Nurse Logic 2.0 - Knowledge and Clinical Judgment - Beginning Test

A Nurse is caring for a patient with rheumatoid arthritis and is prescribed dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication? 1. Hypomagnesemia 2. Hyperglycemia 3. Hyponatremia 4. Hyperkalemia

2. Hyperglycemia Dexamethasone, a glucocorticoid, is a powerful anti-inflammatory and immunosuppressant and is indicated for the treatment of multiple disorders, including rheumatoid arthritis. Adverse effects of dexamethasone increase with the dosage and duration of treatment and can include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing's syndrome among others. 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 preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following should be included as a learning strategy in the program? 1. Watch a video discussing healthy meal preparation. 2. Prepare a healthy meal to serve at the end of class. 3. Read pamphlets about preparing a healthy meal. 4. Discuss healthy meal preparation as a class.

2. Prepare a healthy meal to serve at the end of class. Tactile learners learn best by touching and doing; therefore, having the participants prepare a healthy meal to serve at the end of class is a learning strategy appropriate for tactile learners.

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? 1. mcg 2. q.d. 3. mL 4. PO

2. q.d. To reduce the occurrence of medical errors, the Joint Commission developed a list of do-not-use abbreviations that should be avoided in health care settings. The abbreviation "q.d." was previously used to indicate every day, which can be mistaken as the abbreviation for "four times daily (qid)," resulting in medical errors. The Joint Commission has recommended the use of "daily" to indicate every day. This is not an acceptable abbreviation; therefore, additional teaching is needed.

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

A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? 1. Spongy gums that are receding 2. Fissures at eyelid corners 3. Easily plucked hair 4. Deep reddish-colored tongue

4. Deep reddish-colored tongue Deep reddish-colored tongue is suggestive of a healthy nutritional status. The tongue should be a healthy pink to a deep, reddish color with surface papillae present, without swelling or lesions.

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? 1. Cyanosis 2. Jaundice 3. Erythema ​4. Pallor

​4. Pallor Oxyhemoglobin is the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin molecule that will carry it. In clients who have anemia, the RBCs are reduced, by function or in number, to the point that peripheral tissues are not receiving adequate oxygen because of a decreased amount of circulating oxyhemoglobin. The reduced oxygen supply to the tissues causes changes to the client's skin color. 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. Erythema is a red color of the skin caused by increased blood flow, which enhances the visibility of oxyhemoglobin. Jaundice is a yellow-orange color of the skin caused by increased amounts of bilirubin being deposited in the tissues. Reduced oxygen levels in the tissues because of an increase in circulating deoxygenated hemoglobin results in cyanosis, which is a bluish color to the skin.

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? 1. Twisting at the waist and shoulders 2. Standing with feet in a wide stance 3. Positioning self close to the client 4. Using arms and legs to lift

1. Twisting at the waist and shoulders To prevent a lift injury when transferring the client from the bed to a chair, alignment of the back, neck, pelvis, and feet should be maintained to reduce the risk of injury to the lumbar vertebrae. This action by the newly licensed nurse is not appropriate and indicates a need for additional teaching. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand with the feet in a wide stance because it improves stability. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand close to the client to reduce stress on the back by decreasing the need to reach for the client. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should use the arms and legs to lift because larger muscle groups allow for heavier lifting without causing injury.

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? 1. Urinary retention 2. Rapid respirations 3. Dilated pupils 4. Diarrhea

1. Urinary retention Morphine is an opioid used to treat moderate to severe pain, and can reduce anxiety, produce a sense of well-being, as well as cause drowsiness and mental clouding. Morphine has an agonist effect on opioid receptors in the CNS, causing many of the adverse effects associated with the medication. Urinary retention is an adverse effect of morphine. By increasing bladder sphincter and detrusor muscle tone and reducing awareness of bladder stimuli, morphine can cause urinary hesitancy, urinary retention, and urinary urgency. Respiratory depression is an adverse effect of morphine and can cause pupils to constrict, known as miosis, which can result in impaired vision. Also, decreased GI motility, constipation is an adverse effect of morphine.

A nurse is providing patient education about a new prescription of nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements indicates a needs for further teaching? 1. "I'll make sure that the medication container is kept tightly sealed." 2. "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." 3. "I'll keep my pills in the medicine cabinet when I'm home." 4. "I'll go to the emergency room if my chest pain doesn't go away."

2. "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." Buying nitroglycerin in bulk quantities is not a safe practice. The chemical instability of the medication allows it to lose effectiveness over time. While some nitroglycerin tablets have a shelf life of 24 months, NitroQuick retains its effectiveness for only 8 to 10 months. Because of the shortened shelf life, the client should not buy the medication in bulk quantities, and the client should be instructed to date the bottle when it is first opened. The client should keep the nitroglycerin tablets in a dark, dry place, and in a dark-colored glass bottle with a tight lid. Tablets lose potency in containers made of plastic or cardboard or when mixed with other capsules or tablets. Exposure to air, heat, and moisture cause loss of potency. Going to the emergency department for chest pain is a critical point that can save the client's life. The client should call 911 or go to the nearest emergency department if anginal pain is not relieved within 5 min. Typically, the client can take up to 2 additional nitroglycerin tablets at 5-min intervals while awaiting emergency care.

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? 1. Reposition the client every 4 hr. 2. Cover the area with a transparent wound barrier. 3. Massage areas surrounding the redness. 4. Wash the area with hot water every 8 hr.

2. Cover the area with a transparent wound barrier. Damage to tissues caused by continuous pressure is described as a pressure ulcer. The risk for pressure ulcers can be complicated by factors such as immobility, inadequate nutrition, bowel and bladder incontinence, decreased mental status, reduced sensation, increasing age, and excessive body heat. Appropriate care of pressure ulcers is based on the characteristics and stage of the wound. A wound that manifests as a reddened area is a stage 1 pressure ulcer. A transparent wound barrier applied to reddened skin or a stage 1 pressure ulcer to prevent contamination and reduce friction to the area is an appropriate action by the nurse.

A nurse preceptor is orienting a newly licensed nurse. Which of the following actions indicates a breach of confidentiality and requires intervention by nurse preceptor? 1. Faxing laboratory results to a client's provider 2. Discussing changes in a client's plan of care with his friend who is a nurse on another unit 3. Describing a client's level of independence to the case manager arranging home health services 4. Remaining in the room with the client while he reviews his own medical records

2. Discussing changes in a client's plan of care with his friend who is a nurse on another unit HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. A nurse discussing changes in a client's plan of care with another nurse on another unit is a breach of confidentiality. Client information can only be shared with other health care professionals involved in that client's care. The nurse on the other unit should be directed to the client to request information about changes in the client's plan of care. This action is not appropriate and requires intervention by the nurse preceptor. Faxing laboratory results to a client's provider is not a breach in confidentiality. The provider is involved in the client's care and review of the lab work can impact currently prescribed interventions. When faxing client information, the nurse should verify the fax number, use a cover sheet with a confidentiality statement, and verify receipt of the document with the provider's office. Describing a client's level of independence to the case manager arranging home health services is not a breach in confidentiality. The case manager is directly involved in caring for the client and needs this information to determine which home care services are most appropriate. According to HIPAA, clients have the right to review and request copies of medical records, as well request amendments of those medical records. Policy and procedure regarding these rights of the client varies by facility and can include remaining with the client as he reviews his records.

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

2.5 tablets

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? 1. To the left 2. To the right 3. Away from the body 4. Toward the body

3. Away from the body Sterile packages are resistant to pathogens and are used for specific techniques or procedures to prevent contamination. During such procedures, any sterile item that comes into contact with an unsterile object is considered contaminated. To prevent contamination of the sterile field, nurses follow certain steps when opening sterile packages and creating a sterile field. Opening the sterile package away from the body first allows a nurse to open the remaining flaps without reaching over the sterile field, which could result in contamination. This is the appropriate direction to open the sterile package.

A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is pilled on the floor. which of the following solutions should the nurse use to clean the spill? 1. Isopropyl alcohol 2. Chlorhexidine gluconate (Hibiclens) 3. Chlorine (bleach) 4. Iodophor

3. Chlorine (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. Disinfectants are concentrated solutions that can be toxic to the skin and are typically used to destroy certain pathogens on inanimate objects. Isopropyl alcohol is an antiseptic often found in hand sanitizers and is effective against bacteria, tuberculosis, fungi, and viruses. 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. Isopropyl alcohol should not be used to clean the spill. Chlorhexidine gluconate is an antiseptic skin cleanser with bactericidal properties and is effective against bacteria and viruses. 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. Chlorhexidine gluconate should not be used to clean the spill. Iodophor is a disinfectant that is effective against bacteria, tuberculosis, spores, fungi and viruses, and is used to cleanse equipment. 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. If diluted, iodophor is acceptable for use on skin. This solution should not be used to clean the spill.

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? 1. Silver-colored striae 2. Unilateral nipple inversion present since menarche 3. Dimpling of the tissue in the upper outer quadrant 4. Visible symmetrical venous patterns

3. Dimpling of the tissue in the upper outer quadrant Dimpling of the tissue in the upper outer quadrant should be considered an unexpected finding and reported to the provider. In fact, dimpling that is noted anywhere within the breast tissue should be reported. Dimpling makes the tissue appear retracted in a particular area and can result from underlying scar tissue or an invasive tumor causing ligaments to pull the skin inward toward the tumor. This variation of the breast tissue is consistent with breast cancer.

A nurse is collecting date on a recently admitted patient. Which of the following techniques should the nurse use to measure tissue perfusion? 1. Determining the client's respiratory rate 2. Measuring the client's chest diameter 3. Obtaining the client's level of oxygen saturation 4. Checking the client's depth of respirations

3. 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. Determining the client's respiratory rate is not an appropriate technique of measuring perfusion. The respiratory rate allows the nurse to determine if breathing is rapid, slow, or within the expected reference range for a client who has COPD. Measuring the client's chest diameter is not an appropriate technique of measuring perfusion. Comparison of the anteroposterior chest diameter to the lateral chest diameter can indicate a ratio that is consistent with COPD caused by air trapping, which results in the chest having a rounded, rather than an oval, shape. Checking the client's depth of respirations is not an appropriate technique of measuring perfusion. The depth of respirations allows the nurse to determine if respirations are deep or shallow by determining the degree of lung expansion.

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? 1. Chill formula prior to administration. 2. Verify feeding tube placement. 3. Reduce the rate of the feedings. 4. Place the client supine during feedings.

3. Reduce the rate of the feedings. Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food. Complications of enteral tube feedings include feeding tube regurgitation and aspiration of feedings, delayed gastric emptying, and malabsorption among others. Reducing the rate of feedings is an appropriate action by the nurse to prevent diarrhea after subsequent feedings. A client receiving intermittent enteral tube feedings can experience diarrhea because of the administration of hyperosmolar enteral feedings. To prevent this, administration should be slowed or switched to continuous enteral feedings. Findings associated with tube displacement include coughing, vomiting, and pulmonary aspiration. Chilled formula can cause abdominal cramping, nausea, and vomiting; therefore, formula should be administered at room temperature. The head of the bed should be elevated to at least 30° during the administration of enteral tube feedings to prevent aspiration.

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? 1. "Clients having this surgery are always scared." 2. "Why have you changed your mind about the surgery?" 3. "You shouldn't worry, everything will be fine." 4. "Tell me more about your concerns."

4. "Tell me more about your concerns." The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Giving a general lead encourages the client to openly share feelings and concerns in a non-threatening environment, which will assist in establishing a meaningful nurse-client relationship. This response by the nurse is appropriate and fosters the nurse-client relationship. Sharing generalized beliefs is an automatic response and can result in the client feeling belittled or that her concerns are not being taken seriously. Beginning a question with "why" or requesting an explanation from the client can lead to resentment, mistrust, and insecurity. Offering false reassurance is an attempt to avoid the client's concerns and discourages additional discussions, resulting in a communication block.

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? 1. Living wills require a written prescription from the provider to be legal. 2. Living wills allow the client to designate a health care proxy. 3. Living wills ensure hospitals provide emergency care regardless of health coverage. 4. Living wills detail treatment wishes of the client in the event of terminal illness.

4. Living wills detail treatment wishes of the client in the event of terminal illness. Advance directives include both living wills and durable powers of attorney for health care. The living will details treatment wishes of the client in the event of terminal illness or persistent vegetative state. This information is accurate and should be included in the teaching about living wills Living wills must be signed by the client to be legal, but a prescription from the provider is not necessary. A written prescription from the provider is required for a do-not-resuscitate (DNR) order to take effect. The durable power of attorney for health care allows the client to designate a health care proxy, not the living will. The Emergency Medical Treatment and Active Labor Act ensures that hospitals provide emergency care regardless of health coverage, not the living will.

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? 1. Dorsal recumbent 2. Orthopneic 3. Side-lying ​4. Supine

​4. Supine Indwelling urinary catheters are indicated in numerous situations, such as relief of bladder distension, strict measurement of urinary output, need for bladder irrigations, and surgery. A prescription from the provider is required for urethral catheterization. When preparing to implement this procedure, it is important to ensure client privacy by draping nonessential body parts and positioning the client for optimal visualization while still maintaining comfort. A male client should be positioned in the supine position for insertion of an indwelling urinary catheter. This position allows for optimal visualization, which reduces trauma and increases success of insertion. A female client should be positioned in the dorsal recumbent position for insertion of an indwelling urinary catheter. The orthopneic position improves respiratory effort and is used to increase chest expansion, especially in clients who are having difficulty exhaling. A female client who is unable to abduct the leg at her hip joint should be positioned side-lying with the upper leg flexed at the hip.