Nurse logic: Testing & Remediation

A nurse is preparing to auscultate a client's heart. Which of the following positions is best for detecting a low pitched diastolic murmur?

(Left lateral) lying on side To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, keywords, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to auscultate a client's heart. Question: Which of the following positions is best for detecting a low-pitched diastolic murmur? Person of Focus: The nurse who is preparing to auscultate the client's heart Key Words: auscultate, heart, positions, best, low-pitched diastolic murmur So, the question is asking the best position for detecting a low-pitched murmur. This is a graphic option item, which is similar to traditional multiple choice items except images are used in the options instead of text. The key word "best" in the question indicates this is a priority setting item, which means all four options are correct, but one is better than the others. In this item, all four positions can be used to auscultate the heart, but one position is the best for detecting low-pitched murmurs. Next you should review each option and determine which position is the best. This is the correct position. This image represents the left lateral recumbent position, which is the best position for detecting a low-pitched diastolic murmur.

A nurse is preparing to administer an IM injection to an adult who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle? 1/2 inch 5/8 inch 1 inch 1 1/2 inch

1 1/2 inch To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Question: Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle? Person of Focus: The nurse who is preparing to administer an IM injection Key Words: IM injection, needle lengths, ventrogluteal muscle So, the question is asking which of the needle lengths is appropriate for administering an injection in the ventrogluteal muscle. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 1 1/2 inch is correct. A 1 1/2 inch needle is used for IM injections in adults. This length of needle is appropriate to use when administering an IM injection in the ventrogluteal muscle, which is a site commonly used for IM injections, in adults who have a BMI of 30.

A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed Benadryl 25 mg every 6hrs as needed. Available is Benadryl 12.5mg/5mL. How many teaspoons of Benadryl does the nurse instruct the parents to administer per dose?

2 tsp To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse in a provider's office is reinforcing teaching to the parents of a child who has allergies and is prescribed diphenhydramine (Benadryl) 25 mg every 6 hr as needed. Available is diphenhydramine 12.5mg/5mL syrup. Question: How many teaspoons of diphenhydramine does the nurse instruct the parents to administer per dose? Person of Focus: The nurse who is instructing the parents about administering diphenhydramine. Key Words: diphenhydramine 25 mg, available is diphenhydramine 12.5 mg / 5 mL syrup, teaspoons per dose. So, the question is asking the number of teaspoons of diphenhydramine the nurse should teach the parents to administer for each dose. This is a fill in the blank item, requiring a numerical calculation. Next you should set up the equation to solve this type of problem and calculate the correct dose. To answer correctly, only a number should be entered in the provided space. To answer this calculation fill in the blank question, the nurse should be able to convert 10 mL of medication into a household measurement (teaspoon). The child needs to receive 10 mL of diphenhydramine. There is 5 mL in one teaspoon, so 10 mL = (10 / 5) = 2 tsp. Therefore, you should enter the numeral 2 in the box without any units or spacing devices. STEP 1: What is the dose needed? Dose needed = Desired; 25 mg STEP 2: What is the dose available? Dose available = Have; 12.5 mg STEP 3: Do the units of measurement need to be converted? No (mg = mg) STEP 4: What is the quantity of the dose available? 5 mL STEP 5: Set up an equation and solve: Desired x Quantity / Have = Amount to be given; 25 mg x 5 mL / 12.5 = x mL; 25 x 5 / 12.5 = 125 ÷ 12.5 = 10 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 10 mL / x; 5x = 10; x = 2 tsp. STEP 6: Reassess to determine if the amount to be given makes sense. If there are 12.5 mg/mL and the prescribed amount is 25 mg, it makes sense to give 10 mL, which equals 2 tsp. The nurse should teach the parents to administer diphenhydramine 2 tsp per dose.

A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking blood pressure can result in an inaccurately low reading? Wrapping the cuff loosely around the arm Using a cuff that is too wide Leaving client's arm unsupported Taking client's blood pressure immediately after client sits down

Answer: Using a cuff that is too wide. Rationale: By using a cuff that is too wide the nurse would know that the time may not be recorded accurately and may result in a low reading To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to measure the blood pressure of a client who has hypertension. Question: Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading? Person of Focus: The client who has hypertension and is having his blood pressure measured by the nurse Key Words: measure, blood pressure, inaccurately low reading So, the question is asking which of the actions can cause an inaccurately low reading. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Using a cuff that is too wide is correct. Using a cuff that is too wide can result in a false low blood pressure reading.

A nurse in caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The clients states, I will quit smoking if the results don't come back positive for cancer. Anger Acceptance Bargaining Denial

Bargaining client is making a decision based on the results of another action. This is called bargaining. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is scheduled for a biopsy of a tumor located in her left lower lobe. The client states, "I will quit smoking if the results don't come back positive for cancer." Question: This statement indicates the client is in which of the following stages of grief? Person of Focus: The client scheduled for the biopsy of a lung tumor Key Words: tumor, left lower lobe of lung, "I will quit if" So, the question is asking which of the stages of grief is client is in. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Bargaining is correct. Denial, anger, bargaining, and acceptance are all stages of the dying and grief process. The statement made by the client is an example of bargaining. Clients or families might promise to improve or change habits as a part of the grieving process.

A nurse is performing a respiratory examination on a client whio has pneumonia. Which of the following sounds should be elicted over areas of consolidation during percussion? Dullness Hyper-resonance Resonance Tympany

Dullness To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is performing a respiratory examination on a client who has pneumonia. Question: Which of the following sounds should be elicited over areas of consolidation during percussion? Person of Focus: The client who has pneumonia Key Words: respiratory examination, sounds, consolidation, during percussion So, the question is asking which of the sounds heard during percussion should be elicited over areas of consolidation. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Dullness is correct. Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness. This is the sound that will be elicited during percussion over areas of consolidation.

A nurse us collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first? Percussion Palpation Auscultation Inspection

Inspection nurse should know that this is proper thing to do first so she can assess any other problems To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. Question: When examining the abdomen, which of the following techniques should the nurse perform first? Person of Focus: The client who is reporting abdominal discomfort Key Words: examining, techniques, first So, the question is asking which of the techniques the nurse should perform first when examining the abdomen. This is a positively worded, multiple choice item. The key word "first" in the question indicates this is a priority setting item, which means all four options are correct, but one takes priority over the others. In this item, all four techniques are performed when examining the abdomen, but one of the techniques should be performed before the others. Next you should review each option and determined which to perform first. Inspection is correct. Inspection should be performed first while conducting an abdominal assessment on a client. Inspection allows the nurse to note the contour and symmetry of the abdomen.

A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following? Mood Immunity Memory Vitality

Mood herbal tx for mild to moderate depression and to relieve depression-related anxiety. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is a provider's office is caring for a client who has depression and is taking St. John's Wort. Question: The herbal supplement is thought to improve which of the following? Person of Focus: The client who is taking St. John's Wort Key Words: depression, St. John's Wort, improve So, the question is asking which of the characteristics is thought to improve by taking St. John's Wort. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Mood is correct. St. John's Wort is widely used in the U.S. and other countries as an herbal supplement for treating mild to moderate depression and to relieve depression-related anxiety.

A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer? Partial thickness skin loss Visible subcutaneous fat Nonblanchable redness Exposed muscle

Partial-thickness skin loss To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is immobile and has developed a pressure ulcer. Question: Which of the following characteristics is associated with a stage II pressure ulcer? Person of Focus: The client who has developed a pressure ulcer Key Words: pressure ulcer, characteristics, stage II So, the question is asking which of the characteristics is associated with a stage II pressure ulcer. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Partial thickness skin loss is correct. Staging of pressure ulcers includes the depth of tissue involvement, description of exudates, dimensions of the wound, and the condition of surrounding skin. A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister.

A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury? Lock knees. Stand close to the client. Keep feet close together. Move client by twisting at the waist.

Stand close to patient To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who needs assistance moving from the bed to a chair. Question: The nurse should take which of the following actions to prevent a lift injury? Person of Focus: The client who is being transferred from the bed to a chair Key Words: transfer, prevent, lift injury So, the question is asking which of the actions the nurse should take to prevent sustaining an injury when transferring a client from the bed to a chair. This is a positively worded, traditional multiple choice item, which means there will be four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Stand close to the client is correct. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand close to the client. Standing close to the client decreases reaching for the client and reduces stress on the nurse's back.

A nurse on a Peds unit is caring for an infant who is diagnosed w/laryngotracheobronchitis. While performing a respiratory exam, the nurse hears the sound in the provided audio clip. Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds? Rhonchi Crackles Stridor Wheezes

Stridor harsh high-pitched sound heard on inhalation or expiration. Cause by turbulent air flow 2ndary to narrowing or blockage in upper airway. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse on a pediatric unit is caring for an infant who is diagnosed with laryngotracheobronchitis. While performing a respiratory examination, the nurse hears the sound in the provided audio clip. Question: Based on this finding, the nurse should conclude the client is exhibiting which of the following breath sounds? Person of Focus: The infant diagnosed with laryngotracheobronchitis Key Words: laryngotracheobronchitis, respiratory examination, hears, audio clip, breath sound So, the question is asking which of the manifestations the nurse hears when performing a respiratory assessment. This is an audio format item, which means you have to listen to the provided audio to determine the correct answer. There are four options; one which is correct, called the key, and three that are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Stridor is correct. Stridor is a harsh high-pitched sound heard on inhalation or expiration. It is caused by turbulent air flow secondary to a narrowing or blockage in the upper airway and is a common clinical manifestation of acute laryngotracheobronchitis. The breath sound on the audio clip is an example of stridor.

A nurse is reinforcing teaching to a client who is newly diagnosed w/Lyme disease. The nurses should include that the disease is transmitted in which of the following ways? Vector Airborne Vehicle Bloodborne

Vector To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. Question: The nurse should include that the disease is transmitted in which of the following ways? Person of Focus: The nurse who is reinforcing the teaching Key Words: Lyme disease, transmitted So, the question is asking which of the modes is how Lyme disease is transmitted. This is a positively worded, traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Vector is correct. Vectors are arthropods, which carry and transmit certain illnesses. Examples of illnesses transmitted by vectors include malaria, which is transmitted by mosquitos, and Rocky Mountain spotted fever, which is transmitted by ticks. Lyme disease is transmitted by ixodid, or deer ticks, which is a vector.

A nurse is caring for a client who is receiving vancomycin for a beta hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor? Respiratory depression Hearing loss Hypertension Bradycardia

hearing loss nurse would know that the drug might cause hearing loss. Therefore she would monitor the possibilities of this adverse reaction To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who is receiving vancomycin for a beta-hemolytic streptococci infection. Question: For which of the following adverse effects should the nurse monitor? Person of Focus: The client who is receiving vancomycin Key Words: laboratory values, indicates, nephrotoxicity So, the question is asking which finding the nurse should monitor for in a client who is receiving vancomycin. This was a positively worded, traditional multiple choice item, which means there were four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next, you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Hearing loss is correct. Ototoxicity, an auditory nerve injury, is the most serious adverse effect of vancomycin and can result in hearing loss. The nurse should monitor for this adverse effect.

A nurse on a rehab unit is caring for a client who was admitted 3 days ago. Upon review of the client's med record, which of the follwoign actions should the nurse take?

restrict fluid intake To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse on a rehabilitation unit has just received report on a client who was admitted 3 days ago. Question: Upon review of the client's medical record, which of the following actions should the nurse take? Person of Focus: The nurse caring for the client who was admitted to the rehabilitation unit 3 days ago Key Words: review, medical record, actions This is a positively worded exhibit item presented as a traditional multiple choice item, which means there are four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review the additional data presented in each of the tabs to determine if each option is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Restrict fluid intake is correct. Manifestations of fluid volume excess are indicated in the client's physical assessment findings of 2+ peripheral edema, elevated blood pressure, respiratory crackles bilaterally, and a BUN level that is below the expected reference range; therefore, it is appropriate for the nurse to restrict the client's fluid intake.

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A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed a dose of lorazepam (Ativan) preoperatively. Which of the following statement by the client indicates the medication has been effective? "I am wide awake now." "My mouth is very dry." "I feel very relaxed." "My heart is racing."

"I feel very relaxed now" nurse would know that the purpose of this drug is to promote relaxation. With this response the nurse would know that the drug has done its job effectively To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam preoperatively. Question: Which of the following statements by the client indicates the medication has been effective? Person of Focus: The client who received the preoperative dose of lorazepam Key Words: administers, lorazepam (Ativan), preoperatively, effective So, the question is asking which client statement indicates the medication has been effective. This was a positively worded, traditional multiple choice item, which means there were four options. Of these options, one is correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you have to review each option and determined if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. "I feel very relaxed" is correct. Lorazepam is a benzodiazepine and is frequently given preoperatively to relieve anxiety. This statement by the client indicates the medication has been effective.

A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching? 1/2 cup of white rice 1 slice of wheat bread 1 cup of 2% milk 3/4 cup of canned tomato juice

3/4 cup of canned tomato juice nurse would recognize that the client didn't understand because tomato juice has a lot of sodium in it. To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Question: Which of the following food or beverage selections by the client indicates a need for further teaching? Person of Focus: The client who has been taught about a 2,000 mg sodium-restricted diet Key Words: 2,000 mg sodium-restricted diet, selections, need for further teaching So, the question is asking which of nutritional selections is not appropriate for a client prescribed a 2,000 mg sodium-restricted diet. This is a negatively worded, traditional multiple choice item, which means there are four options. Of these options, three are accurate, called the distracters, and one is inaccurate, which is the key because the item is negatively worded. Because the question indicates there is only one correct answer, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. 3/4 cup of canned tomato juice is correct. Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. This beverage selection has approximately 820 mg of sodium; therefore, this food selection is not appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet. This selection indicates that further teaching is required by the nurse.

A nurse is reinforcing a teaching to a client who has fractured ankle and is learning to walk up the stairs. Identify the sequence of the actions the client should be taught when using a modified 3-point crutch gait.

Answer: Bear weight on unaffected leg, transfer weight to crutches, advance unaffected leg, shift weight from crutches to unaffected leg, and go up stairs. Rationale the nurse would know that this is correct sequence of events for her client. To answer this item you should have started by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority-setting. Let's analyze the item together now. Scenario: A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Question: Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait. Person of Focus: The client who is learning to go up stairs using a modified 3-point crutch gait. Key Words: learning, sequence of actions, up stairs, modified 3-point crutch gait. So, the question is asking for the appropriate sequence of actions when going up stairs using a modified 3-point gait crutch. This is a drag and drop or ordered response item, which means the options were listed unordered in a box on the left side of the screen and had to be "dragged and dropped" into the box on the right side of the screen in the correct order. This is a priority setting item because the options had to be placed in rank order. Next you should have reviewed each option and determined its appropriate placement in the sequence of required actions. The first action the client should be taught when using a 3-point crutch gait to go up stairs is to stand and bear weight on the unaffected leg. The second action the client should be taught when using a 3-point crutch gait to go up stairs is to transfer body weight to the crutches. The third action the client should be taught when using a 3-point crutch gait to go up stairs is to advance the unaffected leg between the crutches. The fourth action the client should be taught when using a 3-point crutch gait to go up stairs is to shift weight from the crutches to the unaffected leg. The fifth action the client should be taught when using a 3-point crutch gait to go up stairs is to align crutches on the stair. If you missed this item, your remediation should include an overview of crutch gaits.

A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client's diet? (select all that apply) Cooked oatmeal Grape juice Applesauce Ice cream Smooth peanut butter

Grape Juice, Ice Cream To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is caring for a client who has been prescribed a full liquid diet. Question: Which of the following is appropriate to include in the client's diet? Person of Focus: The client who has been prescribed a full liquid diet Key Words: full liquid diet, appropriate, include, select all that apply So, the question is asking which of the foods are appropriate to include in a full liquid diet. This is a positively worded, multiple response item, which means there are five or six options. Of these options, two or more are correct. Because the item included correct and incorrect options and you had to select only the correct options, it is not a priority setting item. Next you should review each option and determine if it is probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Cooked oatmeal is incorrect. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Cooked oatmeal is appropriate for a soft diet, but should not be included in a full liquid diet. Grape juice is correct. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Grape juice is appropriate to include in both a clear liquid and a full liquid diet. Applesauce is incorrect. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Applesauce is appropriate for a soft diet, but should not be included in a full liquid diet. Ice cream is correct. A full liquid diet is comprised of liquids and foods that turn to liquid at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Ice cream is appropriate to include in a full liquid diet. Smooth peanut butter is incorrect. A full liquid diet is comprised of liquids and foods that turn to liquid at room temperature and some foods at body temperature, and is prescribed for clients who are unable to tolerate solid or semisolid foods. Because a full liquid diet is low in iron, protein, and calories, it is not recommended for long-term use. Smooth peanut butter does not turn liquid at room temperature, therefore is not a part of a full liquid diet. If you missed this item, your remediation should include an overview of therapeutic diets, specifically the full liquid diet.

A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?

Sims' To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is preparing to administer a tap water enema to a client. Question: In which of the following positions should the nurse place the client? Person of Focus: The client who is being prepared for administration of an enema Key Words: tap water enema, positions So, the question is asking which of the positions the nurse should place the client to administer a tap water enema. This is a positively worded, traditional multiple choice item, which means there are be four options. Of these options, one is be correct, called the key, and three are incorrect, called the distracters. Because the question indicates there is only one correct option, it is not a priority setting item. Next you should review each option and determined if it was probably correct, possibly correct, or probably incorrect, and assign the appropriate code to each option. Sims' is correct. The left side-lying, or Sims' position, places the client on the side with the knee flexed. This position allows the enema to flow along the curve of the sigmoid colon and rectum naturally, which improves retention of the solution.

A nurse is examining a client's lymphatic system. Identify the site nurse should palpate to assess the posterior cervical lymph nodes.

Toward the back of the neck To answer this item, start by critically reading the stem and reviewing the scenario, as well as identifying the person of focus, key words, and what the question is asking. Also, you should have determined if the question was positively worded, negatively worded, or if it involves priority setting. Scenario: A nurse is examining a client's lymphatic system. Question: Identify the site the nurse should palpate to examine the posterior cervical lymph nodes. Person of Focus: The nurse who is examining the client's lymph system Key Words: lymphatic system, identify site, palpate, posterior cervical lymph nodes So, the question is asking the location the nurse should palpate to examine the posterior cervical lymph nodes. This is a Hot Spot item, which means an image is provided with "Hot Spots" indicated in various locations on the image. These Hot Spots indicate the options you have for answering the item. Next you should roll the cursor over the image to locate all of the Hot Spots and determine if each is probably correct, possibly correct, or probably incorrect. Then, you should click on one of the Hot Spots to select it as the correct option. This area, known as the posterior cervical, is correct. While facing the client, the nurse should use the pads of the middle three fingers to gently palpate the nodes in a circular motion and evaluate each for consistency, characteristics, mobility, warmth, and tenderness. This is the location of the posterior cervical lymph nodes, which are a group of lymph nodes located on the sides of the neck.