ATI-Knowledge and clinical judgement(Advanced)

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? A. Hematocrit 32% B. WBC 16/mm3 C. Slurred speech D. Yellow Sclerae

AND C To answer this item, you need knowledge of the pathophysiology of sickle cell anemia, as well as specific nursing knowledge of the expected parameters for laboratory tests and physical findings associated with a vaso-occlusive crisis. Based on an understanding of these concepts, you can identify the life-threatening clinical finding. This item requires critical thinking because you have to infer, or draw a conclusion, based on the client situation to determine which finding is the highest priority. Sickle cell anemia is characterized by the partial or complete replacement of mature hemoglobin with sickled hemoglobin. The sickled shape of cells can block or reduce the flow of blood through blood vessels, resulting in complications. Slurred speech can indicate a cerebrovascular accident (CVA), which is a severe complication of sickle cell anemia. The blockage of blood vessels in the brain by sickled cells results in cerebral infarction, which leads to neurological impairment. Because a CVA threatens the life of the client, this is highest priority finding.

A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested no resuscitative 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-resuscitate (DNR)? a. a written prescription from the provider b. signed documentation from the client c. family support of the decision d. admission to hospice for palliative care

ANS A In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on your knowledge of this concept, you can select the option that describes requirements to legally change the code status of a client to a DNR. This item requires foundational thinking because you have to recall legalities associated with initiating a DNR. A DNR is typically instituted at the request of a client or family member and should be a written order instead of a verbal prescription. Until a DNR prescription exists, every attempt to revive the client should be made in the event of respiratory or cardiac arrest. A written prescription from the provider is necessary to legally change the client's code status to a DNR.

A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective? A.Toast with peanut butterB.Apple juiceC. Yogurt with fruitD. Beef broth

ANS A In this item, you need knowledge of foods that can and cannot be incorporated in the diet of clients who have dumping syndrome. Based on this knowledge, you can evaluate the appropriateness of the client's food selection. This item requires foundational thinking because you have to recall knowledge related to the causes of dumping syndrome, as well as related nutrition principles. Dumping syndrome results from rapid emptying of the stomach into the small intestine after eating, and manifests as a group of vasomotor symptoms, such as vertigo, tachycardia, syncope, sweating, pallor, and palpitations. Additionally, abdominal distension occurs because of the shift of fluid into the intestines. A diet that restricts some foods and includes others as appropriate food choices reduces the occurrence and severity of dumping syndrome. Peanut butter and toast are allowed or encouraged foods for a client who has dumping syndrome.

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 chest. Which of the following actions by the nurse is appropriate? A. Assist the client to a side laying position B. Remove 10mL from the sunction control chamber C. Apply a padded clamp on the tubing for 1-2 min D. Move the drainage system above the level of the clients heart

ANS A In this item, you need knowledge of the care required for a chest tube. Based on this information, you can select the appropriate action for a client who reports a burning pain in his chest. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. Burning sensation or pain can result from the chest tube becoming occluded because it is resting against tissue. It is possible to move the tip of the chest tube away from the tissues by repositioning the client. Repositioning the client is the appropriate action by the nurse.

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. A client who is recovering from cardiac catheterizationB. A client who is in stage 4 of Parkinsons diseaseC. A client who has anorexia and hypotensionD. A client who has a temperature of (39.1 C) 102.4F and is shivering

ANS A In this item, you need nursing knowledge of how blood pressure measurement can be impacted by the stages of Parkinson's disease, hypotension, shivering, and cardiac catheterization. Additionally, specific knowledge of electronic blood pressure measurement is needed to select the correct option. This item requires critical thinking because you have to analyze the four clients and determine for whom an electronic blood pressure is appropriate. Electronic blood pressure measurement is attained through a sensor that detects vibrations caused by blood rushing through the artery, is appropriate for use when the blood pressure must be monitored frequently, and should not be taken on clients with conditions that can result in an inaccurate reading. A client who is recovering from a cardiac catheterization requires frequent blood pressure measurements. It is appropriate to perform an electronic blood pressure measurement on this client.

A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions?A. A client who has rubellaB. A client who has measlesC. A client who has hepatitis AD. A client who has rocky mountain spotted fever

ANS A To answer this item, you need knowledge of the pathophysiology and transmissibility of the diseases listed in the options. Additionally, you have to recall your knowledge of transmission-based precaution levels. Based on your understanding of these concepts, you can determine which client should be placed on droplet precautions. This item requires critical thinking because you have to evaluate the four clients to determine which client requires implementation of droplet precautions. Rubella is transmitted through the nasopharyngeal secretions of the infected person, and is also found in blood, stool, and urine. Because droplets associated with the illness are larger than 5 mcg, the Centers for Disease Control and Prevention recommends placing clients who are diagnosed with rubella on droplet precautions. Droplet precautions include placing the client either in a private room or with other clients who have the same disease, as well as using of a mask or respirator when providing care. This client should be placed on droplet precautions.

A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following findings indicates the client is experiencing an adverse effect of the medication?A. Weight lossB. WBC 2,800/mm3C. HR 54/minD. Insomnia

ANS B ​In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. Based on an understanding of this information, you can identify which is the correct option. This item requires foundational thinking because you have to recall knowledge related to adverse effects of clozapine. Clozapine is a second-generation antipsychotic used to relieve symptoms of schizophrenia and to reduce suicidal behaviors in clients who have schizophrenia or schizoaffective disorder. Adverse effects of clozapine include tachycardia, weight gain, sedation, and agranulocytosis. Agranulocytosis, which is a decrease in one of the WBCs called neutrophils, reduces the ability to fight infection and can be fatal. Because of the potential for agranulocytosis, clients who are taking clozapine are monitored frequently for a decrease in WBC count below 3,000/mm3. The client's WBC and absolute neutrophil count is monitored weekly during the first 6 months of therapy, then every 2 weeks during the next 6 months. A WBC level of 2,800/mm3 indicates the client is experiencing an adverse effect of the medication.

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? A. Requiring that client information be sent to providers using pre-saved numbers on the speed dial of the fax machiene.B.Assigning staff members on each shift the same password for accessing medical recordsC.Allowing nurses to complete electronic documentation on a client while at the clients bedsideD. discussing a clients financial hardship at an interdisaplinary team meeting

ANS B 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 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 determine 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. Each staff member should have a personal password that is not shared with others and is used to enter and sign-off of computerized records. Individuals caring for a client should be the only ones able to access client records. If all staff members on each shift have the same password, limitations exist in tracking who is accessing those records, increasing the possibility that someone not involved in the care of a client could access records out of curiosity. This procedure is not appropriate and requires intervention to prevent the release of confidential information.

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? A. Place the child on the effected side for several minutes upon completion of instillationB. Warm refrigerated drops to room temperature prior to instillationC. Pull the pinna of the ear upward and back during instillationD. Massage the area posterior to the ear after instillation

ANS B This item requires knowledge of appropriate techniques for administering ear drops. Based on your understanding of this concept, you can select the appropriate nursing action. This item requires foundational thinking because you have to recall knowledge of a specific nursing skill to appropriately administer ear drops. This is an appropriate action by the nurse when administering ear drops. Ear drops are topically administered medications, which are slowly absorbed through the skin and primarily provide local results. Because of the anatomy of internal ear structures, it is important to remember that the ear is sensitive to extremes in temperature. Ear drops should be warmed to room temperature prior to instillation to reduce the risk of painful stimuli.

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? A.0.25 mEq/LB.0.75 mEq/LC.1.5 mEq/LD. 2.25 mEq/L

ANS B To answer this item, you need knowledge of therapeutic serum lithium level levels. Based on your understanding of this information, you can select the option with the serum lithium level appropriate for maintenance therapy. This item requires foundational thinking because you have to recall knowledge of therapeutic serum lithium levels. Lithium is a mood-stabilizing medication used in the treatment of bipolar I acute and recurrent manic and depressive episodes. To achieve a therapeutic range, give 300 mg to 600 mg of lithium during the active phase. The therapeutic serum lithium level is between 0.8 mEq/L and 1.4 mEq/L. Maintenance levels of 0.4 to 1.3 mEq/L are then achieved for clients who are prescribed lithium for long-term therapy. Because small increments of dosage separate therapeutic, maintenance, and toxic levels of lithium, knowledge of these levels is essential to ensure safe, quality care. This serum lithium level indicates the client's dosage is appropriate for maintenance therapy.

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? A. Vesicular rashB. RR 54/minC. Abdominal DistensionD. HR 142/min

ANS C In this item, you need knowledge of expected findings, findings that require no intervention, and findings requiring additional intervention when collecting data on a newborn. Based on your understanding of these concepts, you can select the correct option. This item requires critical thinking because you have to analyze the finding described in each option in relation to the gestational age of a newborn who was delivered 30 min ago. Abdominal distension that is present at birth indicates a tumor or an abdominal wall defect, such as a ruptured viscus. This finding should be reported to the provider immediately and evaluated further.

A nurse is caring for a client who is pregnant with a single fetus and has a body mass index (BMI) 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?A. 10-15lbsB.15-20lbsC.25-35 lbsD.35-45lbs

ANS C To answer this item, you need an understanding of both BMI levels and appropriate weight gain in pregnancy. Based on your understanding of these concepts, you can select the option indicating the appropriate weight gain for the client in the scenario. This item requires critical thinking because you have to interpret the client data from the scenario and then explain that data in relation to the expected BMI and the current recommendations regarding weight gain during pregnancy. The recommended weight gain for women with an average BMI is 11.5 to 16 kg, or roughly 25 to 35 lb. This amount is sufficient to ensure that the fetus is adequately nourished.

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? A. HypothermiaB. PolyuriaC. HeadachesD. Seizures

ANS C To answer this item, you need knowledge of lumbar punctures, as well as complications associated with the procedure. Based on an understanding of this information, you can identify the correct option. This item requires foundational thinking because you have to recall potential postprocedure complications associated with a lumbar puncture. Lumbar punctures are performed to withdraw cerebrospinal fluid found in the subarachnoid space for analysis. This is accomplished by inserting a needle into the lumbar subarachnoid space, typically between the third and fourth or fourth and fifth lumbar vertebrae. After the cerebrospinal fluid specimen has been removed, it is not uncommon for leakage of cerebrospinal fluid to continue at the puncture site. The leakage of cerebrospinal fluid leads to insufficient cerebrospinal fluid in the brain, which causes an inability to maintain appropriate mechanical stabilization of the brain. A headache is a manifestation experienced by 15 to 30% of clients following a lumbar puncture that results from cerebrospinal fluid leakage at the puncture site. These headaches are managed primarily with analgesics, hydration, and bed rest.

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?A. "Its quite simple, ill make sure colostomy bag is clean before she leaves and you should have no problems"B."Is the colostomy care the only reason your mother is going to be living with you?"C. "A home health nurse will be stopping by tomorrow. If you have any questions you can ask her."D. "What part of your mothers care concerns you?"

ANS D 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. Clarification encourages the other person to further express concerns so they can be addressed. This is an appropriate response by the nurse because it uses the communication tool of clarification.

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? A. Rapid weight gain B. Tar-colored stools C. Lethargy D. Dark urine

ANS D In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical manifestation the parent should be taught is associated with biliary atresia. This item requires critical thinking because you have to evaluate each finding in relation to the pathophysiology of biliary atresia. Biliary atresia is a progressive process that leads to destruction of the biliary tree. The biliary tree begins as many small ducts that join together into one main common bile duct, similar to the joining of branches to a tree trunk. Bilirubin, created from the breakdown of heme in RBCs and the main pigment in bile, travels to the liver where the liver cells, known as hepatocytes, secretes it into bile. The bile then passes into the small ducts and then travels to the small intestine where bacteria break it down into urobilinogen to be excreted in the feces. Dark urine is a clinical sign of biliary atresia because of conjugated bilirubin escaping from the liver and being excreted in the urine. The nurse should teach the parent that dark urine is a clinical manifestation associated with the illness.

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? A. Tuberculin testB. Chest X-RayC. ELISA testD. Sputum culture of acid fast bacillus

ANS D In this item, you need knowledge of the route of transmission and diagnostic criteria of tuberculosis. Based on an understanding of these concepts, you can identify the correct option. This item requires foundational thinking because you have to recall knowledge of the appropriate diagnostic criteria for pulmonary tuberculosis. Tuberculosis is a bacterial infection caused by Mycobacterium tuberculosis, which is an airborne organism. Once infected, the bacteria multiply freely after reaching the bronchi or alveoli. Typically, acquired immunity protects individuals from attaining active tuberculosis. Infection is most common among those who are immunocompromised and those who have been in repeated, close contact with someone who has an undiagnosed case of active tuberculosis. The lungs are primarily involved, but the infection can spread to other organs. Symptoms of pulmonary tuberculosis include productive cough, fever, fatigue, weight loss, hemoptysis, and night sweats. In cases of active pulmonary tuberculosis, the organism is transmitted through the air because it is found in the sputum and secretions. The presence of acid fast bacillus in the sputum, secretions, or tissues of the client is the only method to confirm the diagnosis of active tuberculosis.

A nurse is reinforcing teaching about a new prescription 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? A " I be be sure to rinse my mouth out after using my cromolyn inhaler" B. " I can't use my cromlyn inhaler for sudden asthma attacks" C. "its will be several weeks before I notice an improvement in my asthma" D. "I will use my chromoly inhaler before using my albuterol inhaler"

ANS D In this item, you need nursing knowledge of cromolyn to recall information about the medication that should be included in client teaching. Based on an understanding of this information, you can identify which of the client statements is not accurate. This is a negatively worded item that asks you to select the option that indicates the client 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 to determine which of the client's statements about cromolyn was false. "I will use my cromolyn nebulizer before using my albuterol inhaler" is not a true statement and indicates a need for further teaching. Cromolyn is an inhalation agent used to reduce bronchial inflammation and for the prophylactic management of mild to moderate asthma. Education to the client about the medication should specifically include that it is not effective for quick relief, and that when administered routinely on a set schedule, both the frequency and intensity of asthma attacks is decreased. However, it is also important to note that cromolyn can reduce exercise-induced bronchospasms when administered 15 min prior to anticipated exertions. When both cromolyn and albuterol are prescribed, albuterol should be inhaled first to open the airways because is a bronchodilator. After waiting a few minutes, the cromolyn can then be inhaled and will reach further into the lungs because of the dilatory effects of albuterol.

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?A. Nephrostomy tube to drainage bagB. Indwelling catheter to gravityC. Chest tube to water sealD. NG tube to suction

ANS D To answer this item, you need nursing knowledge of various drainage tubes, as well as an understanding of fluid and electrolytes, especially potassium. Based on this information, you can determine the drainage tube that causes an increased risk for hypokalemia. This item requires critical thinking because you have to evaluate each option to determine which results in the greatest loss of potassium. Hypokalemia refers to a depletion of potassium and can result from a reduction in total potassium stores or from a temporary shift of extracellular potassium into the cell. Reductions in total potassium are caused by medications, such as diuretics, digitalis, and corticosteroids; Cushing's syndrome; diarrhea; vomiting; and wound drainage among others. Reductions in extracellular potassium caused by potassium shifting back into cells result from alkalosis, hyperinsulinism, total parenteral nutrition, and water intoxication among others. Intestinal suctioning through an NG tube results in the loss of gastric fluids. Potassium exists in large amounts in the GI fluids and is lost when gastric fluids are lost. This client is at an increased risk for hypokalemia.

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? A. DeontologyB. MoralityC. PrinciplismD. Advocacy

ANS D In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw a conclusion, from the provided scenario to decide which principle is represented. A legal and ethical responsibility of nurses is to protect the rights of clients and provide safe, quality nursing care. Advocacy is supporting or seeking a specific course of action for the benefit and on behalf of a person, group, or community. The nurse made the request to remove the playground equipment on behalf of and to benefit the children of the school. This is an example of advocacy.