ATI - NurseLogic Knowledge and Clinical Judgement (beginner)
A nurse is providing education about a new prescription for nitroglycerin ( NitroQuick ) to a client who is diagnosed with angina .Which of thefollowing statements by the client indicates a need for further 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 . The chemical instability of medication leads to loss of effectiveness overtime buying medicine in bulk quantities is not a safe practice
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 . " Do you have effective communication techniques Foster's trust and therapeutic relationships with clients coworkers and members of the interdisciplinary team giving a general lead encourages the client to openly share feelings and concerns in a non-threatening environment will assist in establishing a meaningful client relationship beginning a question with why are requesting an explanation from the client can lead to resentment mistrust and insecurity
A nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribed ciprofloxacin ( Cipro ) 250 mg PO two times daily . The amount available is 100 mg / tablet . How many tablets should the nurse administer with each dose ?
2.5 tablets 250/100= 2.5
* A nurse is providing discharge education to the parents of a preschooler who is prescribed acetaminophen ( Tylenol ) 300 mg every 4 hr as needed . The acetaminophen liquid suspension that has been prescribed provides 120 mg / 5 mL . How many teaspoons should administer per dose ?
2.5 tsp Desired = 300 mg Have = 120 mg Quantity = 5 mL No ( mg - mg ) 300 mg x 5 mL / 120 mg = x ml Desired x Quantity / Have Amount to be given I got answer simply by 300/120 = 2.5 ?
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 . Away from the body . Toward the body
Away from the body . Sterile packages are resistant to pathogens and are used for specific techniques or procedures to prevent contamination during such procedures any sterile item that comes into contact with an unsterile object is considered contaminated to prevent contamination of the sterile field nurses follow certain steps when opening sterile packages and creating a sterile field opening the sterile package away from the body first allows a nurse to open the remaining flaps without reaching over the sterile field which could result in contamination
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 ) lodophor
Chlorine ( bleach ) Must use a disinfectant 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 TB spores fungi and viruses and I specifically recommended for cleaning blood spills. antiseptics prevent or stop the growth of certain pathogens
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 . A wound that manifests as a reddened area is a stage one pressure ulcer a transparent wound barrier applied to reddened skin to prevent contamination and reduce friction to the area is an appropriate action by the nurse clients at risk for impaired skin integrity should be repositioned every two hours instead of four
A nurse is collecting nutritional data on an older adult client . Which of the following findings 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 Deep reddish color is suggestive of a healthy nutritional status color should be a healthy pink to a deep reddish color
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
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
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 Dexamethasone, a glucocorticoid, is it a powerful anti-inflammatory and immunosuppressant and as indicated for the treatment of multiple disorders including rheumatoid arthritis adverse effects increase with dosage and duration of treatment and can include adrenal insufficiency hyperglycemia and elevated blood glucose level is an adverse effect as it affects the production and use of glucose
A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff . Which of the following information should be included about living wills ? 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 . Advanced directives. This includes both living wills and durable powers of attorney for healthcare. The LivingWell details treatment wishes of the client in the event of terminal illness or persistent vegetative state The durable power of attorney for healthcare allows the client to designate a healthcare proxy.
A nurse is 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 Perfusion is the delivery or pumping of Arterial blood through tissues or an organ obtaining the clients level of oxygen saturation is an appropriate technique of measuring perfusion oxygen saturation measures the percent of hemoglobin found with oxygen that has been profused through the arteries and into the tissues
A nurse is caring for a client who is diagnosed with anemia . Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin ? Cyanosis Jaundice Erythema Pallor
Pallor I need nursing knowledge related to oxyhemoglobin and its affect 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 oxygen hemoglobin 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 red blood cells are reduced by function or 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 clients 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 red blood cells that contain oxyhemoglobin. Erythema Is a red color of the skin caused by increased blood flow which enhances the visibility of oxyhemoglobin Jaundice is yellow orange color of the skin caused by increased amounts of billirubin being deposited in the tissues Cyanosis is caused by reduced oxygen levels in the tissues because of an increase in circulating deoxygenated hemoglobin causing a bluish color to the skin.
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 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 . Tactile is touch/do
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 . Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food complications include feeding tube regurgitation and aspiration of feedings delayed gastric emptying and malabsorption among others administration should be slowed or switched to continuous enteral feeding
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 ? Dorsal recumbent Orthopneic Side - lying Supine
Supine
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 Alignment of the back neck pelvis and feet should be maintained to reduce the risk of injury to the lumbar vertebrae
A nurse is collecting data on a client who has received a preoperative dose of morphine . Which of the following indicates the client is experiencing an adverse effect of the medication ? Urinary retention Rapid respirations Dilated pupils Diarrhea
Urinary retention My the respirations are not an address effect of morphine instead by reducing the respiratory center's response to carbon dioxide respiratory depression is an adverse effect of morphine. Urinary retention is an adverse effect of morphine by increasing bladder sphincter and detrusor muscle tone and reducing awareness of bladder stimuli 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. You need knowledge of abbreviations that the joint commission has determined should not be used in documentation. This is a negatively worded item item asks you to select the option that indicates the newly licensed nurse needs additional teaching to reduce the occurrence of medical errors the joint commission developed a list of do not use abbreviations that should be avoided in healthcare settings the abbreviation q.d. Was previously used to indicate every day which can be mistaken as the abbreviation for four times daily (qid). Joint commission as recommended the use of daily to indicate every day
