Knowledge and Clinical Judgement (advanced)

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 (DNR)?

A written prescription from the provider 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 attempts 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

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?

"What part of your mother's care concerns you?"

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 Electronic blood pressure measurement is attained through a sensor that detects vibrations caused by blood rushing through the arteyr, 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 cath requires frequent blood pressure measurements. It is appropriate to perform an electronic blood pressure measurement on this client.

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 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 Dark urine is a clinical sign of biliary atresia because of conjugated bilirubin escaping from the liver and being excreted in the urine. The nurse should teach the parent that dark urine is a clinical manifestation associated with the illness

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?

NG tube to suction

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 inhaler before using my albuterol inhaler." When both cromolyn and albuterol are prescribed, albuterol should be inhaled first to open the airways because it is a bronchodilator. After waiting a few minutes, the cromolyn can then be inhaled and will reach further into the lungs because of the dilatory effects of albuterol.

A nurse is caring for a client who weighs 132 lb and has been prescribed gentamicin (Garamycin) 5mg/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 pregnant with a single fetus and has a body mass index (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?

25 to 35 lb

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?

Abdominal distension

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 headache is a manifestation experienced by 15 to 30% of clients following a lumbar puncture that results from cerebrospinal fluid leakage at the puncture site. These headaches are managed primarily with analgesics, hydration, and bed rest

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?c

Slurred speech Slurred speech can indicate a cerebrovascular accident (CVA), which is a severe complication of sickle cell anemia. The blockage of blood vessels in the brain by sickled cells results in cerebral infarction, which leads to neurological impairment. Because a CVA threatens the life of the client, this is highest priority finding.

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 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 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.

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 Advocacy is supporting or seeking a specific course of action for the benefit and on behalf of a person, group, or community. The nurse made the request to remove the playground equipment on behalf of and to benefit the children of the school. This is an example of 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 If all staff members on each shift have the same password, limitations exist is tracking who is accessing those records, increasing the possibility that someone not involved in the care of a client could access records out of curiosity. This procedure is not appropriate and requires intervention to prevent the release of confidential information.

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?

Sputum culture for acid-fast bacillus Once infected, the bacteria multiply freely after reaching the bronchi or alveoli. Typically, acquired immunity protects individuals from attaining active tuberculosis. Infection is most common among those who are immunocompromised and those who have been in repeated, close contact with someone who has an undiagnosed case of active tuberculosis. The lungs are primarily involved, but the infection can spread to other organs. Symptoms of pulmonary tuberculosis include productive cough, fever, fatigue, weight loss, hemoptysis, and night sweats. In cases of active pulmonary tuberculosis, the organism is transmitted through the air because it is found in the sputum and secretions. The presence of acid fast bacillus in the sputum, secretions, or tissues of the client is the only method to confirm the diagnosis of active tuberculosis.

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 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.

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?

Warm refrigerated drops to room temperature prior to instillation. Because of the anatomy of internal ear structures, it is important to remember that the ear is sensitive to extremes in temp. Ear drops should be warmed to room temp prior to instillation to reduce the risk of painful stimuli

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 medication?

​WBC 2,800/mm3 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.