ATI Nurse Logic: Knowledge and clinical judgement

*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 will be sure to use the nebulizer four times per day." B. "I can't use my cromolyn nebulizer for a sudden asthma attack." C. "It will be several weeks before I notice an improvement in my asthma." D. "I will use my cromolyn nebulizer before using my albuterol inhaler."*

"I will use my cromolyn inhaler before using my albuterol inhaler." 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 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/L B. 0.75 mEq/L C. 1.5 mEq/L D. 2.25 mEq/L*

0.75 mEq/L 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 caring for a client who weighs 132 lb and has been prescribed gentamicin (Garamycin) 5mg/kg/day by IV bolus in three equal doses. Available on hand is 40 mg/mL that is to be added to 50 mL 0.9% sodium chloride. How many mL should the nurse add to the solution per dose?

2.5

*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 to15 lb B. 15 to 20 lb C. 25 to 35 lb D. 35 to 45 lb*

25 to 35 lb

*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 rubella B. A client who has measles C. A client who has hepatitis A D. A client who has Rocky Mountain spotted fever*

A client who has rubella 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 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 a cardiac catheterization B. A client who is in stage 4 of Parkinson's disease C. A client who has anorexia and hypotension D. A client who has a temperature of 39.1° C (102.4° F) and is shivering

A client who is recovering from a cardiac catheterization 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 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

A written prescription from the provider

A school nurse has requested the school board remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following? A. Deontology B. Morality C. Principlism D. Advocacy

Advocacy 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.

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 client information be sent to providers using presaved numbers on speed dial of the fax machine B. Assigning staff members on each shift the same password for accessing medical records C. Allowing nurses to complete electronic documentation on a client while at the client's bedside D. Discussing a client's financial hardship at an interdisciplinary team meeting

Assigning staff members on each shift the same password for accessing medical records

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-lying position. B. Remove 10 mL of water from the suction control chamber. C. Apply a padded clamp on the tubing for 1 to 2 min. D. Move the drainage system above the level of the client's heart.

Assist the client to a side-lying position. 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 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

Dark urine 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 scheduled for a lumbar puncture. The nurse should teach the client that which of the following is a post-procedure complication? A. Hypothermia B. Polyuria C. Headache D. Seizures

Headache 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 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 bag B. Indwelling catheter to gravity C. Chest tube to water seal D. NG tube to suction

NG tube to suction 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 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. Yellowed sclerae

Slurred speech 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 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 test B. Chest x-ray C. Enzyme-linked immunoassay (ELISA) test D. Sputum culture for acid-fast bacillus*

Sputum culture for acid-fast bacillus 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 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 butter B. Apple juice C. Yogurt with fresh fruit D. Beef broth

Toast with peanut butter 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 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 affected side for several minutes upon completion of instillation. B. Warm refrigerated drops to room temperature prior to instillation. C. Pull the pinna of the ear upward and back during instillation. D. Massage the area posterior to the ear after instillation.*

Warm refrigerated drops to room temperature prior to instillation. 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 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 rash B. Respiratory rate 54/min C. Abdominal distension D. Heart rate142/min

Abdominal distension

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. "It's quite simple. I'll make sure that her colostomy bag is clean before she leaves and you'll 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 mother's care concerns you?"

"What part of your mother's care concerns you?"

*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 loss ​B. WBC 2,800/mm3 C. Heart rate 64/min D. Insomnia*

​WBC 2,800/mm3 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.