Knowledge and Clinical Judgment ADVANCED TEST
A nurse is caring for a client who has a new colostomy. The client is being discharged and plans to live with her daughter. Which of the following responses by the nurse is appropriate when the daughter states that she doesn't know how she is going to care for her mother's colostomy?
"What part of your mother's care concerns you?"
A nurse is planning to obtain blood pressure on four clients. On which of the following clients should the nurse perform an electronic blood pressure measurement?
A client who is recovering from a cardiac catheterization
A nurse administrator is reviewing policies and procedures of the facility she works in to ensure confidentiality requirements are being met. Which of the following indicates that intervention is needed to prevent the release of confidential client information?
Assigning staff members on each shift the same password for accessing medical records
A nurse is assigned to care for four clients. The client with which of the following drainage tubes is at an increased risk for hypokalemia?
NG tube to suction
A nurse is caring for a school-age client who was diagnosed with sickle cell anemia and has been admitted for a vaso-occlusive crisis. Which of the following findings has the highest priority?
Slurred speech
A nurse is reinforcing teaching about the diet for dumping sydrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective?
Toast with peanut butter
A nurse is reinforcing teaching about a new precription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a school-age child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching?
"I will use my cromolyn nebulizer before using my albuterol inhaler."
A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium (Lithane). Which of the following serum lithium levels indicates the client's dosage is appropriate for maintenance therapy?
0.75 mEq/L
A nurse is caring for a client who is pregnant with a single fetus and has a body mass index of 23. When asked by the client how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate?
25 to 35 lb
A nurse is collecting data on a newborn who was delivered 30 min ago at the gestational age of 37 weeks. Which of the following findings requires further intervention?
Abdominal distension
A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach the client that which of the following is a post-procedure complication?
Headache
A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine (Americaine) ear drops for pain relief. Which of the following actions by the nurse is appropriate when administering the ear drops?
Warm refrigerated drops to room temperature prior to instillation
A nurse is caring for a client who weighs 132 lb has been prescribed gentamicin (Garamycin) 5mg/kg/day by IV bolus in three equal doses. Available on hand is 40 mg/mL that is to be added to 50 mL 0.9% sodium chloride. How many mL should the nurse add to the solution per dose?
2.5 mL
A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis?
Sputum culture for acid-fast bacillus
A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions?
A client who has rubella
A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. The client reports a burning pain in his cheat. Which of the following actions by the nurse is appropriate?
Assist the client to a side-lying position
A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness?
Dark urine
A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested no resucitative measures be taken in the event of respiratory or cardiac arrest. Which of the following is necessary to legally change the client's code status to do-not-resusciate (DNR)?
A written prescription from the provider
A school nurse has requested the school board remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following?
Advocacy
A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following indicates the client is experiencing an adverse effect of the medication?
WBC 2,800/mm3
