Knowledge and Clinical Judgment- Advanced
A nurse is caring for a patient who has a new colostomy. The patient is being discharged and plans to live with her daughter. Which of the following responses by the nurse is appropriate when the daughter states that she doesn't know how she is going to care for her mother's colostomy?
"What part of your mother's care concerns you?"
A nurse is caring for a patient who weights 132 lbs and has been prescribed gentamicin (Garamycin) 5 mg/kg/day by IV bolus in 3 equal doses. Available on hand is 40 mg/mL that is to be added to 50 mL of 0.9% sodium chloride. How many mL should the nurse add to the solution per dose
2.5mL
A nurse is caring for a patient who is pregnant with a single fetus and has a BMI of 23. When asked by the patient how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate?
25-35 lbs
A nurse is assigned to care for 4 patients. The patient with which of the following drainage tubes is at an increased risk for hypokalemia?
NG Tube w/ suction
A nurse is caring for a patient who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm the diagnosis?
Sputum culture for acid-fast bacillus
A nurse is collecting data on a patient who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following findings indicates the patient is experiencing an adverse effect of the medication?
WBC 2,800/mm
A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions?
a client that has rubella
A school nurse has requested the school board remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following?
advocacy
A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is post-op following a gastrectomy. Which of the following food selections by the Patient indicates the teaching was effective?
toast with peanut butter
A nurse is caring for a toddler who has acute otisis media and is prescribed benzocaine (Americaine) ear drops for pain relief. Which of the following actions by the nurse is appropriate when administering the ear drops?
warm refrigerated drops to room temp prior to installation
A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered dose inhaler (MDI) to a school aged child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching?
"I will use my cromolyn inhaler before using my albuterol inhaler."
A nurse is caring for a patient who is diagnosed with bipolar and is taking lithium (Lithane). Which of the following lithium serum levels indicates the the patient dosage is appropriate for maintenance therapy?
0.75mEq/L
A nurse is planning to obtain blood pressure of four patients. On which of the following patients should the nurse perform an electronic blood pressure measurement?
A patient who is recovering from a cardiac catheterization
A nurse is caring for a patient who has terminal pancreatic cancer. The patient is competent and has requested no resuscitative measures be taken in the event of respiratory or cardiac arrest. Which of the following is necessary to legally change the patients code status to do-not-resuscitate (DNR)?
A written Script from provider
A nurse is collecting data on a newborn who was delivered 30 minutes ago at the gestational age of 37 weeks. Which of the following findings requires further investigation?
abdominal distention
A nurse is caring for a patient who is post-op following a wedge resection of a lung and has a chest tube with a water seal drainage system. The patient reports a burning pain in his chest. Which of the following actions by the nurse is appropriate?
assist client to side lying position
A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness?
dark urine
A nurse is caring for a patient who is scheduled for a lumbar puncture. The nurse should teach the patient that which of the following is a post- procedure complication? :
headache
A nurse is caring for a school aged patient who was diagnosed with sickle cell anemia and has been admitted for a vaso-occlusive crisis. Which of the following findings has the highest priority?
slurred speech
A nurse administrator is reviewing policies and procedures of the facility she works in to ensure confidentiality requirements are being met. Which of the following indicates that intervention is needed to prevent the release of confidential client information?
Assigning staff members on each shift the same password for accessing medical records
