Knowledge and Clinical Judgement (Beginning)

A nurse is providing education about a new Rx for nitroglycerin (NitroQuick) to a client who is dx with angina. Which of the following statements by the client indicates a need for further teaching?

"I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." Rationale: 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 so because of the short shelf life the client should not buy the medication in bulk quantities and the client should also be instructed to date the bottle when it is first opened.

A nurse is providing discharge education to the parents of a preschooler who is Rx acetaminophen 300 mg q4h prn. The liquid suspension provides 120 mg/5 mL. How many tsp should the nurse teach the parents to administer per dose?

2.5 tsp Rationale: tsp/dose = 1 tsp/5 mL x 5mL/120mg x 300mg/dose = 1500/600 = 2.5

A nurse is caring for a client who has been Rx 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 the body Rationale: Opening the sterile package away from the body allows a nurse to open the remaining flaps without reaching over the sterile field which could result in contamination.

A nurse is caring for a client who is Rx IV fluids. While inserting the catheter blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill?

Chlorine (bleach) Rationale: Chlorine is a disinfectant that is specifically recommended to clean blood spills.

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?

Cover the area with transparent wound barrier Rationale: Appropriate care of pressure ulcers is based on characteristics and the stage of the wound. Reddened area is stage 1. A transparent wound barrier applied here prevents contamination and reduces friction.

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 Rationale: The tongue should be a healthy pink to a deep, reddish color with surface papillae present without swelling or lesions.

The nurse is conducting a breast exam on a client who has a family hx of breast cancer. Which of the following should the nurse report to the provider?

Dimpling of the tissue of the upper outer quadrant Rationale: This is an unexpected finding and should be reported to client's hcp. Dimpling makes the tissue appear retracted and can result from underlying scar tissue or an invasive tumor causing ligaments to pull the skin inwards. This variation is consistent with breast cancer.

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?

Discussing changes in a client's plan of care with his friend who is a nurse on another unit Rationale: Client info can only be shared with other health care professionals involved in that client's care.

A nurse is assisting with the prep of an education program regarding advance directives for newly hired staff. Which of the following info should be included about living wills?

Living wills detail tx wishes of the client in the event of terminal illness Rationale: Advance directives include both living wills and durable powers of attorney for health care detailing tx wishes of the client in the event of terminal illness or persistent vegetative state.

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?

Pallor Rationale: In clients who have anemia, the RBCs are reduced to the point peripheral tissues are not receiving adequate O2 because of decreased circulating oxyhemoglobin which causes the changes to the client's skin color.

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?

Reduce the rate of the feedings Rationale: Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food. A client receiving intermittent enteral tube feedings can experience diarrhea because of the administration of hyperosmolar enteral feedings. To prevent this, feedings should be slowed or switched to continuous.

A nurse is caring for a male client who has been Rx an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter?

Supine Rationale: When preparing to implement this procedure it's important to ensure client privacy by draping non-essential 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 allows for optimal visualization which reduces trauma and increases success

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. Rationale: This abbreviation was previously used to indicate everyday which can be mistaken as "four times daily" (qid) resulting in med errors. The Joint Commission has recommended the use of "daily" to indicate everyday. Therefore additional teaching is needed.

A nurse is collecting data on a client who has received a preop dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication?

urinary retention Rationale: 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/retention/urgency.

A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, "I don't think I'm gonna have the surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate?

"Tell me more about your concerns." Rationale: Giving a general lead encourages the client to openly share feelings and concerns in a nonthreatening environment which will assist in establishing a meaningful nurse-client relationship. This response fosters this.

Nurse is caring for a client who is dx with a UTI and is Rx ciprofloxacin (Cipro) 250 mg PO bid. Available is 100 mg/tab. How many tablets should nurse admin per dose?

2.5 tabs Rationale: tab/dose = tab/100mg x 250mg/dose = 250/100 = 2.5

A nurse is caring for a client who is dx with rheumatoid arthritis and is Rx dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication?

Hyperglycemia Rationale: Dexamethason, a glucocorticoid, is a powerful anti-inflammatory and immunosuppressant and is indicated for the treatment of multiple disorders. Adverse effects increase with the dosage and duration of treatment and can include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, PUD and iatrogenic Cushing syndrome among others. Hyperglycemia, an elevated blood glucose level, is an adverse effect because of dexamethasone's effect on the production and use of glucose.

A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissues perfusion?

Obtaining the client's level of oxygen saturation Rationale: Perfusion is the delivery of arterial blood through tissues or organs. Obtaining these levels measures the perfusion by measuring the percent of hgb bound with O2 that is being perfused.

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?

Prepare a healthy meal to serve at the end of class Rationale: 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 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 Rationale: To prevent injury when transferring a client, alignment of the back/neck/pelvis/feet should be maintained. Therefore this action is not appropriate and needs further teaching.