Module 2 Nurselogic

a nurse is preparing to admin an IM injection to an adult who has a BMI of 30. Which of the following needle lengths is appropriate to admin the injection in the ventrogluteal muscle?

1 1/2 inch

a nurse is reinforcing teaching to a client who has recently RX a 2000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?

3/4 cup of canned tomato juice

a nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client?

Acupuncture has been proven to reduce pain and increase function

a charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the child the charge nurse to assign?

An adolescent who is 2 days postoperative following an appendectomy

A nurse is reinforcing teaching to a client who is newly dx w/ htn & has been RX captopril (Capoten). the nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril?

Aspirin (bayer)

A nurse is an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen sat level is 90% on room air. which of the following actions should the nurse take first?

Assist client to cough effectively

A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests a referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles?

Autonomy

A nurse is a local clinic is caring for a female client who is 35 years old. Which of the following screenings should the nurse recommend to the client?

Dermatologist evaluation every 3 years to detect skin cancer

A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting? SATA

Dietician PT Social worker

A nurse is caring for a client following a brochoscopy. Which of the following findings requires immediate intervention?

Difficulty breathing

A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advise?

Discuss the risks associated with leaving with the client

A nurse is preparing to admin oral meds to a client who has uhnilateral weakness following a CVA. Which of the following should be priority action of the nurse?

Have the client position the head w/ the chin down while swallowing

A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client?

Having the client use eye blinks to indicate yes or no

A client is caring for a newly admitted client. Which of the following client needs should the nurse address first?

Hypoxic

A nurse is reinforcing teaching w/ a client who is prescribed buspirone (BuSpar). Which of the following statements by statements by the client indicates an understanding of the teaching?

I can have 1 to 2 alcoholic beverages each week

A nurse is reinforcing teaching about HIV w/ a group of high school students. Which of the following information is appropriate for the nurse to include?

Initial HIV symptoms are often similar to the flu

A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate?

Let's discuss some strategies you can use when this happens again

A nurse on the coronary care unit for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized she asks the nurse why she had to be transferred to a unit where her family will unable to stay with her all the time. Which of the following responses is appropriate?

Let's talk for a minuite about your concerns

A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include in the teaching to place the client in which of the following positions?

Lithotomy

Which of the following drainage tubes is at an increased risk for hypokalemia?

NG tube to suction

a nurse is reviewing the lab results for 4 clients. The client w/ which of the following value requires immediate intervention?

Platelets 95,000 mm3

A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention?

Potassium 2.5 mEq/L

A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abd. surgery. for which of the following responses by the client should the nurse postpone teaching?

States that pain is an 8 on a scale of 0 to 10

A nurse has assigned four tasks to an AP. Which of the followingshould the nurse instruct the AP to perform first?

Take an ABG specimen to the lab

a nurse is reinforcing teaching about transdermal nitroglycerin (Nitro-Dur) to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective?

The patch should be effective within a hour of a being applied

A nurse is reinforcing teaching to a client who is newly RX w/ Lyme disease. The nurse should include that the disease is transmitted in which of the following ways?

Vector

a nurse has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first?

a client following knee replacement surgery complaining of pain and warmth in the calf

A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first?

a client who had abd. surgery 10 days ago and feeling his incision pop

a nurse on a medical unit has received report on four clients. which of the following clients should the nurse evaluate first?

a client who has a fever of 101.2 F w/ tenderness in the right lower quadrant

a nurse in a provider's office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurse's priority concern?

a client who is 34 weeks of gestation and reporting abd. tenderness

a nurse in a provider's office has collected data on four clients. Which of the following should be the nurse's priority concerns?

a client who is having a nosebleed associated with hypertension

a nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention?

a client who is prescribed digoxin (lanoxin) and has 3 episodes of vomiting

A nurse working the 7 PM to 7 AM shift on the pediatric unit has received report on four post operative clients. Which of the following requires immediate intervention?

a preschooler who is postop following a tonsillectomy and is experiencing frequent swallowing

a nurse is collecting data on a newborn who was delivered 30 mins ago at the gestational age of 37 weeks. which of the following findings requires further interventions?

abd. distention

A nurse is working w/ the info technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality?

ability of staff to access electronic health records of clients throughout the facility

a nurse is caring for a client who is 48 hr postoperative following an abd. aortic aneurysm resection. Which of the following findings is the most urgent

absent dorsalis pedis pulses

A nurse is caring for a school-age child newly dx w/ type 1 DM. Which of the following actions by the nurse is appropriate to prepare the child for admin of insulin?

allow the child to manipulate the medical equipment

a nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following stages of grief?

bargaining

A nurse is caring for an older adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly dx with osteoarthritis. The client states, "I keep seeing commericials on TV for Celebrex and I want to try it and see if it will help my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following

celecoxib is contraindicated in clients with an allergy to sulfonamide

a nurse is caring for a client who has a compound fracture of the tibia and fibula and is in the skin traction. The client reports pain of 6 on a scale of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first?

check pedal pulse

A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first?

check the client

A nurse is caring for a client who is dx with gastroenteritis. Which of the following actions should the nurse take first when evaluating for a fluid volume deficit?

check the heart rate and bp

a nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take?

check the leg for warmth and edema

a nurse is caring for an older adult who recently experienced the death of her partner. Which of the following is the priority need of the client?

creating meaningful social relationships

A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching?

cue the client by providing picture cards that portray common needs

A nurse is collecting data on a client who has dx of myasthenia gravis. For which of the following complication is it most important for the nurse to monitor?

decreased respiratory effort

a nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors by the client best indicate to the nurse that teaching has been effective?

demonstrating independent performance of the procedure

a nurse is caring for a toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse?

determine o2 stat

A nurse is caring for a client who has a UTI and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take?

determine respiratory status

A nurse discovers that a client who is dx with dementia received the wrong medication. Which of the following should be the nurse's first action?

determine the client's condition

a nurse in a long-term care facility is assisting w/ the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first?

determine the mobility status of each client

a nurse is collecting data on four clients. which of the following is the highest priority finding by the nurse?

diarrhea

A nurse is conducting therapeutic medication on four clients. Which of the following findings should be immediately reported to the provider?

digoxin 3.0 ng/mL

a nurse is collecting data on a child who is DX w/ bacterial epiglottitis. Which of the following clinical finding are associated w/ the illness? SATA

drooling, stridor, difficulty swallowing, high-grade fever is correct

a nurse is performing a respiratory exam on a client w ho has pneumonia. Which of the following sound should elicited over areas of consolidation during percussion?

dullness

a nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following finding is associated with dx?

elevated temp

a nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first?

engage the client in physical activity

a nurse is caring for a client who has a fractured hip and respiratory rate of 26/min. Which of the following actions should the nurse take first?

evaluate LOC

a nurse is caring for a client who has a radial head fracture. Which of the following should be the priority action by the nurse following application of the cast?

evaluate neurovascular status

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication?

excessive vomiting

A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following?

facial edema

a nurse is caring for a client who has been rx a full liquid diet. Which of the following is appropriate to include in the client's diet? SATA

grape juice + ice cream

The nurse is caring for a client who is receiving vancomycin (Vancocin) for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor?

hearing loss

A nurse is caring for a neonate who has delivered at 30 weeks of gestation after his mother received 2 injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects?

hypoglycemia

A nurse is assisting with admission of a client who is scheduled for a surgical procedure. The nurse admins a RX dose of lorazepam (Ativan) preop. Which of the following statements by the client indicates the medication has been effective?

i feel very relaxed

A newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster?

immediate

A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires the nurse preceptor to intervene?

including in a client's nurse' note that an incident report was completed after medication error

a public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurse's priority concern?

incomplete amputation of the foot

a nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following should the nurse take first?

initiate a bladder training schedule

a nurse is collecting data on a newly admitted client who is reporting abd discomfort. When examining the abd, which of the following techniques should the nurse perform first

inspection

A nurse is reinforcing teaching about client consent to treatment with group of newly licsened nurse. Which of the following statements by a newly licensed nurse indicates a need for further teaching?

it is the responsibility of the provider to obtain express consent

A nurse is caring for a client who had a CVA 2 days ago. Which of the following is the first sign of ICP?

lethargy

A nurse is caring for a client who is dx w/ active pulmonary TB and is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol?

loss of color discrimination

a nurse is caring for a client who is in the immediate postop period following tracheotomy. Which is the following is the nurse's priority action?

maintaining a patent airway

a nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. Which of the following client data is most important or the nurse to monitor?

maternal respirations

A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. the herbal supplement is thought to improve which of the following?

mood

a nurse is caring for a client who has a UTI. The client is disoriented and found wandering on another uni. which of the following actions should the nurse take first?

move the client to a room near the nurses' station

a nurse is caring for a client who was admitted to the unit 3 hr ago following a total hip arthroplasty. Which of the following findings should be nurse's priority concern?

o2 stat of 90% on oxygen at 2 L per nasal cannula

A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first?

obtain an ECG

a nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak?

oliguria

A nurse at a long-term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among client who are immobile?

outcome audit

A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?

partial thickness skin loss

Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?

perform fingersticks for glucose levels on clients who have DM

A nurse is assisting w/ the care of client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding for the vaginal and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action the nurse?

place client in knee-chest postion

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?

place the client in the orthopneic position

A nurse is reinforcing discharge teaching to a new mother regarding SIDS. Which of the following is the highest priority to include in the instructions?

place the infant in a supine position when sleeping

a nurse is caring for a client who is dx w/ bipolar disorder and is currently experiencing an acute manic episode. Which of the following is the priority concern of the nurse?

preventing injury

a nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern?

promoting oxygenation

A nurse is caring for an older adult client who was admitted 3 days ago w/ fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse's priority goal?

protect the client from further abuse

A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion?

reduced bleeding time

A nurse is caring for a client who has nausea and a prescription for promethazine (Phenergan) 25 mg IM. which of the following is appropriate when preparing a medication for administration from an ampule?

set the ampule on a flat surface to withdraw the promethazine

a nurse is preparing to administer a tap water enema to a client. In which of the following position should the nurse place the client

sims'

A nurse is caring for a school-age client who was dx w. sickle cell anemia & has been admitted for a vaso-occlusive crisis. Which of the following findings has the highest priority?

slurred speech

A nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication?

speech pathologist

a nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury?

stand close to the client

A nurse is caring for a client who is receiving parenteral nurtrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to jugular vein. Which of the following actions should the nurse take first?

stop the infusion

a nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions?

supine with head of the elevated to 30 degrees

a school nurse is reinforcing teaching regarding bicycle safety to a group of school-age children. Which of the following is the most important concept to include in the teaching?

use a properly-fitted bicycle helmet

a nurse is preparing to measure the blood pressure of client who has hypertension. Which of the following actions by the nurse when taking the BP can result in an inaccurately low reading?

using a cuff that is too wide

A nurse is collecting data on four clients? which of the followng is most urgent?

warmth and pain in the calf