ATI: Nursing Logic Knowledge and Clinical Judgement

Prepare a health meal to serve at the end of class

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

Urinary retention

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

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

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? 1. living wills require a written prescription from the provider to be legal 2. living wills allow the client to designate a health care proxy 3. living wills ensure hospitals provide emergency care regardless of health coverage 4. living wills detail treatment wishes of the client in the event of terminal illness

away from the body

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? 1. to the left 2. to the right 3. away from the body 4. toward the body

Pallor

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? 1. cyanosis 2. jaundice 3. erythema 4. pallor

hyperglycemia

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? 1. hypomagnesemia 2. hyperglycemia 3. hyponatremia 4.hyperkalemia

Chlorine (bleach)

A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood spilled on the floor. Which of the following solutions should the nurse use to clean the spill? 1. isopropyl alcohol 2. chlorhexidine gluconate (hibiclens) 3. chlorine (bleach) 4. Iodophor

Reduce the rate of the feedings

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? 1. chill formula prior to administration 2. verify feeding tube placement 3. reduce the rate of the feedings 4. place the client supine during feedings

Tell me more about your concerns

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? 1. Clients having this surgery are always scared 2. Why have you changed your mind about the surgery 3. You shouldn't worry, everything will be fine 4. Tell me more about your concerns

supine

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? 1. dorsal recumbent 2. orthopneic 3. side-lying 4. supine

obtaining the client's level of oxygen saturation

A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion 1. determining the client's respiratory rate 2. measuring the client's chest diameter 3. obtaining the client's level of oxygen saturation 4. checking the client's depth of respirations

Deep reddish-colored tongue

A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? 1. spongy gums that are receding 2. fissures at eyelid corners 3. easily plucked hair 4. deep reddish-colored tongue

dimpling of the tissue in the upper outer quadrant

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 tot he provider? 1. silver-colored striae 2. unilateral nipple inversion present since menarche 3. dimpling of the tissue in the upper outer quadrant 4. visible symmetrical venous patterns

q.d.

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 1. mcg 2. q.d. 3. mL 4. PO

2.5 tsp

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

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

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? 1. I'll make sure that the medication container is kept tightly sealed 2. I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities 3. I'll keep my pills in the medicine cabinet when I'm home 4. I'll go to the emergency room if my chest pain doesn't go away

Cover the area with a transparent wound barrier

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? 1. reposition the client every 4 hr 2. cover the area with a transparent wound barrier 3. massage areas surrounding the redness 4. wash the area with hot water every 8 hr

Twisting at the waist and shoulders

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 1. twisting at the waist and shoulders 2. standing with feet in a wide stance 3. positioning self close to the client 4. using arms and legs to lift

2.5 tablets

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

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

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? 1. faxing lab results to a client's provider 2. discussing changes in a client's plan of care with his friend who is a nurse on another unit 3. describing a client's level of independence to the case manager arranging home health services 4. remaining in the room with the client while he reviews his own medical records