ATI Nurse Logic 2.0 Knowledge and Clinical Judgment

a nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a school-age child who has asthma. which of the following statements should indicate to the nurse that the child needs further teaching?

"i will use my cromolyn nebulizer before using my albuterol inhaler

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? -"ill make sure that the medication container is kept tightly sealed" -"im lucky i have a prescription plan that allows me to buy pills in bulk quantities" -"ill keep my pills in the medicine cabinet when im home" -"ill go to the emergency room if my chest pain doesnt go away"

"im lucky i have a prescription plan that allows me to buy pills in bulk quantities

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? -"its quite simple. i'll make sure her colostomy bag is clean before she leaves and you'll have no problems." -"is the colostomy care the only reason your mother is going to be living with you?" -"a home health nurse will be stopping by tomorrow. if you have any questions you can ask her." -"what part of your mother's colostomy care concerns you?"

"what part of your mother's colostomy care concerns you"

pharmacology-related nursing responsibilities

-administering drugs -evaluating therapeutic responses to drugs -promoting client adherence -providing education -intervene for adverse effects

clinical judgment requires the nurse to use critical thinking skills when:

-analyzing client data and related evidence -ascertaining the meaning of the data and evidence -determining client outcomes desired and/or achieved as indicated by evidence-based best practices

a nurses knowledge base includes:

-biological, physical, and social sciences -pathophysiology -understanding of nursing procedures

explanation requires you to:

-clarify the assumptions and reasoning processes followed -justify one's reasoning and conclusions concepts used: -evidence -concepts -methodologies -contextual considerations

nurse competencies

-client centered care -interdisciplinary collaboration -evidence based practice -quality improvement -informatics -safety -client education -professionalism -leadership -priority setting

nutrition knowledge

-counsel -provide nutritional education -nutritional screenings -nutritional assessment

evaluation requires you to assess:

-credibility of sources of information -strength of evidence -relevance, significance, value, or applicability of information

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

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

inference requires the ability to:

-draw conclusions based on evidence -differentiate between conclusions and hypotheses -identify knowledge gaps or needs

mathematic calculations why are they important?

-drug administration -nutritional needs -intake and output -incidence and prevalence rates -morbidity and mortality rates -percentage of weight loss -body mass index

analyzing information requires you to:

-examine -organize -validate -categorize or prioritize

foundational thinking in clinical practice

-expected signs and symptoms of an illness -expected reference range for laboratory results -risk factors for an alteration in health -expected side effects of a medication or treatment -nursing interventions that are appropriate to help meet a specified client need

nursing knowledge

-focuses on knowledge needed for care of clients -based on nursing research and research from other disciplines -evidence-based practices use evidence from research for nursing best practices

using the clinical decision making process how do you select best action using clinical judgment?

-identify client issue/problem -analyze/interpret data -make inferences -list possible outcomes -list possible actions -evaluate each action -select best action

clinical decision-making process

-identify that a client issue or problem exists -analyze and interpret relevant data -make inferences based on this interpretation to determine possible causes -list all possible actions that could be taken -evaluate each action and possible outcome -select best action

you should understand legal requirements of:

-informed consent -advanced health care directives -health insurance portability and accountability act

knowledge of physiology and pathophysiology allows the nurse to:

-make appropriate nursing judgments -project client needs -anticipate changes

content of nursing knowledge

-physiology and pathophysiology -pharmacology -nutrition -nursing procedures -mathematics -information technology -legal issues -ethical issues -effective communication

nurses use this knowledge to critically think and make sound judgments to:

-promote health -prevent disease -empower others

what does interpretation require you to do?

-recognize -understand -describe

sound clinical judgments help ensure:

-safe care -high-quality care -client-centered care

analysis inovlves:

-scrutinizing all of the data -determining the significance of each piece -distinguishing relevant from irrelevant data -various interventions are then considered in relation to potential outcomes and the risk of positive and negative consequences

what information will you have to analyze?

-signs and symptoms of illness or injury -evidence, facts, and research findings -concepts and ideas -beliefs and points of view

what is some information for interpretation

-the meanings of written materials -verbal and non verbal communications -assessments and empirical data -graphics

requirements of clinical reasoning

-the nurse must simultaneously analyze and evaluate assessment data during its compilation -the nurse uses the retained data to begin drawing a conclusion about the situation -clinical reasoning supports the clinical-decision making process

communication includes:

-verbal -written word -expressions -gestures -attitudes

a nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium (Lithane). which of the following serum lithium levels indicates the client's dosage is appropriate for maintenance therapy?

0.75 mEq/L

a nurse is caring for a client who weights 132 lb and has been prescribed gentamicin (Garamycin) 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

a nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribed ciprofloxicin (Cipro) 250 mg PO two times daily. the amount available is 100 mg/tablet. how many tables 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 acetaminophen liquid suspension that has been prescribed provides 120 mg/5 mL. how many teaspoons should the nurse teach the parents to administer per dose?

2.5 tsp

a nurse is caring for a client who is pregnant with a single fetus and has a BMI 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? -10-15 lb -15-20 lb -25-35 lb -35-45 lb

25-35 lb

a nurse is assigned to care for four clients. the client with which of the following drainage tubes is at an increased risk for hypokalemia? -nephrostomy tube to drainage bag -indwelling catheter to gravity -chest tube to water seal -NG tube to suction

NG tube to suction

a nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). which of the following findings indicates the client is experiencing an adverse effect of the medicaiton?

WBC 2,800/mm^3

a nursing supervisor is determining bed placement for four clients. which of the following clients should be placed on droplet precautions? -a client who has rubella -a client who has measles -a client who has hepatitis A -a client who has Rocky Mountain spotted fever

a client who has rubella

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 client who is recovering from a cardiac catheterization -a client who is in stage 4 of Parkinson's disease -a client who has anorexia and hypotension -a client who has a temperature of 39.1C (102.4F) and is shivering

a client who is recovering from a cardiac catheterization

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 cardiac arrest. which of the following is necessary to legally change the client's code status to do-not-resuscitate (DNR)?

a written prescription from the provider

a nurse is collecting data on a newborn who was delivered 30 min ago at the gestational age of 37 weeks. which of the following findings requires further intervention? -vesicular rash -respiratory rate 54/min -abdominal distension -heart rate 142/min

abdominal distension

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?

advocacy

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?

assigning staff members on each shift the same password for accessing medical records

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?

assist the client to a side-lying position

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 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. which of the following solutions should the nurse use to clean up 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. which of the following actions should the nurse take? -reposition the client every 4 hr -cover the area with a transparent wound barrier -massage areas surrounding the redness -wash the area with hot water every 8 hr

cover the area with a transparent wound barrier

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?

dark urine

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

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

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?

headache

a nurse is caring for a client who is diagnosed with RA and is prescribed dexamethasone (Prednisone). which of the following indicates the client is experiencing an adverse effect of the medication?

hyperglycemia

clinical judgment

is the decision made regarding a course of action based on a critical analysis of data when nursing knowledge is applied to a clinical situation

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?

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

a nurse is collecting data on a recently admitted client. which of the following techniques 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. which of the following skin color variations 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. which of the following activities should be included as a learning strategy in the program? -watch a video discussing healthy meal preparation -prepare a healthy meal to serve at the end of class -read pamphlets about preparing a healthy meal -discuss health meal preparation as a class

prepare a healthy meal to serve at the end of class

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? -mcg -q.d. -mL -PO

q.d.

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 feedings

a nurse is caring for a school-age client who was diagnosed with sickle cell anemia and has been admitted for a vasoocclusive crisis. which of the following findings has the highest priority? -hematocrit 32% -WBC 16/mm^3 -slurred speech -yellowed sclerae

slurred speech

a nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have pulmonary tuberculosis. which of the following tests is used to confirm this diagnosis?

sputum culture for acid-fast bacillus

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? -dorsal recumbent -orthopneic -side-lying -supine

supine

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?

tell me more about your concerns

clinical reasoning

the mental process used when analyzing all elements of a clinical situation and making a decision based on that analysis

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? -toast with peanut butter -apple juice -yogurt with fresh fruit -beef broth

toast with peanut butter

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 -standing with feet in a wide stance -positioning self close to the client -using arms and legs to lift

twisting at the waist and shoulders

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? -urinary retention -rapid respirations -dilated pupils -diarrhea

urinary retention

a nurse is caring for a toddler who has acute otitis media and is prescribed benzocaine (Americaine) ear drops for pain relief. which of the following actions by the nurse is appropriate when administering the ear drops? -place the child on the affected side for several minutes upon completion of installation -warm refrigerated drops to room temperature prior to installation -pull the pinna of the ear upward and back during installation -massage the area posterior to the ear after installation

warm refrigerated drops to room temperature prior to installation