ATI: Nurse Logic 2.0: Nursing Concepts (Advance Test)

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis? A. Increased appetite B. Elevated temperature C. Bradycardia D. Drowsiness

B. Elevated temperature *The content of this question emphasizes the concept of client-centered care through identifying findings associated with a client's diagnosis. An elevated temperature is a finding associated with acute alcohol delirium.

A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate? A. "I know this must be difficult, but your mother will calm down soon." ​B. "Let's discuss some strategies you can use when this happens again." C. "Individuals near death are ready to let go toward the end." D. "Have you determined why she is crying and saying she is ready to die?"

​B. "Let's discuss some strategies you can use when this happens again." *The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. This response by the nurse offers to provide information, which can reduce anxiety and enhance decision-making. This response by the nurse creates a safe and secure environment, fosters trust and respect, and is appropriate.

A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following? A. Facial edema B. Urinary frequency C. Acid indigestion D. Breast leakage

A. Facial edema *The content of this question emphasizes the concept of client education by determining manifestations the client should be taught to immediately report to the provider. Facial edema is an indication of pregnancy-induced hypertension and should be reported immediately to the provider.

A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects? A. Tachycardia B. Sternal retractions C. Hypoglycemia D. Hypothermia

C. Hypoglycemia *The content of this question emphasizes the concept of safety through the recognition of a potential adverse effect that can result in physical harm. Betamethasone is a glucocorticoid used in the prevention of respiratory distress syndrome in premature infants. Betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.

A nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions? A. Prone with head of the bed flat B. Dorsal recumbent with head of the bed elevated to 15° C. Supine with head of the bed elevated to 30° D. Side-lying with head of the bed elevated to 45°.

C. Supine with head of the bed elevated to 30° *The content of this question emphasizes the concept of safety through selection of the appropriate position for a child who is postoperative following a supratentorial craniotomy. Following a supratentorial craniotomy, the client should be maintained in a position that facilitates drainage of cerebrospinal fluid and prevents hemorrhage by reducing blood flow to the brain. Positioning the client supine with the head of the bed elevated to 30° is appropriate.

A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting? (Select all that apply.) Dietician Physical therapist Hospice nurse Social worker Respiratory therapist

*Dietician is correct. Dieticians have expertise related to dietary contributions to maintaining health and treating disease and can offer the team suggestions that promote wound healing and muscle repair. *Physical therapist is correct. Physical therapists have expertise related to the musculoskeletal system and implements therapeutic treatments that will rebuild and improve strength, teach new skills, and regain mobility. *Social worker is correct. Social workers have expertise in working with clients and families to resolve issues that arise due to health problems and can link the client with community resources, assist with developing the discharge plan, and resolve conflict.

A nurse working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching? A. "I will have my husband wear a condom during intercourse." B. "I will check my temperature every 4 hours." C. "I will wipe from front to back after bowel movements." D. "I will notify my doctor if my baby moves fewer than 4 times in the 2 hours following each meal."

A. "I will have my husband wear a condom during intercourse." *The content of this question emphasizes the concept of client education by determining the need for additional teaching. The client who has experienced a premature rupture of membranes should not engage in sexual activity or insert anything in the vagina because of the increased risk for infection. This statement by the client indicates a need for additional teaching.

A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching? A. Cue the client by providing picture cards that portray common needs. B. Increase the volume of the voice when speaking to the client. C. Encourage the client to limit hand gestures when communicating. D. Vary the use of phrases and terminology in discussions.

A. Cue the client by providing picture cards that portray common needs. *The content of this question emphasizes the concept of client education by determining the appropriate communication strategy to include in teaching to the caregiver of a client who has aphasia. Clients who have aphasia have difficulty expressing themselves and understanding what is being said. Using picture cards that portray common needs provides cues for the client and enhances communication. The nurse should include this communication strategy in the teaching.

A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion? A. Reduced bleeding time D. Decreased plasma globulins C. Improved activity tolerance D. Increased immune functioning

A. Reduced bleeding time *The content of this question emphasizes the concept of safety through an understanding of the purpose of a platelet transfusion. Platelets are responsible for triggering the process of blood clotting. In response to intrinsic factors, such as abnormal blood, or extrinsic factors, such as inflammation or damage to blood cells because of trauma, platelets form platelet plugs. The formation of a platelet plug then triggers the more formal process of blood coagulation. Clients who have leukemia are prone to bleeding because of low platelet counts and should, therefore, experience a reduced bleeding time as a result of a transfusion of platelets.

A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first? A. Take an ABG specimen to the laboratory. B. Transport a client to the radiology department for an x-ray. Obtain a clean catch urine sample from a newly admitted client. Pass fresh water to clients.

A. Take an ABG specimen to the laboratory. *The content of this question emphasizes the concept of leadership by prioritizing completion of assigned tasks. When making assignments, a leader should be certain to include a timeline for completion. ABG samples are kept on ice and should be transported immediately to the laboratory or the specimen will deteriorate, which will cause inaccurate and meaningless results. This is the task the nurse should instruct the AP to perform first.

A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching? A. "I will only be on this medication 4 to 6 months because it can lead to physical dependence." B. "I can have 1 to 2 alcoholic beverages each week." C. "I will need to stop taking Xanax two weeks before I can begin taking this medication." D. "I can have 6 to 8 ounces of grapefruit juice each day."

B. "I can have 1 to 2 alcoholic beverages each week." *The content of this question emphasizes the concept of client education by determining which statement by the client indicates effectiveness of the teaching. Buspirone is an anxiolytic medication used to treat anxiety, but is different from benzodiazepines because of the fact that it is not a CNS depressant. Because of this, buspirone does not interfere with CNS depressants, such as benzodiazepines, alcohol, or barbiturates, and it is acceptable to have 1 to 2 alcoholic beverages each week. This statement by the client is true and indicates an understanding of the teaching.

A nurse at a long-term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile? A. Prospective audit B. Outcome audit C. Process audit D. Structure audit

B. Outcome audit *The content of this question emphasizes the concept of quality improvement by selecting the appropriate audit to conduct when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile. The primary goal of quality improvement is developing and implementing a plan to improve health care services and better meet the needs of clients. To accomplish this goal it is necessary to recognize client and facility issues that impact the provision of safe, quality care, as well as identify gaps between current practices and best practices. Audits are a process of measuring the quality of delivered care so better practices can be developed and implemented when needed. An outcome audit is conducted to determine the actual result a specific nursing intervention has had on client outcomes. This type of audit is appropriate to use when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile.

A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching? A. "It is necessary to have written consent for invasive procedures." B. "Implied consent is appropriate for some aspects of nursing care." C. "It is the responsibility of the provider to obtain express consent." D. "Informed consent should be obtained separately for each surgical procedure."

C. "It is the responsibility of the provider to obtain express consent." *The content of this question emphasizes the concept of professionalism by ensuring understanding of the legal concept of consent. Nurses frequently obtain express consent by witnessing a client sign a consent form after ensuring the client has received and understands necessary information regarding the procedure. This is not an appropriate statement by a newly licensed nurse and requires further teaching.

A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take? A. Administer epinephrine (Adrenaline). B. Elevate the lower extremities. C. Determine respiratory status. D. Apply oxygen via non-rebreather mask.

C. Determine respiratory status. *The content of this question emphasizes the concept of priority setting by determining priority nursing action for a client experiencing an allergic reaction. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This item can be answered using both nursing process and the ABC priority setting framework. The client is experiencing angioedema, indicating the possibility of an anaphylactic reaction, which is life-threatening; therefore, the nurse should first determine the client's respiratory status.

A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice? A. Assign a security guard to stay at the client's door. B. Request a prescription from the provider for soft restraints. C. Discuss the risks associated with leaving with the client. D. Remove the telephone from the client's room.

C. Discuss the risks associated with leaving with the client. *The content of this question emphasizes the concept of professionalism by determining the legal actions of the nurse when a client leaves a facility against medical advice. Discussing the risks associated with leaving the facility against medical advice with the client is a priority concern. The client should be made aware of potential negative outcomes that could occur if he chooses to leave the facility prior to physician-prescribed discharge.

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? A. Pupil dilation B. Ataxia C. Lethargy D. Bradycardia

C. Lethargy *The content of this question emphasizes the concept of safety through the identification of an initial manifestation of increased ICP. Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in the level of consciousness, such as restlessness, irritability, and disorientation, lethargy is the first sign of increased ICP.

A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin? A. Provide a toy doctor's kit to play with. B. Keep all syringes and needles out of sight until needed. C. Use an approach that is firm but direct. D. Allow the child to manipulate the medical equipment.

D. Allow the child to manipulate the medical equipment. *The content of this question emphasizes the concept of client-centered care by implementing age-appropriate strategies to prepare a client for a procedure. By using age-appropriate strategies, nurses facilitate the provision of individualized, high-quality care. Allowing the child to manipulate the equipment facilitates mastery and gives the child a sense of accomplishment. This action is appropriate when preparing a school-age child for a procedure.

A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign? A. A preschooler with a hip spica cast who is being discharged today B. An infant scheduled for a surgical repair of a ventricular septal defect tomorrow C. A toddler with a fractured femur who has been in Bryant's traction for 5 days D. An adolescent who is 2 days postoperative following an appendectomy

D. An adolescent who is 2 days postoperative following an appendectomy *The content of this question emphasizes the concept of leadership through the coordination of client care by making appropriate assignments. The care of an adolescent who is 2 days postoperative following an appendectomy requires postoperative care including education, infection prevention, and medications that require fundamental nursing skills and knowledge; therefore, it is appropriate to assign this client to the nurse who has floated from the labor and delivery unit.

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication? A. Hyperkalemia B. Severe diarrhea C. Atelectasis D. Excessive vomiting

D. Excessive vomiting *The content of this question emphasizes the concept of safety through the identification of a specific manifestation that can lead to metabolic alkalosis. Metabolic alkalosis is a potential complication of excessive vomiting because of the loss of acid from the body.

A nurse is caring for a client who is receiving parenteral nutrition through a non tunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first? A. Notify the provider. B. Obtain a chest x-ray. C. Flush the catheter. D. Stop the infusion.

D. Stop the infusion. *The content of this question emphasizes the concept of priority setting by determining the first action the nurse should take when suspecting a central venous catheter has migrated to the jugular vein. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. Stopping the infusion is the first action the nurse should take when suspecting a central venous catheter has migrated to the jugular vein. This prevents further damage to vessel and minimizes any additional harm to the client.