Knowledge and Clinical Judgement - Advanced Test

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 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 associated tremors can result in an inaccurate reading by causing the sensor to detect these vibrations instead of blood rushing through the artery(stage 4 parkinson's disease)

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 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 present at birth indicates a tumor or an abdominal wall defect, such as ruptured viscus vesicular rash treatment is not required

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 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." cromolyn has a slow onset and will not relieve an acute asthma attack.

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 Morality is the premise of right or wrong actions based on shared societal or generational expectations.

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. clamping the tube should be brief to prevent a tension pneumothorax. apply a padded clamp on the tubing for 1 to 2 min is not an appropriate action by the nurse

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 chest tubes are used to evacuate air or blood from the pleural space and are NOT associated with potassium loss.

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 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

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. 3 years should be pulled downward and back , instead of upward and back.