ATI Nurse Logic 2.0 ~ Knowledge and Clinical Judgement (Advanced Test)

A nurse is caring for a client who weighs 132 lb and has been prescribed gentamicin 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 Rationale: 1. 132 lb/2.2 = 60 kg 2. (5 mg/kg/day) x (60 kg) = 300 mg/day 3. (300 mg/day)/(3 doses/day) = 100 mg/dose 4. 40 mg/1 mL = 100 mg/x mL 5. 40x = 100 6. x = 2.5 mL

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. A client who has rubella Rationale: A. To answer this item, you need knowledge of the pathophysiology and transmissibility of the diseases listed in the options. Additionally, you have to recall your knowledge of transmission-based precaution levels. Based on your understanding of these concepts, you can determine which client should be placed on droplet precautions. This item requires critical thinking because you have to evaluate the four clients to determine which client requires implementation of droplet precautions. Rubella is transmitted through the nasopharyngeal secretions of the infected person, and is also found in blood, stool, and urine. Because droplets associated with the illness are larger than 5 mcg, the Centers for Disease Control and Prevention recommends placing clients who are diagnosed with rubella on droplet precautions. Droplet precautions include placing the client either in a private room or with other clients who have the same disease, as well as using of a mask or respirator when providing care. This client should be placed on droplet precautions. B. To answer this item, you need knowledge of the pathophysiology and transmissibility of the diseases listed in the options. Additionally, you have to recall your knowledge of transmission-based precaution levels. Based on your understanding of these concepts, you can determine which client should be placed on droplet precautions. This item requires critical thinking because you have to evaluate the four clients to determine which client requires implementation of droplet precautions. Measles is transmitted through respiratory secretions of the infected person and is also found in blood and urine. Because droplets associated with this illness are smaller than 5 mcg, the Centers for Disease Control and Prevention recommends placing clients who a

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 39.1° C (102.4° F) and is shivering

A. A client who is recovering from a cardiac catheterization Rationale: A. In this item, you need nursing knowledge of how blood pressure measurement can be impacted by the stages of Parkinson's disease, hypotension, shivering, and cardiac catheterization. Additionally, specific knowledge of electronic blood pressure measurement is needed to select the correct option. This item requires critical thinking because you have to analyze the four clients and determine for whom an electronic blood pressure is appropriate. Electronic blood pressure measurement is attained through a sensor that detects vibrations caused by blood rushing through the artery, is appropriate for use when the blood pressure must be monitored frequently, and should not be taken on clients with conditions that can result in an inaccurate reading. A client who is recovering from a cardiac catheterization requires frequent blood pressure measurements. It is appropriate to perform an electronic blood pressure measurement on this client. B. In this item, you need nursing knowledge of how blood pressure measurement can be impacted by the stages of Parkinson's disease, hypotension, shivering, and cardiac catheterization. Additionally, specific knowledge of electronic blood pressure measurement is needed to select the correct option. This item requires critical thinking because you have to analyze the four clients and determine for whom an electronic blood pressure is appropriate. A client in stage 4 of Parkinson's disease has bilateral limb involvement and resting tremors. Associated tremors can result in an inaccurate reading by causing the sensor to detect these vibrations instead of blood rushing through the artery. It is not appropriate to perform an electronic blood pressure measurement on this client. C. In this item, you need nursing knowledge of ho

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

C. Headache Rationale: A. To answer this item, you need knowledge of lumbar punctures, as well as complications associated with the procedure. Based on an understanding of this information, you can identify the correct option. This item requires foundational thinking because you have to recall potential post procedure complications associated with a lumbar puncture. Hypothermia is not a manifestation that results from cerebrospinal fluid leakage at the puncture site following a lumbar puncture. Instead, the client can experience a slightly elevated temperature. B. To answer this item, you need knowledge of lumbar punctures, as well as complications associated with the procedure. Based on an understanding of this information, you can identify the correct option. This item requires foundational thinking because you have to recall potential postprocedure complications associated with a lumbar puncture. Polyuria is not a manifestation that results from cerebrospinal fluid leakage at the puncture site following a lumbar puncture. Instead, the client can experience difficulty voiding. C. To answer this item, you need knowledge of lumbar punctures, as well as complications associated with the procedure. Based on an understanding of this information, you can identify the correct option. This item requires foundational thinking because you have to recall potential postprocedure complications associated with a lumbar puncture. Lumbar punctures are performed to withdraw cerebrospinal fluid found in the subarachnoid space for analysis. This is accomplished by inserting a needle into the lumbar subarachnoid space, typically between the third and fourth or fourth and fifth lumbar vertebrae. After the cerebrospinal fluid specimen has been removed, it is not uncommon for leakage of cerebrospinal fluid to continue at the puncture site

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

D. Advocacy Rationale: A. In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw a conclusion, from the provided scenario to decide which principle is represented. Deontology is an ethical theory based on the idea that actions must be based on moral rules or duty regardless of the consequences. The nurse's actions are not an example of deontology. B. In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw a conclusion, from the provided scenario to decide which principle is represented. Morality is the premise of right or wrong actions based on shared societal or generational expectations. The nurse's actions are not an example of morality. C. In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw a conclusion, from the provided scenario to decide which principle is represented. Principlism is the dominant approach to ethical decision making and is comprised of the principles of respect for autonomy, nonmaleficence, beneficence, and distributive justice. The nurse's actions are not an example of principlism. D. In this item, you need knowledge of specific ethical theories and principles. Based on your understanding of these concepts, you can select the appropriate ethical principle. This item requires critical thinking because you have to infer, or draw

A nurse is assigned to care for four clients. The client with which of the following drainage tubes is at 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

D. NG tube to suction Rationale: A. To answer this item, you need nursing knowledge of various drainage tubes, as well as an understanding of fluid and electrolytes, especially potassium. Based on this information, you can determine the drainage tube that causes an increased risk for hypokalemia. This item requires critical thinking because you have to evaluate each option to determine which results in the greatest loss of potassium. A nephrostomy tube drains urine, and although the kidneys filter potassium and can be a source of potassium loss, without a secondary risk factor, such as taking thiazide or loop diuretics, another client would be at greater risk for hypokalemia. B. To answer this item, you need nursing knowledge of various drainage tubes, as well as an understanding of fluid and electrolytes, especially potassium. Based on this information, you can determine the drainage tube that causes an increased risk for hypokalemia. This item requires critical thinking because you have to evaluate each option to determine which results in the greatest loss of potassium. An indwelling catheter is inserted in the bladder to drain urine. Although the kidneys filter potassium and can be a source of potassium loss, without a secondary risk factor, such as taking diuretics, another client would be at greater risk for hypokalemia. C. To answer this item, you need nursing knowledge of various drainage tubes, as well as an understanding of fluid and electrolytes, especially potassium. Based on this information, you can determine the drainage tube that causes an increased risk for hypokalemia. This item requires critical thinking because you have to evaluate each option to determine which results in the greatest loss of potassium. Chest tubes are used to evacuate air or blood from the pleural space and are not associated wit

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

D. Sputum culture for acid-fast bacillus Rationale: A. In this item, you need knowledge of the route of transmission and diagnostic criteria of tuberculosis. Based on an understanding of these concepts, you can identify the correct option. This item requires foundational thinking because you have to recall knowledge of the appropriate diagnostic criteria for pulmonary tuberculosis. A positive tuberculin test indicates the client has been exposed to tuberculosis and has developed antibodies to the bacillus. While the tuberculin test is an effective screening tool, it is not helpful in distinguishing between an active case of tuberculosis and a client who was previously exposed to tuberculosis. This test does not confirm active pulmonary tuberculosis. B. In this item, you need knowledge of the route of transmission and diagnostic criteria of tuberculosis. Based on an understanding of these concepts, you can identify the correct option. This item requires foundational thinking because you have to recall knowledge of the appropriate diagnostic criteria for pulmonary tuberculosis. A chest x-ray can be helpful for detecting old or new lesions that are large enough to be visualized; however, this test does not confirm a diagnosis of active pulmonary tuberculosis. C. In this item, you need knowledge of the route of transmission and diagnostic criteria of tuberculosis. Based on an understanding of these concepts, you can identify the correct option. This item requires foundational thinking because you have to recall knowledge of the appropriate diagnostic criteria for pulmonary tuberculosis. The ELISA is a rapid test where an antibody or antigen is linked to an enzyme as a means of detecting a match between the antibody and antigen, such as the ELISA screening test performed to detect whether or not a client is HIV positive. T

A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and has requested no resuscitative measures be taken in the event of respiratory or cardiac arrest. Which of the following is necessary to legally change the client's code status to do-not-resuscitate? 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. A written prescription from the provider Rationale: A. In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on your knowledge of this concept, you can select the option that describes requirements to legally change the code status of a client to a DNR. This item requires foundational thinking because you have to recall legalities associated with initiating a DNR. A DNR is typically instituted at the request of a client or family member and should be a written order instead of a verbal prescription. Until a DNR prescription exists, every attempt to revive the client should be made in the event of respiratory or cardiac arrest. A written prescription from the provider is necessary to legally change the client's code status to a DNR. B. In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on your knowledge of this concept, you can select the option that describes requirements to legally change the code status of a client to a DNR. This item requires foundational thinking because you have to recall legalities associated with initiating a DNR. The client, or the client's health care proxy if the client is not competent, should be notified by the provider before writing a prescription for a DNR. While the client and family should be in agreement, signed documentation is not a legal requirement to change the client's code status to a DNR. C. In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on your knowledge of this concept, you can select the option that describes requirements to legally change the code status of a client to a DNR. This item requires foundational thinking because you have to recall legalities associated with initiating a DNR. Because the client is competent to make decisions, his req

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.

A. Assist the client to a side-lying position. Rationale: A. In this item, you need knowledge of the care required for a chest tube. Based on this information, you can select the appropriate action for a client who reports a burning pain in his chest. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. Burning sensation or pain can result from the chest tube becoming occluded because it is resting against tissue. It is possible to move the tip of the chest tube away from the tissues by repositioning the client. Repositioning the client is the appropriate action by the nurse. B. In this item, you need knowledge of the care required for a chest tube. Based on this information, you can select the appropriate action for a client who reports a burning pain in his chest. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. An air vent is created for the chest drainage system by placing an open tube in the water of the suction control chamber. The depth of this open tube in the water controls the amount of suction in the drainage system and should be maintained at the level prescribed by the provider. Removing 10 mL of water from the suction control chamber is not an appropriate action by the nurse. C. In this item, you need knowledge of the care required for a chest tube. Based on this information, you can select the appropriate action for a client who reports a burning pain in his chest. This item requires critical thinking because you have to analyze elements of the provided clinical situation and make a decision based on that analysis. A padded clamp may be applied briefly to the tubing if continuous bubbling is noted in th

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

A. Toast with peanut butter Rationale: A. In this item, you need knowledge of foods that can and cannot be incorporated in the diet of clients who have dumping syndrome. Based on this knowledge, you can evaluate the appropriateness of the client's food selection. This item requires foundational thinking because you have to recall knowledge related to the causes of dumping syndrome, as well as related nutrition principles. Dumping syndrome results from rapid emptying of the stomach into the small intestine after eating, and manifests as a group of vasomotor symptoms, such as vertigo, tachycardia, syncope, sweating, pallor, and palpitations. Additionally, abdominal distension occurs because of the shift of fluid into the intestines. A diet that restricts some foods and includes others as appropriate food choices reduces the occurrence and severity of dumping syndrome. Peanut butter and toast are allowed or encouraged foods for a client who has dumping syndrome. B. In this item, you need knowledge of foods that can and cannot be incorporated in the diet of clients who have dumping syndrome. Based on this knowledge, you can evaluate the appropriateness of the client's food selection. This item requires foundational thinking because you have to recall knowledge related to the causes of dumping syndrome, as well as related nutrition principles. Beverages with high sugar content, such as apple juice, lead to rapid gastric emptying because of high osmolarity and should be avoided. C. In this item, you need knowledge of foods that can and cannot be incorporated in the diet of clients who have dumping syndrome. Based on this knowledge, you can evaluate the appropriateness of the client's food selection. This item requires foundational thinking because you have to recall knowledge related to the causes of dumping syndrome, as we

A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium. 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

B. 0.75 mEq/L Rationale: A. To answer this item, you need knowledge of therapeutic serum lithium level levels. Based on your understanding of this information, you can select the option with the serum lithium level appropriate for maintenance therapy. This item requires foundational thinking because you have to recall knowledge of therapeutic serum lithium levels. This serum lithium level indicates the client's dosage is too low for maintenance therapy. B. To answer this item, you need knowledge of therapeutic serum lithium level levels. Based on your understanding of this information, you can select the option with the serum lithium level appropriate for maintenance therapy. This item requires foundational thinking because you have to recall knowledge of therapeutic serum lithium levels. Lithium is a mood-stabilizing medication used in the treatment of bipolar I acute and recurrent manic and depressive episodes. To achieve a therapeutic range, give 300 mg to 600 mg of lithium during the active phase. The therapeutic serum lithium level is between 0.8 mEq/L and 1.4 mEq/L. Maintenance levels of 0.4 to 1.3 mEq/L are then achieved for clients who are prescribed lithium for long-term therapy. Because small increments of dosage separate therapeutic, maintenance, and toxic levels of lithium, knowledge of these levels is essential to ensure safe, quality care. This serum lithium level indicates the client's dosage is appropriate for maintenance therapy. C. To answer this item, you need knowledge of therapeutic serum lithium level levels. Based on your understanding of this information, you can select the option with the serum lithium level appropriate for maintenance therapy. This item requires foundational thinking because you have to recall knowledge of therapeutic serum lithium levels. This serum lithium level suggests ad

A nurse administrator is reviewing policies and procedures of the facility she works in to 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

B. Assigning staff members on each shift the same password for accessing medical records Rationale: A. In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to determine the one that results in a breach of confidentiality. Having fax numbers presaved on the fax machine eliminates the possibility of an entry-error when sending client information to providers. This procedure is appropriate and does not require intervention to prevent the release of confidential information. B. In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to determine the one that results in a breach of confidentiality. HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. Each staff member should have a personal password that is not shared with others and is used to enter and sign-off of computerized records. Individuals caring for a client should be the only ones able to access client records.

A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine. Which of the following findings indicates the client is experiencing an adverse effects of the medication? A. Weight loss B. WBC 2,800/mm3 C. Heart rate 64/min D. Insomnia

B. WBC 2,800/mm3 Rationale: A. In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. Based on an understanding of this information, you can identify which is the correct option. This item requires foundational thinking because you have to recall knowledge related to adverse effects of clozapine. Weight loss does not indicate the client is experiencing an adverse effect of the medication. Instead, weight gain is an adverse effect that can occur in clients who are taking clozapine because of the blockage of H1 histamine receptors. B. ​In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. Based on an understanding of this information, you can identify which is the correct option. This item requires foundational thinking because you have to recall knowledge related to adverse effects of clozapine. Clozapine is a second-generation antipsychotic used to relieve symptoms of schizophrenia and to reduce suicidal behaviors in clients who have schizophrenia or schizoaffective disorder. Adverse effects of clozapine include tachycardia, weight gain, sedation, and agranulocytosis. Agranulocytosis, which is a decrease in one of the WBCs called neutrophils, reduces the ability to fight infection and can be fatal. Because of the potential for agranulocytosis, clients who are taking clozapine are monitored frequently for a decrease in WBC count below 3,000/mm3. The client's WBC and absolute neutrophil count is monitored weekly during the first 6 months of therapy, then every 2 weeks during the next 6 months. A WBC level of 2,800/mm3 indicates the client is experiencing an adverse effect of the medication. C. In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. B

A nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine 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.

B. Warm refrigerated drops to room temperature prior to instillation. Rationale: A. This item requires knowledge of appropriate techniques for administering ear drops. Based on your understanding of this concept, you can select the appropriate nursing action. This item requires foundational thinking because you have to recall knowledge of a specific nursing skill to appropriately administer ear drops. This is not an appropriate action by the nurse when administering ear drops. The toddler should be positioned on the unaffected side, instead of the affected side, for several minutes after instilling the ear drops to prevent the drops from flowing out of the canal. B. This item requires knowledge of appropriate techniques for administering ear drops. Based on your understanding of this concept, you can select the appropriate nursing action. This item requires foundational thinking because you have to recall knowledge of a specific nursing skill to appropriately administer ear drops. This is an appropriate action by the nurse when administering ear drops. Ear drops are topically administered medications, which are slowly absorbed through the skin and primarily provide local results. Because of the anatomy of internal ear structures, it is important to remember that the ear is sensitive to extremes in temperature. Ear drops should be warmed to room temperature prior to instillation to reduce the risk of painful stimuli. C. This item requires knowledge of appropriate techniques for administering ear drops. Based on your understanding of this concept, you can select the appropriate nursing action. This item requires foundational thinking because you have to recall knowledge of a specific nursing skill to appropriately administer ear drops. This is not an appropriate action by the nurse when administering ear drops for a tod

A nurse is caring for a client who is pregnant with a single fetus and has a body mass index 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 to 15 lb B. 15 to 20 lb C. 25 to 35 lb D. 35 to 45 lb

C. 25 to 35 lb Rationale: A. To answer this item, you need an understanding of both BMI levels and appropriate weight gain in pregnancy. Based on your understanding of these concepts, you can select the option indicating the appropriate weight gain for the client in the scenario. This item requires critical thinking because you have to interpret the client data from the scenario and then explain that data in relation to the expected BMI and the current recommendations regarding weight gain during pregnancy. A weight gain of 10 to 15 lb is below the recommended weight gain for a client who has a normal BMI and is pregnant with a single fetus. Too little or too much weight gain could mean potential health problems. B. To answer this item, you need an understanding of both BMI levels and appropriate weight gain in pregnancy. Based on your understanding of these concepts, you can select the option indicating the appropriate weight gain for the client in the scenario. This item requires critical thinking because you have to interpret the client data from the scenario and then explain that data in relation to the expected BMI and the current recommendations regarding weight gain during pregnancy. A weight gain of 15 to 20 lb is below the recommended weight gain for a client who has a normal BMI and is pregnant with a single fetus. C. To answer this item, you need an understanding of both BMI levels and appropriate weight gain in pregnancy. Based on your understanding of these concepts, you can select the option indicating the appropriate weight gain for the client in the scenario. This item requires critical thinking because you have to interpret the client data from the scenario and then explain that data in relation to the expected BMI and the current recommendations regarding weight gain during pregnancy. The recommended

A nurse is collecting data on a newborn who was delivered 30 minutes 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

C. Abdominal distension Rationale: A. In this item, you need knowledge of expected findings, findings that require no intervention, and findings requiring additional intervention when collecting data on a newborn. Based on your understanding of these concepts, you can select the correct option. This item requires critical thinking because you have to analyze the finding described in each option in relation to the gestational age of a newborn who was delivered 30 min ago. A vesicular rash is indicative of erythema toxicum, which is a transient rash caused by an inflammatory response in neonates born at 36 weeks of gestation or more. It is thought that the rash is caused by the presence of eosinophils, which assist in reducing inflammation, in small vesicles that appear suddenly on the body during the first 3 weeks of life. Treatment of the rash is not required, as it has no clinical significance. B. In this item, you need knowledge of expected findings, findings that require no intervention, and findings requiring additional intervention when collecting data on a newborn. Based on your understanding of these concepts, you can select the correct option. This item requires critical thinking because you have to analyze the finding described in each option in relation to the gestational age of a newborn who was delivered 30 min ago. Shallow, irregular respirations of 54/min is within the expected reference range for a newborn. This finding does not require further intervention. C. In this item, you need knowledge of expected findings, findings that require no intervention, and findings requiring additional intervention when collecting data on a newborn. Based on your understanding of these concepts, you can select the correct option. This item requires critical thinking because you have to analyze the finding described in

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? A. Hematocrit 32% B. WBC 16/mm3 C. Slurred speech D. Yellowed sclerae

C. Slurred speech Rationale: A. To answer this item, you need knowledge of the pathophysiology of sickle cell anemia, as well as specific nursing knowledge of the expected parameters for laboratory tests and physical findings associated with a vaso-occlusive crisis. Based on an understanding of these concepts, you can identify the life-threatening clinical finding. This item requires critical thinking because you have to infer, or draw a conclusion, based on the client situation to determine which finding is the highest priority. A hematocrit of 32% is not the priority finding. The hematocrit level of clients who have sickle cell anemia is often below the expected reference range because of the destruction and shortened life span of RBCs. B. To answer this item, you need knowledge of the pathophysiology of sickle cell anemia, as well as specific nursing knowledge of the expected parameters for laboratory tests and physical findings associated with a vaso-occlusive crisis. Based on an understanding of these concepts, you can identify the life-threatening clinical finding. This item requires critical thinking because you have to infer, or draw a conclusion, based on the client situation to determine which finding is the highest priority. A WBC count of 16/mm3 is not the priority finding. The WBC level of clients who have sickle cell anemia is often above the expected reference range because of chronic inflammation caused by tissue hypoxia and ischemia. C. To answer this item, you need knowledge of the pathophysiology of sickle cell anemia, as well as specific nursing knowledge of the expected parameters for laboratory tests and physical findings associated with a vaso-occlusive crisis. Based on an understanding of these concepts, you can identify the life-threatening clinical finding. This item requires critical thinkin

A nurse is reinforcing teaching about a new prescription for cromolyn sodium metered dose inhaler 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."

D. "I will use my cromolyn nebulizer before using my albuterol inhaler." Rationale: A. In this item, you need nursing knowledge of cromolyn to recall information about the medication that should be included in client teaching. Based on an understanding of this information, you can identify which of the client statements is not accurate. This is a negatively worded item that asks you to select the option that indicates the client needs further teaching. You will learn more about negatively worded items in Module 4.This item requires foundational thinking because you have to recall knowledge to determine which of the client's statements about cromolyn was false. "I will be sure to use the nebulizer four times per day." is a true statement and does not indicate the need for further teaching. B. In this item, you need nursing knowledge of cromolyn to recall information about the medication that should be included in client teaching. Based on an understanding of this information, you can identify which of the client statements is not accurate. This is a negatively worded item that asks you to select the option that indicates the client needs further teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge to determine which of the client's statements about cromolyn was false. "I can't use my cromolyn nebulizer for a sudden asthma attack." is a true statement and does not indicate a need for further teaching. Cromolyn has a slow onset and will not relieve an acute asthma attack. A fast-acting bronchodilator should be given if the client is experiencing an acute bronchospasm. C. In this item, you need nursing knowledge of cromolyn to recall information about the medication that should be included in client teaching. Based on an unde

A nurse is caring for a client who has a new colostomy. The client is being discharged 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?"

D. "What part of your mother's care concerns you?" Rationale: A. In this item you, need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques, but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. False reassurance is often an attempt by the nurse to avoid dealing with the other person's concerns and discourages further discussion of feelings. This is not an appropriate response by the nurse because it uses the communication block of false reassurance. B. In this item you, need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques, but must also evaluate the statement in each option and determine if it represents a therapeutic or nontherapeutic technique. Asking personal questions typically does not yield information that is relevant to the situation and does not exemplify professional communication. This is not an appropriate response by the nurse because it uses the communication block of asking personal questions. C. In this item you, need knowledge of therapeutic and nontherapeutic communication techniques. Based on your understanding of these concepts, you can select the appropriate response by the nurse. This item requires critical thinking because you not only have to have knowledge of the specific techniques, but must also evaluate the statement in each option and determine if it represents a thera

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

D. Dark urine Rationale: A. In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical manifestation the parent should be taught is associated with biliary atresia. This item requires critical thinking because you have to evaluate each finding in relation to the pathophysiology of biliary atresia. Biliary atresia is a progressive process that leads to destruction of the biliary tree. The biliary tree begins as many small ducts that join together into one main common bile duct, similar to the joining of branches to a tree trunk. Bilirubin, created from the breakdown of heme in RBCs and the main pigment in bile, travels to the liver where the liver cells, known as hepatocytes, secretes it into bile. The bile then passes into the small ducts and then travels to the small intestine where bacteria break it down into urobilinogen to be excreted in the feces. Because of the progressive damage to the biliary tree, bile delivered to the small intestine is reduced, altering the metabolism of fats in infants who are diagnosed with biliary atresia. This difficulty in metabolizing fat leads to poor weight gain, instead of rapid weight gain. The nurse should not teach the parent that rapid weight gain is a clinical manifestation associated with the illness. B. In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical manifestation the parent should be taught is associated with biliary atresia. This item requires critical thinking because you have to evaluate each finding in relation to the pathophysiology of biliary atresia. Biliary atresia is a progressive process that leads to de