ATI- NurseLogic 2.0
A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status?
Deep reddish-colored tongue
A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse?
Diarrhea
A nurse in a providers office is reinforcing teaching to the parents of a child who has allergies and is prescribed Benadryl 25mg every six hours as needed. Available is diphenhydramine 12.5/5mL. How many teaspoons of medicine does the nurse need to instruct the parents to administer per dose?
2 tsp
A Nurse is providing discharge education to parents of preschooler who is prescribed acetaminohen (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
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?
2.5
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?
"I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities"
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
"Tell me more about your concerns"
A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the vetrogluteal muscle?
1 ½ 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 rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first?
A client who had abdominal surgery 10 days ago and reports feeling his incision pop
A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern?
A client who is having a nosebleed associated with hypertension
A nurse is working with the information technology department of the the facility to establish protocol regarding security mechanisms that will protect the electronic health records of clients period which of the following could result in a violation
Ability of staff to access electronic health records of clients throughout the facility The ability of staff to access electronic health records of clients throughout the facility allows for viewing confidential information on clients the staff might not directly be involved in the care of. The majority of staff should only be allowed to access the electronic health records of clients on the unit where he or she works The content of this question emphasizes the concept of informatics through determining activities that can result in a breach of client confidentiality. Informatics is the storage, retrieval, communication, and management of data through the use of information technology. In current practice, nurses use a variety of technologies, such as the electronic medical record, bar coding and auto-identification systems, electronic prescribing, telehealth, and portable computer systems. It is important for privacy and confidentiality of client information to be considered when using information technologies in order to meet the requirements of HIPAA. This action is not appropriate and can result in a violation of client confidentiality
A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client?
Acupuncture has been proven to reduce pain and increase function Acupuncture has been proven to reduce pain and increase function among clients who have osteoarthritis through clinical research studies. Clinical research has also shown additional benefits of acupuncture, such as improving memory and orientation among clients who have certain types of dementia. The content of this question emphasizes the concept of evidence-based practice through specific knowledge of a client's use of alternative therapy. Evidence-based practice is the use of current knowledge from research and other credible sources to make clinical judgments and client care decisions. Using evidence as the basis for nursing care promotes optimum care of the client and yields a higher level of positive outcomes. Knowledge and understanding of various alternative therapies enables nurses to safely incorporate therapies being used by a client in the provision of care. The nurse should include this information in discussions with the client.
A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first?
Assist client to cough effectively
A nurse is caring for a client who has cancer. The client has decided to stop treatment and request a referral to hospice. They making the referral as requested the nurses illustrating which type of ethical principles?
Autonomy Autonomy is respecting the client's right to make personal health care decisions, whether or not the nurse believes those decisions are in the best interest of the client. This is the ethical principle the nurse is illustration by making the referral as requested The content of this question emphasizes the concept of professionalism by using ethical principles to guide nursing practice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. - Justice is the use of fairness, which is not the ethical principle the nurse is illustrating by making the referral as requested. Examples of justice in nursing practice includes advocating for fair distribution of resources or providing all clients with the same level of care regardless of his or her level of health benefits. - Veracity is the act of truth-telling. This is not the ethical principle the nurse is illustrating by making the referral as requested. An example of veracity in nursing practice includes telling a client of his terminal diagnosis when he asks, even if it goes against the wishes of the family. - Fidelity is the act of keeping promises. This is not the ethical principle the nurse is illustrating by making the referral as requested. An example of fidelity includes following through on a promise to return with pain medication in a specified period of time
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?
Away from body
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.
Bargaining. 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 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.
Bear weight on unaffected leg, transfer weight to crutches, advance unaffected leg, shift weight from crutches to unaffected leg, and go up stairs.
A nurse is caring for an older adult who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states that keep seeing commercials on TV for Celebrex and want to try it period upon review of scientific evidence the nurse should inform the client which of the following?
Celecoxib is contraindicated in clients with allergy to sulfonamides Celecoxib (Celebrex) is a non-steroidal anti-inflammatory, cyxlooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib contains a sulfa molecule; therefore, celecoxib is contraindicated in clients who have an allergy to sulfa
A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first?
Check on the client
A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for fluid volume deficit?
Check the heart rate and blood pressure
A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take?
Check the leg for warmth and edema
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?
Chlorine (bleach)
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?
Cover area with transparent wound barrier
A nurses caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client?
Creating meaningful social relationships
A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors of the client indicates that teaching has been effective?
Demonstrating independent performance of the procedure Return demonstration is the best evaluation tool for psycho-motor learning, which is the acquisition of knowledge or skills that integrate mental and muscular activity.
A nurse in a local Clinic is caring for a female client who is 35 years old. Which of the following screening should the nurse recommend to the client?
Dermatologist evaluation every three years to detect skin cancer Men and women between the ages of 20 and 40 should have skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations The content of this question emphasizes the concept of client-centered care through the recommendation of age-appropriate health screenings. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By recommending age-appropriate screenings, nurses facilitate the provision of individualized, high-quality care. A dermatologist evaluation every 3 years is an appropriate screening to recommend to a 35-year-old client. - A mammogram every year is not an appropriate screening to recommend to a 35-year-old client. Women ages 40 or older should have annual mammograms. - A colonoscopy every 10 years is not an appropriate screening to recommend to a 35-year-old client. Men and women ages 50 and older should have a colonoscopy every 10 years. - A complete eye examination every year is not an appropriate screening to recommend to a 35-year-old client. Clients ages 40 or below should have a complete eye examination every 3 to 5 years. Clients between the ages of 40 and 64 should have a complete eye examination every 2 years, and clients older than 65 should have a complete eye examination annually.
A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action?
Determine the client's condition The client is the immediate concern, and determining his condition is crucial to the delivery of safe, effective care. The content of this question emphasizes the concept of safety by following the appropriate steps after a medication administration error. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By ensuring clients remain the top priority in the provision of care, nurses are able to assist in achieving National Patient Safety Goals, preventing or minimizing physical injury. This is the first action the nurse should take when discovering a medication error. ~Other answers (not most correct answer): - Complete an Incident Report: This is not the first action the nurse should take when discovering a medication error. While creating an incident report is important and should typically occur within 24 hr of the incident, there is another action that better ensures the safety of the client. - Inform the Nurse Manager & Notify the Provider
A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first?
Determine the mobility status of each patient
A nurse is caring for a client following a Bronchoscopy . Which of the following findings requires immediate intervention?
Difficulty breathing This finding can lead to hypoxia; therefore, immediate intervention is warranted. The difficulty in breathing can be caused by edema in the larynx or trachea and is a serious complication The content of this question emphasizes the concept of priority setting by requiring the determination of which finding requires immediate intervention. 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. ~ other answer (wrong/not most right) rationales: - This finding may require intervention if it doesn't resolve within a specified time frame; however, it does not require immediate intervention. Blood-tinged mucous and sputum is an expected finding following the procedure because of trauma of the tissue of the larynx, trachea, or bronchi when the bronchoscope is inserted - This finding may require intervention to relieve discomfort; however, it does not require immediate intervention. A hoarse voice is an expected finding following a bronchoscopy. The client may complain of hoarseness after the bronchoscopy because of the trauma to tissue of the larynx and the trachea. - This finding may require intervention to relieve discomfort; however, it does not require immediate intervention. Painful swallowing is an expected finding following a bronchoscopy. The swallowing reflex is usually blocked for about 6 hr after the procedure. When the reflex returns, the client may experience some discomfort and difficulty when swallowing.
A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider?
Digoxin 3.0ng/mL
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?
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 indicates a breach of confidentiality and requires intervention by nurse preceptor?
Discussing changes in clients plan of care with his friend who is a nurse on another unit
A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should the client be elected over areas if consolidation during percussion?
Dullness The nurse would know that a client with pneumonia likely would have a dullness sound in his lungs.
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 clients diet?
Grape Juice, Ice Cream
A nurse is preparing to administer oral medication to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse?
Have the client position the head with the chin down while swallowing
A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client?
Having the client use eye blinks to indicate yes or no This action reduces anxiety of the client, allows for appropriate communication, and reduces the risk for miscommunication The content of this question emphasizes the concept of client-centered care by identifying the appropriate technique to communicate with a client who is diagnosed with aphasia. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using appropriate communication strategies, the nurse enhances the provision of safe, quality care. Having a client who has aphasia use eye blinks to indicate yes or no is an appropriate action by the nurse. This action reduces anxiety of the client, allows for appropriate communication, and reduces the risk for miscommunication.
A nurse is caring for a patient with rheumatoid arthritis and is prescribed Prednisone. Which of the following indicates the client is experiencing an adverse effect?
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 is caring for a newly admitted client. Which of the following client needs should the nurse address first?
Hypoxic
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 preoperatively. Which of the following statement by the client indicates the medication has been effective?
I feel very relaxed now Lorazepam is a benzodiazepine and is frequently given preoperatively to relieve anxiety and to promote relaxation. With this response the nurse would know that the drug has done its job effectively
A newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster?
Immediate
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires a nurse preceptor to intervene?
Including in a client notes that an incident report was completed after a medication error When an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record The content of this question emphasizes the concept of professionalism through the recognition of documentation requirements. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behavior. This is not an appropriate action and requires intervention from the nurse preceptor. Incident reports are completed for incidents that are considered to be a deviation from expected outcomes of routine care and are often used in quality improvement programs for the facility. While an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record. - The nurse should draw a horizontal line through blank spaces in the nurses' notes to prevent incorrect information being added by another individual. - The nurse should not chart vital signs taken by another nurse. The vital signs might not be accurate and the nurse is accountable for the information she documents - The nurse should document when a provider is contacted to clarify a questionable prescription because the nurse is legally responsible, and liable, for carrying out the prescription.
A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include
Initial HIV symptoms are often similar to the flu HIV infection consists of three stages. The client typically experiences flu-like symptoms in the first or primary infection stage. Then, during the clinical latency stage, the client is asymptomatic. The final stage is characterized by the development of AIDS, which is when the client becomes symptomatic and has a severely compromised immune system The content of this question emphasizes the concept of client education by determining information that is appropriate to include in an educational program. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that information provided in educational programs be both useful to the client and based on current evidence. This is appropriate for the nurse to include.
A nurse is 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?
Inspection 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 on the coronary care unit is caring for a client who was transferred from the medical for from experience of myocardial infraction. After the client is stabilized she asked why she had been transferred where her family is unable to visit. What is the appropriate response?
Lets talk for a minute about your concerns Discussing the client's concerns and providing appropriate information will lower the client's anxiety level and establish an environment of open communication
A nurse in a provider's office is orientating a newly licensed nurse on how to position a client in a vaginal examination. The nurse include in the teaching to place a client in which following position?
Lithotomy The lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of the female genitalia. The nurse should drape the client appropriately to minimize exposure and embarrassment. The content of this question emphasizes the concept of leadership by providing education to a newly licensed nurse. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. Nurses assume various types of leadership roles in the provision of client care, including delegator, coordinator, educator, advocate, and change agent. This is the appropriate position for the nurse to place the client. ~ other answer (wrong/not most right) rationales: - The dorsal recumbent position can be used as an alternative to the supine position when assessing the head and neck, lungs, breasts, axillae, heart, and abdomen. - The prone position is used to assess hip joint extension, skin, and buttocks. - The lateral recumbent position is used to detect heart murmurs when assessing the heart.
A nurse is assisting with the preparations of an education program regarding advance directives for new hires. Which of the following information should be included about living wills?
Living wills detail treatment wishes of a client in the event of terminal illness
Hunter's is caring for a client who is diagnosed with active pulmonary tuberculosis is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client acetate the discontinuation of ethambutol?
Loss of color discrimination The most commonly reported toxic reaction to normal therapeutic doses of ethambutol is ocular toxicity as evidenced by visual disturbances. Examples include changes of color vision (especially red and green) and loss of visual acuity. Treatment with ethambutol should be stopped immediately if ocular toxicity develops The content of this question emphasizes the concept of safety through the recognition of an adverse effect that can result in physical injury to the client. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Ethambutol and isoniazid are both antitubercular medications. ~ other answer (wrong/not most right) rationales: - Ethambutol is well absorbed from the GI tract in either the presence or absence of food. Adverse GI effects are not common. -
A nurses caring for a client who is in the immediate post operative period following a tracheotomy. Which of the following is the nurses priority action?
Maintaining a patent airway
A nurse in a provider's office is caring for a client who has depression and is taking St. Johns Wort. The herbal supplement is thought to improve which of the following?
Mood 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 nurses caring for a client who has a urinary track infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first?
Move the client to room near the nurses station
A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first?
Obtain an ECG
A nurse is collecting data on a recently admitted patient. Which of the following techniques should the nurse use to measure tissue perfusion?
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 patient who is diagnosed with anemia. Which of the following skin variations is caused by reduced amount of oxyhemoglobin?
Pallor
A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?
Place the client in the orthopneic position
A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions?
Place the infant in a supine position when sleeping
A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention?
Platelets 95,000 mm3
A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration which of the following findings requires immediate intervention
Potassium 2.5 mEq/L A potassium level of 2.5 mEq/L is below the expected reference range. Hypokalemia can lead to arrhythmia's or cardiac arrest. Because this level is life threatening, it is the priority at this time. The content of this question emphasizes the concept of priority setting by requiring the determination of which laboratory value requires immediate intervention. 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 finding requires immediate intervention. ~Other answers (not most correct answer): - Blood Glucose 150 mg/dL: This finding does not require immediate intervention. While this blood glucose level is above the expected reference range, it will not cause life-threatening complications. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time. - Total Protein 5.2 g/dL: This finding does not require immediate intervention. While this total protein level is below the expected reference range, it will not cause life-threatening complications. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time. - Urine Specific Gravity 1.040: While this urine specific gravity is above the expected reference range, it will not cause life-threatening complications. A natural mechanism of the body is to conserve urine when fluids are being lost in other places. This finding should be monitored to determine the need for intervention; however, another finding is a higher priority at this time.
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?
Prepare healthy meal to serve at the end of class
A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregiver. Which of the following should be the nurse's priority goal?
Protect the client from further abuse The content of this question emphasizes the concept of safety through prioritizing the needs of a client who has been abused. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By intervening appropriately and acting as an advocate for clients who have been abused, nurses can assist in preventing or minimizing physical injury to the client. Protecting the client from further abuse should be the nurse's priority goal, as failure to do so can result in additional harm to the client. Maslow's Hierarchy of Needs states that if there is not a physiological need, then safety needs must be considered first. Because the client has been hospitalized for 3 days, physiological needs have most likely been taken care of; therefore, the nurse should act to keep the client safe from harm.
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?
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 preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?
Sims
A nurse on a pediatric unit is caring for an infant who is diagnosed with larynotrachebronchitis. While performing a respiratory examination the nurse hears which sound?
STRIDOR 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 laryngotracheobronchiti
A nurse is caring for a client who has nausea and prescription for promethazine (Phenergan) 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule?
Set ampule on a flat surface to withdraw the promethazine To withdraw the medication, the ampule can be set on a flat surface or held upside down, tilted at a slight angle. After the ampule is broken, the rim is considered contaminated and should not be touched with the needle The content of this question emphasizes the concept of safety by appropriately preparing a medication from an ampule. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care. By adhering to protocols and procedures based on scientific literature, nurses are able to prevent injury and improve and create a safe environment for clients, self, and co-workers. This action by the nurse is appropriate. ~ other answer (wrong/not most right) rationales: - The ampule should be broken away from the body to prevent injury from the shattering glass. - Expelling air bubbles back into the ampule creates pressure in the ampule, which forces the medication out, wasting it. Air bubbles should be expelled by removing the needle from the ampule and tapping the side of the syringe, then pulling back on the plunger, and finally pushing the plunger up gently to remove the air. - A filter needle should be used to withdraw the medication from the ampule, but should be replaced with a regular needle before administering the medication to the client.
A nurse is caring for a client who has a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professional should attend the clients next interdisciplinary team meeting to address this complication?
Speech pathologist A speech pathologist identifies clients at risk for aspiration and develops recommendations for therapy. The speech pathologist should attend the next meeting address difficulty swallowing in a client who has had a CVA
A nurse is preparing to transfer a client from a bed to a chair. The nurse should take which of the following actions to prevent a lift injury?
Stand close to the client 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 is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. Which of the following responses by the client should the nurse postpone the teaching?
States that pain is an 8 on a scale of 0 to 10 Physical symptoms, such as pain, fatigue, or anxiety, can prevent the client from learning because of a reduced ability to focus on and participate in education The content of this question emphasizes the concept of client education by recognizing physical symptoms that can impair the client's readiness and ability to learn. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for nurses to develop skills in identifying client learning needs, as well as client- and educator-related barriers to learning. This response by the client indicates the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. A key principle of teaching and learning is to first determine the client's readiness and ability to learn. ~ other answer (wrong/not most right) rationales: - states that partner should be given the information: - This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. The fact that the client believes that learning how to deep breathe and cough is the responsibility of her partner should indicate to the nurse that additional teaching is needed. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching. - This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications and can be uncomfortable. The fact that the client is expressing concern about the exercises causing pain when performed after surgery should indicate to the nurse the need for additional explanation, such as mechanisms that will be used to control the pain. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching. - This response by the client does not indicate the nurse should postpone teaching. Deep breathing and coughing exercises help prevent postoperative respiratory complications. The fact that the client is expressing uncertainty about the benefits of the exercises should indicate to the nurse that reinforcing the importance of the exercises, and a description of possible negative outcomes, should be discussed. The client does not exhibit any physical symptoms, such as pain, fatigue, or anxiety, that necessitate postponing the teaching
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?
Supine
A nurse is reinforcing teaching about trans dermal nitroglycerin (Nitro-Dur) to a client who is stable angina. Which of the following indicates teaching has been effective?
The patch should be effective within one hour of being applied Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.
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
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
A nurse is collecting data on a client who had received a preoperative dose of morphine. Which of the following indicated the client is experiencing an adverse effect of the medication?
Urinary retention
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?
Using a cuff that is too wide. Using a cuff that is too wide can result in a false low blood pressure reading.
A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should indicate that the diseases could by transmitted in which of the following ways?
Vector The nurse would know that the way Lyme disease is typically transmitted is through a tick, therefore it would fall in the vector category.
A nurse is collecting data on four clients. Which of the following findings is the most urgent?
Warmth and pain in the calf
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?
hearing loss THIS drug might cause hearing loss. Ototoxicity, an auditory nerve injury, is the most serious adverse effect of vancomycin and can result in hearing loss.
A nurse is preparing to ausculate a clients heart. Which of the following positions is best for detecting a low pitched diastolic murmur?
lying on side This image represents the left lateral recumbent position, which is the best position for detecting a low-pitched diastolic murmur.
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 Characteristics for a stage II ulcer include partial thickness skin loss. The nurse would know this because she is familiar with the stages of pressure ulcers.
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?
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 on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take?
restrict fluid intake 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.
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?
¾ cup of canned tomato juice The nurse would recognize that the client didn't understand because tomato juice has a lot of sodium in it.
