ATI Nurse Logic: Knowledge and Clinical Judgement

While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take? A. Reposition the client every 4 hours B. Cover the area with a transparent wound barrier C. Massage areas surrounding the redness D. Wash the area with hot water every 8 hours

Cover the area with a transparent wound barrier

A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin? A. Cyanosis B. Jaundice C. Erythema D. Pallor

Pallor

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? A. Dorsal recumbent B. Orthopneic C. Side-lying D. Supine

Supine

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

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? A. Twisting at the waist and shoulders B. Standing with feet in a wide stance C. Positioning self close to the client D. Using arms and legs to lift

Twisting at the waist and shoulders

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

A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, "I don't think I'm going to have the surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate? A. "Clients having this surgery are always scared." B. "Why have you changed your mind about the surgery." C. "You shouldn't worry, everything will be fine." D. "Tell me more about your concerns."

"Tell me more about your concerns."

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. 10-15 lb B. 15-20 lb C. 25-35 lb D. 35-45 lb

25-35 lb

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

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

A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills? A. Living wills require a written prescription from the provider to be legal B. Living wills allow the client to designate a health care proxy C. Living wills ensure hospitals provide emergency care regardless of health coverage D. Living wills detail treatment wishes of the client in the event of terminal illness

Living wills detail treatment wishes of the client in the event of terminal illness

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

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? Hematocrit 32% WBC 16/mm3 Slurred speech Yellowed sclerae

Slurred speech

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? A. mcg B. q.d. C. mL D. PO

q.d.

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 nebulizer before using my albuterol inhaler."

A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements by the client indicates a need for further teaching? A. "I'll make sure that the medication container is kept tightly sealed." B. "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." C. "I'll keep my pills in the medicine cabinet when I'm home." D. "I'll go to the emergency room if my chest pain doesn't go away."

"I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities."

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

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

2.5 mL

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

2.5 tablets

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 39.1C (102.4F) and is shivering

A client who is recovering from a cardiac catheterization

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 rate 142/min

Abdominal distension

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

A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurses should first open the sterile package in which of the following directions? A. To the left B. To the right C. Away from the body D. Toward the body

Away from the body

A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill? A. Isopropyl alcohol B. Chlorohexidine gluconate (Hibiclens) C. Chlorine (bleach) D. Iodophor

Chlorine (bleach)

A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone (prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication? A. Hypomagnesemia B. Hyperglycemia C. Hyponatremia D. Hyperkalemia

Hyperglycemia

A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication? A. Urinary retention B. Rapid respirations C. Dilated pupils D. Diarrhea

Urinary retention

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

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? A. Silver-colored striae B. Unilateral nipple inversion present since menarche C. Dimpling of the tissue in the upper outer quadrant D. Visible symmetrical venous patterns

Dimpling of the tissue in the upper outer quadrant

A nurse is caring for a client who is receiving intermittent enteral tube feedings and having diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings? A. Chill formula prior to administration B. Verify feeding tube placement C. Reduce the rate of the feedings D. Place the client supine during feedings

Reduce the rate of the feedings

A nurse is caring for a client who has a new colostomy. The client is being discharge 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 providing discharge education to the parents of a preschooler who is prescribed acetaminophen (Tylenol) 300 mg every 4 hr as needed. The acetaminophen liquid suspension that has been prescribed provides 120 mg/5 mL. How many teaspoons should the nurse teach the parents to administer per dose?

2.5 tsp

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 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

A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following activities should be included as a learning strategy in the program? A. Watch a video discussing healthy meal preparation B. Prepare a healthy meal to serve at the end of class C. Read pamphlets about preparing a healthy meal D. Discuss healthy meal preparation as a class

Prepare a healthy meal to serve at the end of class

A nurse is caring for a client who is experiencing night swats 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

A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested o resuscitative measures be taken in the event of a 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 nurse administrator is reviewing policies and procedures of the facility she works in the 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 pre-saved 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 collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? A. Spongy gums that are receding B. Fissures at eyelid corners C. Easily plucked hair D. Deep reddish-colored tongue

Deep reddish-colored tongue

A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates a breach of confidentiality and requires intervention by the nurse preceptor? A. Faxing laboratory results to a client's provider B. Discussing changes in a client's plan of care with his friend who is a nurse on another unit C. Describing a client's level of independence to the case manager arranging home health services D. Remaining in the room with the client while he reviews his own medical records

Discussing changes in a client's plan of care with his friend who is a nurse on another unit

A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion? A. Determining the client's respiratory rate B. Measuring the client's chest diameter C. Obtaining the client's level of oxygen saturation D. Checking the client's depth of respirations

Obtaining the client's level of oxygen saturation