ATI Knowledge and Clinical Judgment

A nurse is providing patient education about a new prescription of nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements indicates a needs for further teaching?

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

A nurse preceptor is orienting a newly licensed nurse. Which of the following actions indicates a breach of confidentiality and requires intervention by nurse preceptor?

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

A nurse is caring for a patient who is diagnosed with anemia. Which of the following skin variations is caused by reduced amount of oxyhemoglobin?

Pallor

A nurse is caring for a patient who 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

"Tell me more about your concerns"

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

2.5

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

2.5

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?

Away from 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?

Chlorine (bleach)

When 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 area with transparent wound barrier

A nurse is collecting nutritional data on an older adult client. Which of the following findings 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. Which of the following should the nurse report to the provider?

Dimpling of the tissue in the upper outer quadrant in this item, you need nursing knowledge related to data collection of the breasts and knowledge of deviations from the expected that are indicative of cancer. Based on an understanding of these concepts, you can identify which option describes a finding that is not within the expected range and can indicate a cancerous lesion. This item requires foundational thinking because you have to identify which finding is outside the expected range. Dimpling of the tissue in the upper outer quadrant should be considered an unexpected finding and reported to the provider. In fact, dimpling that is noted anywhere within the breast tissue should be reported. Dimpling makes the tissue appear retracted in a particular area and can result from underlying scar tissue or an invasive tumor causing ligaments to pull the skin inward toward the tumor. This variation of the breast tissue is consistent with breast cancer.

A nurse is caring for a patient with rheumatoid arthritis and is prescribed Prednisone. Which of the following indicates the client is experiencing an adverse effect?

Hyperglycemia In this item, you need nursing knowledge of dexamethasone to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of dexamethasone. Dexamethasone, a glucocorticoid, is a powerful anti-inflammatory and immunosuppressant and is indicated for the treatment of multiple disorders, including rheumatoid arthritis. Adverse effects of dexamethasone increase with the dosage and duration of treatment and can include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing's syndrome among others. Hyperglycemia, an elevated blood glucose level, is an adverse effect of dexamethasone. Both hyperglycemia and glycosuria can be manifested in clients who are taking dexamethasone because of its effect on the production and use of glucose

A nurse is assisting with the preparations of an education program regarding advance directives for new hires. Which of the following information should be included about living wills?

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

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

Obtaining the client's level of oxygen saturation In this item, you need nursing knowledge related to what the term tissue perfusion means. Based on an understanding of this, you can identify which of the following findings is an indicator of adequate tissue perfusion. This item requires foundational thinking because you only need to identify which of the following options describes a technique for measuring tissue perfusion. Perfusion is the delivery or pumping of arterial blood through tissues or an organ. Obtaining the client's level of oxygen saturation level is an appropriate technique of measuring perfusion. Oxygen saturation measures the percent of hemoglobin bound with oxygen that is being perfused through the arteries and into the tissues.

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 should be included?

Prepare healthy meal to serve at the end of class

A nurse is caring for a client who is receiving intermittent enteral tube feedings and have 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 In this item, you need nursing knowledge of how to administer enteral tube feedings, complications of enteral tube feedings, and appropriate nursing actions in the event of those complications. Based on an understanding of these concepts, you can identify which option describes an intervention the nurse should implement for a client who is receiving enteral tube feedings and has diarrhea. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food. Complications of enteral tube feedings include feeding tube regurgitation and aspiration of feedings, delayed gastric emptying, and malabsorption among others. Reducing the rate of feedings is an appropriate action by the nurse to prevent diarrhea after subsequent feedings. A client receiving intermittent enteral tube feedings can experience diarrhea because of the administration of hyperosmolar enteral feedings. To prevent this, administration should be slowed or switched to continuous enteral feedings.

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?

Supine

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

A nurse is collecting data on a client who had received a preoperative dose of morphine. Which of the following indicated the client is experiencing an adverse effect of the medication?

Urinary retention

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 In this item, you need knowledge of abbreviations that the Joint Commission has determined should not be used in documentation. This is a negatively-worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively-worded items in Module 4. This item requires foundational thinking because you only need to recall knowledge related to the abbreviations that are not acceptable for use when charting. To reduce the occurrence of medical errors, the Joint Commission developed a list of do-not-use abbreviations that should be avoided in health care settings. The abbreviation "q.d." was previously used to indicate every day, which can be mistaken as the abbreviation for "four times daily (qid)," resulting in medical errors. The Joint Commission has recommended the use of "daily" to indicate every day. This is not an acceptable abbreviation; therefore, additional teaching is needed.