glycosuria can be manifested in clients who are taking dexamethasone because of its effect on the production and use of glucose.

A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills?

Living wills detail treatment wishes of the client in the event of terminal illness.

A nurse is collecting date on a recently admitted patient. Which of the following techniques should the nurse use to measure tissue perfusion?

Obtaining the client's level of oxygen saturation Perfusion is the delivery or pumping of arterial blood through tissues or an organ. Obtaining the client's level of oxygen saturation level is an appropriate technique of measuring perfusion. Oxygen saturation measures the percent of hemoglobin bound with oxygen that is being perfused through the arteries and into the tissues.

A nurse is caring for a patient who is diagnosed with anemia. Which of the following skin variations is caused by reduced amount of oxyhemoglobin?

Pallor Pallor is caused by a reduced amount of oxyhemoglobin. Pallor is a decrease in the coloring of the peripheral tissues that is caused by an overall reduction in the blood flow or by a decrease in the number of RBCs that contain oxyhemoglobin, which reduces the visibility of oxyhemoglobin.

A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following should be included?

Prepare healthy meal to serve at the end of class

A nurse is caring for a client who is receiving intermittent enteral tube feedings and have diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings?

Reduce the rate of the feedings.

A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter?

Supine

A nurse is caring for a patient who scheduled for cardiac surgery and tells the nurse, " I don't think I'm going to have the surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate?

Tell me more about your concerns.

A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicates a need for further teaching to prevent lift injuries?

Twisting at the waist and shoulders

A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication?

Urinary retention By increasing bladder sphincter and detrusor muscle tone and reducing awareness of bladder stimuli, morphine can cause urinary hesitancy, urinary retention, and urinary urgency.

A nurse is precepting a newly licensed nurse while he is charting. Use of which of the following abbreviations indicates a need for further teaching?

q.d.