ATI Knowledge and Clinical Judgement
A nurse is caring for a client who is 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? "Clients having this surgery are always scared." "Why have you changed your mind about the surgery?" "You shouldn't worry, everything will be fine." "Tell me more about your concerns."
"Tell me more about your concerns." In this item, you need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. 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.
A nurse is caring for a client who is diagnosed with a UTI and is prescribed ciprofloxacin (Cipro) 250mg PO two times dail. The amount available is 100mg/tablet. How many tablets should the nurse administer each dose>
2.5 Tablets
A nurse is providing discharge education to the parents of a preschooler who is prescribed acetaminophen (Tylenol) 300mg every 4 hours as needed. The acetaminophen liquid suspension that has been prescribed provides 120mg/5ml. How many teaspoons should the nurse teach the parents to administer each dose?
2.5 tsp In this item, you need knowledge of basic mathematic skills and the formula used for this type of calculation. Based on your understanding of these concepts, you can determine the number of teaspoons the nurse should teach the parents to administer. This item requires critical thinking because you have to analyze the provided information to determine the dosage, select the formula, enter data into the formula, and then perform the needed calculations. STEP 1: What is the dose needed? Dose needed = Desired; 300 mg STEP 2: What is the dose available? Dose available = Have; 120 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; 300 mg x 5 mL / 120 mg = x mL; x = 12.5 mL. Convert to tsp: Equivalents: 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? To the left To the right Toward the body Away from the body
Away from the body To answer this item, you need knowledge of sterile procedures. This item required foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. 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.
While 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? Reposition the client every 4 hr. Cover the area with a transparent wound barrier. Massage areas surrounding the redness. Wash the area with hot water every 8 hr.
Cover the area with a transparent wound barrier. In this item, you need knowledge of appropriate skin care interventions for clients who are immobile with indications of a stage I pressure ulcer. This item requires foundational thinking because you have to recall interventions that are appropriate for maintaining skin integrity in clients who are immobile. 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 is assisting with the preparation of an education program regarding advanced directives for newly hired staf. Which of the following information should be included about living wills? Living wills require a written prescription from the provider to be legal. Living wills allow the client to designate a health care proxy. Living wills ensure hospitals provide emergency care regardless of health coverage. Living wills detail treatment wishes of the client in the event of terminal illness.
Living wills detail treatment wishes of the client in the event of terminal illness. In this item, you need knowledge of advance directives. Based on this information, you can select the option that would be appropriate to include when teaching staff about living wills. This is a foundational item because you have to recall knowledge specific to the content and purpose of a living will. 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.
A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of people who are tactile learners. Which of the following activities should be included as a learning strategy in the program? Watch a video discussing healthy meal preparation. Prepare a healthy meal to serve at the end of class. Read pamphlets about preparing a healthy meal. Discuss healthy meal preparation as a class.
Prepare a healthy meal to serve at the end of class. In this item, you need knowledge of learning styles in order to determine strategies that enhance learning for each of the styles. This item requires critical thinking because you need to recall knowledge of each of the learning styles in order to analyze the options and determine which strategy is appropriate to enhance the transfer of knowledge for tactile learners. Learning styles are simply different approaches to learning. For learning to be effective, it is important to identify and recognize learning styles of the clients being taught. 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 collecting data on a client who has received a postoperative dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication? Urinary retention Rapid respirations Dilated pupils Diarrhea
Urinary retention In this item, you need nursing knowledge related to morphine to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of morphine. 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.
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? mcg q.d. mL PO
q.d. In this item, you need knowledge of abbreviations that the Joint Commission has determined should not be used in documentation. This is a negatively-worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively-worded items in Module 4. This item requires foundational thinking because you only need to recall knowledge related to the abbreviations that are not acceptable for use when charting. 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 caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by the reduced amount of oxyhemoglobin? Cyanosis Jaundice Erythema Pallor
Pallor In this item, you need nursing knowledge related to oxyhemoglobin and its effect on skin color. Based on an understanding of these two concepts, you can identify indicators of decreased oxyhemoglobin. This item requires critical thinking because you have to analyze the findings in relation to the expected color of the skin when there is a decreased level of oxyhemoglobin in the blood. 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.
A nurse is providing education about a new prescription for nitroglycerin for a client who is diagnosed with angina. Which of the following statements by the client indicate a further need for teaching? "I'll make sure that the medication container is kept tightly sealed." "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." "I'll keep my pills in the medicine cabinet when I'm home." "I'll go to the emergency room if my chest pain doesn't go away."
"I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." In this item, you need nursing knowledge related to the proper administration and storage of nitroglycerin. Based on an understanding of this information, you can identify which option describes a statement by the patient that does not reflect accurate understanding of the medication. This is a negatively worded item that asks you to select the option that indicates the patient needs further teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the administration and storage of nitroglycerin. This statement by the client indicates a need for further teaching. 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.
A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill? Isopropyl alcohol Chlorhexidine gluconate (Hibiclens) Chlorine (bleach) Iodophor
Chlorine (bleach) This item requires foundational thinking because you have to recall knowledge specific to disinfectants that are effective against bloodborne pathogens. Disinfectants are concentrated solutions that can be toxic to the skin and are typically used to destroy certain pathogens on inanimate objects. 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.
A nurse is collecting nutritional data on an older adult client. Which of the following finding is suggestive of a healthy nutritional status? Spongy gums that are receding Fissures at eyelid corners Easily plucked hair Deep reddish-colored tongue
Deep reddish-colored tongue A nur In this item, you need nursing knowledge of clinical findings that are associated with healthy nutrition. Based on an understanding of this information, you can identify which option describes an expected finding in clients who are properly nourished. This item requires foundational thinking because you only need to recall knowledge related to expected clinical findings. 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 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? Silver-colored striae Unilateral nipple inversion present since menarche Dimpling of the tissue in the upper outer quadrant Visible symmetrical venous patterns
Dimpling of the tissue in the upper outer quadrant In this item, you need nursing knowledge related to data collection of the breasts and knowledge of deviations from the expected that are indicative of cancer. Based on an understanding of these concepts, you can identify which option describes a finding that is not within the expected range and can indicate a cancerous lesion. This item requires foundational thinking because you have to identify which finding is outside the expected range. 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 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? Faxing laboratory results to a client's provider Discussing changes in a client's plan of care with his friend who is a nurse on another unit Describing a client's level of independence to the case manager arranging home health services Remaining in the room with the client while he reviews his own medical records
Discussing changes in a client's plan of care with his friend who is a nurse on another unit In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention by the nurse preceptor is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to interpret the one that results in a breach of confidentiality. 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.
A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication? Hypomagnesemia Hyperglycemia Hyponatremia Hyperkalemia
Hyperglycemia In this item, you need nursing knowledge of dexamethasone to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of dexamethasone. 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 collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion? Determining the client's respiratory rate Measuring the client's chest diameter Obtaining the client's level of oxygen saturation Checking the client's depth of respirations
Obtaining the client's level of oxygen saturation In this item, you need nursing knowledge related to what the term tissue perfusion means. Based on an understanding of this, you can identify which of the following findings is an indicator of adequate tissue perfusion. This item requires foundational thinking because you only need to identify which of the following options describes a technique for measuring tissue perfusion. 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 client who is receiving intermittent enteral tube feedings and having diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings? Chill formula prior to administration. Verify feeding tube placement. Reduce the rate of the feedings. Place the client supine during feedings.
Reduce the rate of the feedings. In this item, you need nursing knowledge of how to administer enteral tube feedings, complications of enteral tube feedings, and appropriate nursing actions in the event of those complications. Based on an understanding of these concepts, you can identify which option describes an intervention the nurse should implement for a client who is receiving enteral tube feedings and has diarrhea. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. 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.
A nurse is caring for a male client who has been prescribed an indwelling catheter. In which of the following positions should the client be placed for insertion of the catheter? Dorsal recumbent Orthopneic Side-lying Supine
Supine To answer this item, you need knowledge of inserting an indwelling urinary catheter on a male client. This item requires foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. 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 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 Standing with feet in a wide stance Positioning self close to the client Using arms and legs to lift
Twisting at the waist and shoulders In this item, you need nursing knowledge related to body mechanics. Based on an understanding of this concept, you can identify which option describes an action by the nurse that does not reflect good body mechanics. This is a negatively worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the use of appropriate body mechanics. 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.
