(ATI) Knowledge and Clinical Judgement (Beg Test)

A nurse is providing discharge education to parents of preschooler who is prescribed 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 rationales: 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 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 Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. Wound dehiscence or evisceration most commonly occurs 3 to 11 days following surgery and can be caused by not splinting the surgical site when moving, forceful coughing, vomiting, or straining. Clients often report feeling the incision "pop," indicating either dehiscence or evisceration has occurred. Based on the acute versus chronic priority setting framework, the nurse should evaluate this client first.

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 Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase - so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. A nose bleed, or epistaxis, is an acute condition requiring immediate intervention to prevent further blood loss. Additionally, this finding can be associated with a blood pressure that is above the expected reference range, indicating the need for further intervention. Based on the acute versus chronic priority setting framework, this client should be the nurse's priority. incorrect: A client who is reporting pain associated with osteoarthritis of the knees: Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase - so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. Osteoarthritis is a chronic illness; therefore, this client should not be the nurse's priority. A client who has a history of heart failure: Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase - so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. Heart failure is a chronic illness; therefore, this client should not be the nurse's priority. A client who has type 1 diabetes mellitus: Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase - so they don't escalate into a life-threatening event or evolve into a chronic alteration in health. Diabetes mellitus is a chronic illness; therefore, this client should not be the nurse's priority.

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. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. If the client is able to be aroused or a pulse is palpated, then the client is not in cardiac arrest, and there is a problem with the monitoring equipment. It is common for leads to become loose or fall off clients when they move around, resulting in the monitor detecting an absence of cardiac function. Therefore, checking on the client is the first action the nurse should take.

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 a fluid volume deficit?

Check the heart rate and blood pressure. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. An increase in heart rate and decrease in blood pressure are consistent with a fluid volume deficit. Using the least restrictive, least invasive priority setting framework, this action is less invasive than the other actions and should be the nurse's first action.

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. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. If warmth and edema is found in the leg, this indicates that the decreased circulation could be due to a deep-vein thrombosis. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

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 client. Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. Determining the mobility status of each client will help to identify those patients who are at risk for falls. This knowledge will ensure the implementation of education and prevention efforts specific to the needs of each client. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

A nurse is preparing to administer oral medications 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. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Clients are at risk for aspiration following a CVA, and having the client position the head with the chin down while swallowing reduces this risk. Based on the safety and risk reduction priority setting framework, this should be the nurse's priority action. Preventing aspiration is further supported as the priority by the ABC priority setting framework.

A nurse is providing patient education about a new prescription of nitroglycerin 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 rationales: 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 collecting date 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 rationales: 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 having difficulty breathing. Which of the following actions should the nurse take first?

Place the client in the orthopneic position. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. Placing the client in the orthopneic position allows for maximum chest expansion, which improves respiratory effort. Based on the least restrictive, least invasive priority setting framework, this should be the first action the nurse takes.

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 Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients are the priority because of needs that threaten their survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option poses the greatest risk to the client. This platelet level is below the expected reference range and indicates the client is at risk for bleeding. Based on the stable versus unstable priority setting framework and nursing knowledge, the client with this laboratory value requires immediate intervention.

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 rationales: ​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.

nurse logic: priority framework A nurse is collecting data on four clients. Which of following is the highest priority finding by the nurse?

correct: Diarrhea Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is the highest priority because the airway must be open and clear for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining circulation is the nurse's priority concern. Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume. Based on this knowledge and using the ABC priority setting framework, this is the highest priority finding by the nurse. Headache: Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is the highest priority because the airway must be open and clear for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The nurse should further evaluate a finding of headache; however, there is another finding that is a higher priority. Anorexia: Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is the highest priority because the airway must be open and clear for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The nurse should further evaluate a finding of anorexia; however, there is another finding that is a higher priority. Malaise: Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is the highest priority because the airway must be open and clear for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The nurse should further evaluate a finding of malaise; however, there is another finding that is a higher priority.

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 an hour of being applied." The content of this question emphasizes the concept of client education by evaluating teaching effectiveness. 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 evaluation of teaching be an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This statement by the client is true and indicates teaching has been effective. Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.

Compare and contrast accountability and responsibility.

A sense of obligation and being dependable to complete all tasks inherent to the provision of nursing care is known as responsibility. Responsibility is also one of the components of accountability, which is being responsible and answerable for ones actions.

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 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. 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.

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?

Acupuncture has been proven to reduce pain and increase function. 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. 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.

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. Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is the highest priority because the airway must be open and clear for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Assisting the client to cough effectively opens the airway by removing secretions. Based on the ABC priority setting framework, this is the first action the nurse should take because a clear airway is necessary for oxygen exchange to occur.

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 rationales: 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.

Which of the following solutions should the nurse use to clean a blood spill that occurred while inserting a catheter?

Bleach rationales: 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 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 an allergy to sulfonamide. Celecoxib is contraindicated in clients with an allergy to sulfonamide. MY ANSWER The content of this question emphasizes the concept of evidence-based practice through the review of scientific literature to determine contraindications of a medication. 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. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-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.

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 rationales: 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 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 Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The third level of Maslow's Hierarchy of Needs includes love, affection, and social relationships in fulfilling love and belonging needs. Social relationships are a component of friendship, which would be included in the third level of Maslow's Hierarchy of Needs. Based on Maslow's Hierarchy of Needs, this is the client's priority need.

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 The content of this question emphasizes the concept of client education by determining the best indicator of teaching effectiveness. 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 evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. This is the best indicator of teaching effectiveness. Return demonstration is the best evaluation tool for psychomotor 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 3 years to detect skin cancer 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. Men and women between the ages of 20 and 40 should have a skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations.

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?

Determine the client's condition. 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. The client is the immediate concern, and determining his condition is crucial to the delivery of safe, effective care.

A nurse is caring for a client following a Bronchoscopy . Which of the following findings requires immediate intervention?

Difficulty breathing 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. 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.

A nurse is conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider? Options: Magnesium sulfate 4 mEq/L Peak serum gentamicin 6 mcg/mL Lithium carbonate 0.8 mEq/L Digoxin 3.0 ng/mL

Digoxin 3.0 ng/mL Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients get priority because of needs that threaten their survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option poses the greatest risk to the client. This digoxin level is above the expected reference range and indicates digoxin toxicity. Based on the unstable versus stable priority setting framework and nursing knowledge, this lab value is the priority and should be immediately reported to the provider.

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 rationales: 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 friend who is a nurse on another unit rationales: 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 newly hired nurse is reviewing the facility's emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide priority care to clients who are in which of the following categories during a disaster?

Immediate Answering this item requires application of the survival potential priority setting framework. Use of this framework is typically reserved for mass casualty situations, when resources are scarce and are allocated to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The highest priority is assigned to the client with injuries that are severe, but has the potential to survive with treatment. Clients assigned to the immediate triage category in a mass casualty event have life-threatening, but survivable injuries if immediate care is received. Based on the survival potential priority setting framework, the nurse should provide priority care to clients in this category.

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's nurses' note that an incident report was completed after a medication error 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.

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. 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. 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 become symptomatic and has a severely compromised immune system.

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 wished of a client in the event of terminal illness rationales: 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.

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 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. 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.

A nurse is caring for a client who is in the immediate postoperative period following a tracheotomy. Which of the following is the nurse's priority action?

Maintaining a patent airway Answering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating that oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC priority setting framework, maintaining a patent airway is the nurse's priority action for a client who is in the immediate postoperative period following a tracheotomy. An airway obstruction is a potential complication for clients following head and neck surgery secondary to production of mucus and need for suctioning. Based on this knowledge and using the ABC priority setting framework, the nurse's priority action is to maintain a patent airway.

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? Options: Obtain an ECG. Administer oral potassium. Encourage potassium-rich foods Monitor I & O.

Obtain an ECG. Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. Obtaining an ECG will assist in determining the presence of dysrhythmias related to a serum potassium level below the expected reference range. According to Maslow's Hierarchy of Needs priority setting framework, physiological needs, such as adequate cardiac functioning, receive highest priority. This action is further supported by the ABC priority setting framework due to the impact of cardiac function on circulation.

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 rationales: 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 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. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Evidence-based practice and current recommendations of the American Academy of Pediatrics include positioning the infant supine while sleeping. This intervention has had the greatest impact on reducing the occurrence of SIDS. Using the safety and risk reduction priority setting framework and nursing knowledge, this is the priority information to include in the discharge teaching.

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 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. A potassium level of 2.5 mEq/L is below the expected reference range. Hypokalemia can lead to arrhythmias or cardiac arrest. Because this level is life threatening, it is the 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 a healthy meal to serve at the end of class rationales: 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 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 rationales: 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 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 The content of this question emphasizes the concept of the interdisciplinary collaboration by recognizing the health care professional who should be present at the next interdisciplinary team meeting for a client who is experiencing difficulty swallowing. Interdisciplinary collaboration is a partnership between multi-disciplinary members of the health care team that maximizes the expertise of each team member to enhance team decision making, as well as achieve continuity of care and positive client outcomes. A speech pathologist identifies clients at risk for aspiration and develops recommendations for therapy. The speech pathologist should attend the next meeting to address difficulty swallowing in a client who has had a cerebrovascular accident.

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 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. 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.

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 rationales: 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.

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?

​"Let's talk for a minute about your concerns." ​The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The use of therapeutic communication helps develop nurse-client relationships that foster trust and respect. "Let's talk for a minute about your concerns" is an appropriate response by the nurse. 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 is caring for a newly admitted client. Which of the following client needs should the nurse address first?

​Hypoxic ​Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. Hypoxemia indicates reduced blood oxygen levels, which involves the physiological needs of the client and is the first level of Maslow's Hierarchy of Needs. Because oxygen is considered the most basic physiological need, this is the need the nurse should address first. This is further supported using the ABC priority setting framework.

Nurse Logic: Nursing Concept A beginning student nurse is providing client-centered care for an adolescent who was admitted for tests to determine if he has type 1 diabetes mellitus. Which of the following statements by the student indicates a need for further teaching?

"I will keep my communication with the client to a minimum." The student should use knowledge and a variety of skills when providing client-centered care. These include the nursing process, therapeutic communication, cultural competence, and advocacy. Based on proper use of these skills, the student should communicate as necessary in order to obtain a thorough history of his present illness and identify needs as perceived by the client. Keeping communication with the client to a minimum indicates a need for further teaching. Obtaining a health assessment should be one of the first things the student does to establish the client's physical, cognitive, and psychological baseline and identify current alterations in health and client needs. Having the provider talk to the client about his fears and concerns is an appropriate example of client advocacy. And finally, since the client's family is from Vietnam, the client may have cultural preferences in relation to food and health care.

An advanced student nurse assigned to clinical in a rehabilitation setting is preparing to participate in a team meeting. Which of the following statements by the student indicates a need for further teaching?

"The provider will not be at the meeting because she is not a member of the interdisciplinary team." The provider is a member of the interdisciplinary team. The statement that indicates the provider is not a member of the interdisciplinary team indicates a need for further teaching. The nurse, social worker, and physical therapist are all members of the interdisciplinary team and as such, should be expected to provide a client report at the team meeting.

A nurse is caring for a patient who diagnosed with urinary tract infection and is prescribed ciprofloxacin 250 mg PO two times daily. The amount is available is 100 mg/tablet. How many tablets should the nurse administer?

2.5 rationales: 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 tablets the nurse should administer. This item requires critical thinking because you have to analyze the provided facts to determine the dosage, select a formula, enter data into the formula, and then perform the needed calculations. STEP 1: What is the dose needed? Dose needed = Desired; 250 mg STEP 2: What is the dose available? Dose available = Have; 100 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? 1 tablet STEP 5: Set up an equation and solve: Desired x Quantity / Have = Amount to be given; 250 mg x 1 tablet / 100 mg = x tablets; 250 x 1 / 100 = 2.5; x = 2.5 tablets.

A nurse is making rounds on clients, who were assigned to a team of nurses, to determine if charting and client care was completed. This nurse is demonstrating which leadership role of the nurse?

A nurse who is making rounds on clients and evaluating if charting and client care was completed is demonstrating the leadership role of coordinator. After client care responsibilities have been assigned to other nurses, it is the role of the nurse who made the assignments to supervise the delegated tasks and ensure they have been completed. This action by the nurse is not consistent with the leadership roles of delegator, client advocate, or change agent.

A student is developing a plan of care for a client who has been diagnosed with cancer of the pancreas. Which of the following would be an appropriate resource to use in the development of an evidence-based plan of care?

CINAHL, MedlinePlus, and OVID CINAHL, MedlinePlus, and OVID are appropriate resources to use in the development of an evidence-based plan of care. While Google is a search engine, it does not discriminate between evidence-based resources and popular or opinion-based literature. A wiki is a program that allows open-editing of content by various individuals. While some wikis are reviewed by content experts wikis in general should not be considered a valid source of research-based evidence.

a nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status?

Deep red tongue rationales: 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 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 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? a.

Hyperglycemia rationales: 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.

Web-based information should be evaluated for which of the following? (Select all that apply.)

Information accessed on the Web should be evaluated to determine its accuracy. Web-based information should also be evaluated for sponsorships, as this can impact objectivity and presentation of the content. To ensure the information is the based on the most recent data its currency should also be evaluated. Security of Web-based information is not evaluated; however, this is something that should be considered when entering personal information on the Web. Additionally, links are not specifically evaluated, but can be followed to locate additional sources of information, which should then be evaluated.

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 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. 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.

A nurse is caring for a client who has a urinary tract 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 a room near the nurses' station. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using physical restraints. Physical restraints should only be used when the safety of the client, staff, or others is at risk. Moving the client to a room near the nurses' station allows for more frequent observation and promotes client safety. Using the least restrictive, least invasive priority setting framework, this action is less restrictive than the other actions and should be the nurse's first action.

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 the ampule on a flat surface to withdraw the promethazine. 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. 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.

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 rationales: 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 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 rationales: 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 collecting data on four clients. Which of the following findings is the most urgent?

Warmth and pain in the calf Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. Using the urgent versus non-urgent priority setting framework, the most urgent finding is warmth and pain in the calf of a client. Warmth and pain in the calf is indicative of deep-vein thrombosis, which places the client at risk for pulmonary embolism. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the most urgent need. This option is further supported by the ABC priority setting framework.

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?

correct: Autonomy 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. 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 illustrating by making the referral as requested. incorrect: Justice: 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: 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. 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: 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. 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.

Which of the following are client attributes that impact safety? (Select all that apply.)

lifestyle choices, communication patterns, and cognitive awareness Client attributes such as lifestyle choices, communication patterns, and cognitive awareness must be considered when determining safety hazards that exist for a client. Additionally, environmental influences in the home, workplace, community, and healthcare facility must also be considered. Both geographic location and unsanitary living conditions are examples of environmental influences on client safety.

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 rationales: 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.