Knowledge and clinical judgment

A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is diagnosed with angina. What statement by the client indicates a need for further teaching?

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

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 at sometime." What response by the nurse is appropriate?

"Tell me more about your concerns."

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

2.5 tablets

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 acetmainophen liquid suspension that has been prescribed provides 120mg/5mL. How many teaspoons should the nurse teach the parents to administer per dose?

2.5 tsp, because 1 tsp = 5 mL

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 direction?

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. What solution should the nurse use to clean the spill?

chlorine (bleach)

While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. What action should the nurse take?

cover the area with a transparent wound barrier

A nurse is collecting nutritional data on an older adult. What finding is suggestive of a healthy nutritional status?

deep reddish-colored tongue

A nurse is conducting a breast examination on a client who has a family history of breast cancer. What should the nurse report to the provider?

dimpling of the tissue in the upper outer quadrant

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?

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

A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone (Prednisone). What indicates the client is experiencing an adverse effect of the medication?

hyperglycemia

A nurse is assisting in preparation of an education program regarding advance directives for newly hired staff. What information should be included about living wills?

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

A nurse is collecting data on a recently admitted client. What technique should the nurse use to measure tissue perfusion?

obtaining the client's level of oxygen saturation

A nurse is caring for a client who is diagnosed with anemia. What skin color variation is caused by a reduced amount of oxyhemoglobin?

pallor

A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. What activity should be included as a learning strategy in the program?

prepare a healthy meal to serve at the end of class

A nurse is precepting a newly licensed nurse while he is charting. What abbreviation indicates a need for further teaching?

q.d. (should be qid)

A nurse is caring for a client who is receiving intermittent enteral tube feedings and having diarrhea after each feeding. What action should the nurse take in an attempt to prevent diarrhea after feedings?

reduce the rate of the feedings

A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. Which position should the client by placed for insertion of the catheter?

supine

A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. What actions by the nurse indicates a need for further teaching to prevent lift injuries?

twisting at the waist and shoulders

A nurse is collecting data on a client who has received a preoperative dose of morphine. What indicates the client is experiencing an adverse reaction to the medication?

urinary retention