Preview Extract
ATI Nurse Logic: Knowledge and Clinical Judgement
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?
Answer: Discussing changes in a client's plan of care with his friend who is a nurse on another
unit
Rationale:
The discussion of a client's plan of care with someone who is not directly involved in their care
violates the client's right to confidentiality. Even though the friend may be a nurse, sharing
specific patient information without proper authorization breaches patient confidentiality and can
lead to consequences for both the nurse and the healthcare institution.
Other options:
1. Documenting a client's vital signs in the electronic medical record (EMR) - This action is
within the scope of the nurse's duties and does not breach confidentiality. It is essential for
providing continuity of care and ensuring accurate documentation.
2. Discussing a client's diagnosis with their family member who is designated as the primary
caregiver - Sharing information with a designated family member involved in the client's care is
appropriate and respects the client's right to have their family involved in their healthcare
decisions.
3. Asking a coworker to cover her shift because she feels unwell - This action does not involve
breaching patient confidentiality. It's a personal matter related to the nurse's own health and work
responsibilities.
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?
Answer: Cover the area with a transparent wound barrier
Rationale:
Covering the reddened area with a transparent wound barrier provides protection from further
friction or pressure, helping to prevent the development of pressure ulcers. It also allows for
continuous monitoring of the area without disturbing it. This action aligns with preventive
measures for pressure ulcer management.
Other options:
1. Document the finding in the client's medical record and continue routine care - Documenting
the finding is essential for tracking changes in the client's condition, but simply documenting
without taking preventive action may increase the risk of pressure ulcer development.
2. Apply a thick layer of petroleum jelly to the area - While petroleum jelly can provide a barrier
to moisture, it may not be the most appropriate choice for covering a reddened area at risk for
pressure ulcer development. A transparent wound barrier is specifically designed for this purpose
and allows for easier monitoring.
3. Leave the area exposed to air to promote healing - While exposing wounds to air can be
beneficial in some cases, covering the reddened area with a transparent wound barrier provides a
protective barrier against further damage while still allowing for airflow. This helps to maintain a
moist wound environment, which is conducive to healing.
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?
Answer: 2.5 tsp
Rationale:
To determine the number of teaspoons to administer per dose, first, calculate the total volume
needed to achieve the prescribed dose of 300 mg. Since the concentration of the liquid
suspension is 120 mg/5 mL, divide 300 mg by the concentration (120 mg/5 mL) to find out how
many milliliters are needed for one dose. Then convert the milliliters to teaspoons.
Since 1 teaspoon is approximately equal to 5 mL, divide 12.5 mL by 5 mL per teaspoon to find
out how many teaspoons are needed for one dose.
Therefore, the nurse should teach the parents to administer 2.5 teaspoons per dose.
Other options:
1. 1 tsp - This is not the correct amount. Using the calculation, the correct amount is 2.5
teaspoons per dose based on the concentration of the acetaminophen suspension.
2. 3 tsp - This is not the correct amount. Using the calculation, the correct amount is 2.5
teaspoons per dose based on the concentration of the acetaminophen suspension.
3. 5 tsp - This is not the correct amount. Using the calculation, the correct amount is 2.5
teaspoons per dose based on the concentration of the acetaminophen suspension.
A nurse is collecting data on a recently admitted client. Which of the following techniques
should the nurse use to measure tissue perfusion?
Answer: Obtaining the client's level of oxygen saturation
Rationale:
Oxygen saturation measurement is a non-invasive technique used to assess tissue perfusion
indirectly. It measures the percentage of hemoglobin saturated with oxygen in the blood,
reflecting the adequacy of oxygen delivery to tissues. A normal oxygen saturation level indicates
good tissue perfusion, while a decreased level may indicate poor tissue perfusion.
Other options:
1. Assessing capillary refill time - Capillary refill time is a technique used to assess peripheral
perfusion by observing the time it takes for color to return to a compressed nail bed. While it
provides information about peripheral circulation, it is not as direct a measure of tissue perfusion
as oxygen saturation.
2. Monitoring blood pressure - Blood pressure measurement provides information about the
pressure exerted by circulating blood on the walls of blood vessels. While blood pressure is
important for assessing cardiovascular function, it does not directly measure tissue perfusion.
3. Checking for the presence of pedal pulses - Pedal pulses assessment evaluates peripheral
circulation by palpating pulses in the feet. While it provides information about peripheral
perfusion, it is not as direct a measure of tissue perfusion as oxygen saturation.
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?
Answer: "Tell me more about your concerns."
Rationale:
This response demonstrates therapeutic communication by inviting the client to express their
concerns and fears openly. It allows the nurse to gain insight into the client's perspective, address
specific worries, and provide appropriate support and education. Encouraging the client to share
their feelings can help alleviate anxiety and enhance their coping mechanisms during the
decision-making process.
Other options:
1. "Don't worry, you'll be fine. The surgery is necessary for your health." - This response
dismisses the client's concerns and does not acknowledge their fears or uncertainties. It may
increase the client's anxiety and inhibit open communication.
2. "You're scheduled for the surgery, and it's essential for your health. You need to go through
with it." - This response is directive and may come across as confrontational, potentially
escalating the client's resistance to the surgery. It does not address the underlying reasons for the
client's reluctance.
3. "Many people have had this surgery before, and they've done well. You'll be in good hands." While this response attempts to offer reassurance, it may minimize the client's feelings and fail
to address their specific concerns. It does not actively encourage the client to express their
thoughts and emotions.
A nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribed
ciprofloxacin (Cipro) 250 mg PO two times daily. The amount available is 100 mg/tablet. How
many tablets should the nurse administer with each dose?
Answer: 2.5 tablets
Rationale:
To determine the number of tablets to administer per dose, divide the prescribed dose by the
amount of medication per tablet.
Therefore, the nurse should administer 2.5 tablets per dose.
Other options:
1. 1 tablet - This is not the correct amount. The prescribed dose of ciprofloxacin is 250 mg, and
each tablet contains 100 mg. Therefore, 1 tablet is insufficient to achieve the prescribed dose.
2. 2 tablets - This is not the correct amount. The prescribed dose of ciprofloxacin is 250 mg, and
each tablet contains 100 mg. Therefore, 2 tablets are insufficient to achieve the prescribed dose.
3. 3 tablets - This is not the correct amount. While 3 tablets would exceed the prescribed dose, it
is not necessary to administer more than the prescribed amount. Administering 2.5 tablets
achieves the prescribed dose of 250 mg.
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?
Answer: "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities."
Rationale:
This statement suggests that the client plans to stockpile or purchase a large quantity of
nitroglycerin pills. However, nitroglycerin is a medication that should be stored and used with
caution due to its potential to rapidly decrease blood pressure. Storing excessive amounts of
nitroglycerin pills may increase the risk of accidental overdose or misuse. Therefore, the client
needs further education on the appropriate storage and use of nitroglycerin, including the
importance of following the prescribed dosing regimen and seeking medical assistance if
experiencing angina symptoms.
Other options:
1. "I understand that I should take the nitroglycerin when I have chest pain." - This statement
indicates the client's understanding of the purpose of nitroglycerin and its use for relieving chest
pain associated with angina. It does not indicate a need for further teaching.
2. "I know that I should place the nitroglycerin tablet under my tongue for faster absorption." This statement demonstrates the client's knowledge of the correct administration technique for
nitroglycerin, which is sublingual administration for rapid onset of action. It does not indicate a
need for further teaching.
3. "I will call 911 if I take the nitroglycerin and my chest pain doesn't improve after five
minutes." - This statement shows the client's understanding of the need to seek emergency
medical assistance if chest pain persists after taking nitroglycerin. It does not indicate a need for
further teaching.
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?
Answer: Supine
Rationale:
The supine position (lying flat on the back with legs extended) is commonly used for the
insertion of an indwelling urinary catheter in male clients. This position allows easy access to the
urethral meatus and provides optimal visualization of the genital area, facilitating the catheter
insertion process. Additionally, it promotes client comfort and relaxation during the procedure.
Other options:
1. Prone - The prone position (lying flat on the stomach) is not suitable for the insertion of an
indwelling urinary catheter in male clients. It does not provide easy access to the urethral meatus
and may cause discomfort and difficulty in visualizing the genital area.
2. Side-lying (lateral) - While the side-lying position can be used for certain medical procedures,
it is not typically recommended for the insertion of an indwelling urinary catheter in male
clients. This position may impede access to the genital area and make the catheter insertion
process more challenging.
3. Fowler's - The Fowler's position (sitting up in bed with the head of the bed elevated) is not
typically used for the insertion of an indwelling urinary catheter in male clients. While this
position may be suitable for certain medical procedures or for clients with respiratory or
cardiovascular issues, it does not provide optimal access to the urethral meatus for catheter
insertion.
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?
Answer: Prepare a healthy meal to serve at the end of class
Rationale:
This activity engages tactile learners by providing hands-on experience in preparing and
handling food. Tactile learners learn best through physical interaction and manipulation of
objects. By actively participating in meal preparation, they can reinforce their understanding of
healthy nutrition concepts, such as portion sizes, food selection, and meal planning. Additionally,
tasting the prepared meal allows tactile learners to experience the sensory aspects of food,
enhancing their learning experience.
Other options:
1. Watch a documentary about healthy eating habits - While watching a documentary may be
informative, it does not directly engage tactile learners in hands-on activities. Tactile learners
benefit more from active participation and physical interaction with materials.
2. Listen to a lecture on the benefits of healthy nutrition - Tactile learners may find it challenging
to stay engaged and retain information solely through listening to a lecture. They benefit more
from interactive and experiential learning activities that involve physical manipulation.
3. Discuss the nutritional content of various food items using visual aids - While discussing
nutritional content using visual aids can be helpful for visual learners, it may not fully engage
tactile learners. Tactile learners prefer hands-on activities that allow them to actively participate
and manipulate objects to reinforce learning.
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?
Answer: Twisting at the waist and shoulders
Rationale:
Twisting at the waist and shoulders while transferring a client can lead to musculoskeletal
injuries for both the nurse and the client. Proper body mechanics involve keeping the spine
aligned and avoiding twisting movements, as twisting can strain the muscles and ligaments of
the back. Instead, the nurse should pivot the entire body with the feet to face the direction of
movement, maintaining alignment and reducing the risk of injury.
Other options:
1. Keeping feet shoulder-width apart - This action demonstrates proper body mechanics by
providing a stable base of support, which helps distribute the weight of the client evenly and
reduces the risk of injury to the nurse.
2. Using the leg muscles to lift the client - This action indicates proper body mechanics by
utilizing the stronger muscles of the legs rather than relying solely on the back muscles, reducing
the risk of back strain and injury.
3. Ensuring the client's arms are crossed over the chest - This action helps maintain the client's
safety and comfort during the transfer by securing their arms and preventing them from reaching
out or grabbing onto objects, which could destabilize the transfer process.
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?
Answer: Away from the body
Rationale:
Opening the sterile package away from the body helps minimize the risk of contamination by
reducing the likelihood of any particles or microorganisms from the package coming into contact
with the nurse's sterile gloves or the catheter itself. This practice follows principles of aseptic
technique, maintaining the sterility of the equipment and reducing the risk of infection for the
client.
Other options:
1. Toward the body - Opening the sterile package toward the body increases the risk of
contamination, as any particles or microorganisms released from the package could potentially
come into contact with the nurse's sterile gloves or the catheter. This practice does not adhere to
principles of aseptic technique.
2. Upward - Opening the sterile package upward may result in particles or microorganisms
falling onto the nurse's sterile gloves or the catheter, especially if the package is held above the
level of the gloves or catheter. This practice increases the risk of contamination and does not
follow principles of aseptic technique.
3. Downward - Opening the sterile package downward may cause particles or microorganisms to
fall away from the nurse's sterile gloves or the catheter, reducing the risk of contamination
compared to other directions. However, it is still preferable to open the package away from the
body to minimize the risk further and adhere to principles of aseptic technique.
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 the spill?
Answer: Chlorine (bleach)
Rationale:
Chlorine (bleach) is an effective disinfectant that is commonly used to clean up spills of blood
and other bodily fluids. It has strong antimicrobial properties that can help eliminate pathogens
and reduce the risk of contamination. However, it is important to use the correct dilution of
bleach according to facility protocols to ensure effective disinfection while minimizing potential
harm to surfaces and individuals.
Other options:
1. Soap and water - Soap and water are suitable for cleaning spills of blood and other bodily
fluids. While soap helps to remove visible contaminants, water helps to dilute the spill. However,
soap and water alone may not provide sufficient disinfection, especially for areas where there is
a risk of transmission of infectious pathogens.
2. Hydrogen peroxide - Hydrogen peroxide is another disinfectant that can be used to clean up
spills of blood and bodily fluids. It has antimicrobial properties and can help reduce the risk of
contamination. However, like bleach, it is essential to use the correct dilution according to
facility protocols to ensure effective disinfection.
3. Rubbing alcohol (isopropyl alcohol) - Rubbing alcohol is effective for disinfecting surfaces
and can be used to clean up spills of blood and bodily fluids. It evaporates quickly and leaves
minimal residue, making it suitable for use on a variety of surfaces. However, it may not be as
effective as bleach or hydrogen peroxide against certain pathogens, so it is important to follow
facility protocols for cleaning and disinfection.
A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed
dexamethasone (prednisone). Which of the following indicates the client is experiencing an
adverse effect of the medication?
Answer: Hyperglycemia
Rationale:
Hyperglycemia, or elevated blood glucose levels, is a known adverse effect of corticosteroids
such as dexamethasone (prednisone). Corticosteroids can increase insulin resistance and impair
glucose tolerance, leading to hyperglycemia, particularly in clients with pre-existing diabetes
mellitus or those at risk for developing diabetes. Monitoring blood glucose levels is essential in
clients receiving corticosteroid therapy to detect and manage hyperglycemia promptly.
Other options:
1. Decreased white blood cell count - While corticosteroids can suppress the immune system and
lead to a decreased white blood cell count, this is an expected pharmacological effect rather than
an adverse effect. Corticosteroids are often prescribed to suppress inflammation in conditions
like rheumatoid arthritis.
2. Increased appetite - Increased appetite, or polyphagia, is a common side effect of
corticosteroid therapy, but it is not necessarily indicative of an adverse effect. It can contribute to
weight gain and may require dietary adjustments or monitoring, but it is not typically considered
a serious adverse reaction.
3. Decreased blood pressure - Corticosteroids can cause fluid retention and sodium retention,
leading to increased blood pressure rather than decreased blood pressure. While hypertension is a
potential adverse effect of corticosteroid therapy, decreased blood pressure is not a typical
adverse effect.
A nurse is collecting nutritional data on an older adult client. Which of the following findings is
suggestive of a healthy nutritional status?
Answer: Deep reddish-colored tongue
Rationale:
A deep reddish-colored tongue is indicative of good vascularization and hydration, which can be
suggestive of a healthy nutritional status. It may indicate adequate intake of nutrients, including
iron and B vitamins, which contribute to the overall health of the mucous membranes, including
the tongue. However, it is essential to consider other factors and perform a comprehensive
nutritional assessment to confirm the client's nutritional status fully.
Other options:
1. Dry, cracked lips - Dry, cracked lips are often associated with dehydration and may indicate
inadequate fluid intake or poor hydration status. While this finding is not specific to nutritional
status, it can be suggestive of insufficient fluid intake, which may impact overall health and
nutritional status negatively.
2. Spoon-shaped nails (koilonychia) - Spoon-shaped nails can be indicative of iron deficiency
anemia, which may suggest poor nutritional status, particularly inadequate intake or absorption
of iron. This finding warrants further investigation into the client's nutritional intake and iron
levels.
3. Pale conjunctiva - Pale conjunctiva can be a sign of anemia, which may result from various
nutritional deficiencies, including iron, folate, or vitamin B12 deficiencies. While it is not
specific to nutritional status alone, it can indicate potential nutritional deficiencies that require
further assessment and intervention.
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?
Answer: Urinary retention
Rationale:
Urinary retention, or the inability to empty the bladder completely, is a known adverse effect of
opioids such as morphine. Opioids can cause relaxation of the smooth muscles of the urinary
tract, including the bladder sphincter, leading to urinary retention. This adverse effect can result
in discomfort, urinary distention, and potentially urinary tract infections if not promptly
addressed. Monitoring for urinary retention is essential in clients receiving opioids, particularly
before surgery when bladder emptying is important to prevent complications during anesthesia
and surgery.
Other options:
1. Decreased respiratory rate - While opioids such as morphine can cause respiratory depression
as an adverse effect, it is more commonly associated with decreased respiratory rate rather than
increased respiratory rate. Respiratory depression is a serious adverse effect that requires prompt
intervention, including monitoring of respiratory rate and depth.
2. Hypertension - Hypotension, or low blood pressure, is a more common adverse effect of
opioids such as morphine, particularly with the initial doses or in clients who are opioid-naïve.
Hypertension, or high blood pressure, is not typically associated with morphine administration
and may suggest other underlying factors requiring further assessment.
3. Increased gastrointestinal motility - Opioids such as morphine commonly cause decreased
gastrointestinal motility, leading to constipation rather than increased gastrointestinal motility.
Constipation is a well-known adverse effect of opioids due to their actions on opioid receptors in
the gastrointestinal tract, resulting in decreased peristalsis and transit time.
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?
Answer: q.d.
Rationale:
The abbreviation "q.d." is ambiguous and can be misinterpreted as both "every day" and "every
other day." Its use can lead to medication errors and patient harm. To avoid confusion and ensure
clarity in documentation, it is recommended to use "daily" or "every day" instead of "q.d."
Further teaching is necessary to emphasize the importance of avoiding ambiguous abbreviations
and using standardized terminology in documentation to promote patient safety.
Other options:
1. TID - "TID" is a commonly used abbreviation for "three times a day" and is considered
acceptable for use in medical documentation. It accurately communicates the frequency of
medication administration and is less likely to be misinterpreted compared to "q.d."
2. PO - "PO" is an abbreviation for "by mouth" and is commonly used to indicate the route of
medication administration. It is considered acceptable for use in medical documentation when
indicating oral medication administration.
3. PRN - "PRN" is an abbreviation for "as needed" and is commonly used to indicate
medications that are to be administered based on the patient's specific needs or symptoms. It is
considered acceptable for use in medical documentation when indicating PRN medication
administration.
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?
Answer: Pallor
Rationale:
Pallor refers to a paleness of the skin that occurs due to a decreased amount of oxyhemoglobin,
which is the oxygenated form of hemoglobin in the blood. In anemic conditions, there is a
reduced number of red blood cells or a decreased hemoglobin concentration, leading to
decreased oxygenation of the blood and subsequent pallor of the skin. Pallor is a common
clinical manifestation of anemia and can be observed in various areas of the body, including the
skin, mucous membranes, and nail beds.
Other options:
1. Cyanosis - Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to
increased amounts of deoxygenated hemoglobin in the blood. It occurs when oxygen saturation
levels in the blood are decreased, leading to a bluish tint of the skin. Cyanosis is not typically
associated with anemia but rather with conditions that cause hypoxemia or inadequate
oxygenation of the blood.
2. Jaundice - Jaundice refers to a yellowish discoloration of the skin, sclerae (whites of the eyes),
and mucous membranes due to elevated levels of bilirubin in the blood. It occurs when there is
impaired liver function or excessive breakdown of red blood cells, leading to the accumulation
of bilirubin in the bloodstream and subsequent deposition in tissues. Jaundice is not directly
related to anemia but can occur concurrently with certain types of anemia or as a result of
underlying liver or hematologic disorders.
3. Erythema - Erythema refers to redness or inflammation of the skin due to increased blood flow
to the affected area. It is caused by vasodilation of blood vessels in response to various stimuli,
such as injury, infection, or allergic reactions. Erythema is not typically associated with anemia
but rather with inflammatory or vascular conditions.
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?
Answer: Dimpling of the tissue in the upper outer quadrant
Rationale:
Dimpling of the breast tissue, also known as skin retraction, is a concerning finding that can
indicate underlying breast pathology, including breast cancer. It occurs when the fibrous bands
within the breast tissue become shortened or tethered, causing the skin to pull inward and create
dimples or indentations. Dimpling of the breast tissue is often associated with malignant breast
tumors that are pulling on the surrounding tissue. Therefore, it is essential to report this finding
promptly to the healthcare provider for further evaluation, including imaging studies and
possible biopsy to rule out breast cancer.
Other options:
1. Small, mobile lump in the breast - A small, mobile lump in the breast may be a benign finding,
such as a cyst or fibroadenoma, especially if it is smooth, well-defined, and easily movable.
However, any new breast lump should be reported to the healthcare provider for further
evaluation to rule out malignancy, particularly in clients with a family history of breast cancer.
2. Nipple discharge upon manipulation - Nipple discharge can be caused by various factors,
including hormonal changes, benign breast conditions (such as intraductal papilloma), or less
commonly, breast cancer. The presence of nipple discharge alone may not necessarily indicate
breast cancer but should be evaluated further by the healthcare provider to determine the
underlying cause.
3. Skin thickening and redness around the nipple - Skin thickening and redness around the nipple
can be signs of inflammatory breast cancer, a rare and aggressive form of breast cancer. This
finding should be promptly reported to the healthcare provider for further evaluation and
management, including imaging studies and possible biopsy to confirm the diagnosis.
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?
Answer: Living wills detail treatment wishes of the client in the event of terminal illness
Rationale:
Living wills are legal documents that allow individuals to specify their healthcare preferences
and treatment wishes in the event they become unable to communicate or make decisions for
themselves, particularly in situations of terminal illness or end-stage conditions. Living wills
typically outline preferences regarding life-sustaining treatments, such as mechanical ventilation,
artificial nutrition and hydration, and cardiopulmonary resuscitation (CPR), based on the
individual's values, beliefs, and desired quality of life. Including information about living wills
in the education program helps staff understand the importance of advance care planning and
respecting patients' autonomy and preferences regarding end-of-life care.
Other options:
1. Living wills are only valid if witnessed by a family member - This statement is incorrect.
While some states may require witnesses or notarization for validity, living wills can also be
valid if signed in accordance with state laws and regulations, which may vary.
2. Living wills can only be completed by older adults - This statement is incorrect. Living wills
can be completed by any competent adult, regardless of age, who wishes to document their
healthcare preferences and treatment wishes for future reference. Advance care planning is
encouraged for individuals of all ages to ensure their wishes are known and respected in the
event of incapacity.
3. Living wills can only be updated by the healthcare provider - This statement is incorrect.
Living wills are legal documents that can be updated or modified by the individual at any time,
as long as they are competent to do so. It is important for individuals to review and update their
living wills periodically to reflect any changes in their preferences or healthcare circumstances.
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?
Answer: Reduce the rate of the feedings
Rationale:
Diarrhea after enteral tube feedings can occur due to various factors, including the rate of
administration, the osmolality of the formula, and the tolerance of the gastrointestinal tract.
Reducing the rate of the feedings can help slow the delivery of nutrients into the gastrointestinal
tract, allowing for better absorption and digestion, which may help reduce the incidence of
diarrhea. Slowing the rate of feedings also gives the gastrointestinal tract more time to adapt to
the enteral feeding and may improve tolerance over time. However, it is essential to monitor the
client closely for signs of intolerance or malabsorption and adjust the feeding rate accordingly.
Other options:
1. Increase the concentration of the formula - Increasing the concentration of the enteral feeding
formula may exacerbate diarrhea by increasing the osmotic load in the gastrointestinal tract,
leading to fluid shifts and diarrhea. Therefore, increasing the concentration of the formula is not
recommended as an initial intervention for preventing diarrhea.
2. Administer an antidiarrheal medication before feedings - While antidiarrheal medications may
help manage diarrhea symptoms, they do not address the underlying cause of diarrhea after
enteral feedings. Additionally, routine use of antidiarrheal medications may mask important
signs and symptoms of gastrointestinal intolerance or complications. Therefore, administering
antidiarrheal medications before feedings is not typically recommended as a first-line
intervention for preventing diarrhea.
3. Switch to a different enteral feeding formula - Switching to a different enteral feeding formula
with lower osmolality or different nutrient composition may help improve tolerance and reduce
the incidence of diarrhea. However, it is essential to consider individual client factors, such as
allergies, intolerances, and nutritional needs, when selecting an appropriate enteral feeding
formula. Consulting with a dietitian or healthcare provider is recommended before making
changes to the enteral feeding regimen.
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?
Answer: Advocacy
Rationale:
Advocacy involves speaking up on behalf of individuals or groups to promote their rights, needs,
and well-being. In this scenario, the school nurse is advocating for the safety and welfare of the
students by requesting the removal of playground equipment that poses a risk of injury. By
bringing attention to the documented increase in injuries linked to the equipment, the nurse is
taking proactive steps to protect the students and prevent further harm. Advocacy efforts like this
aim to create positive change and improve the overall safety of the school environment.
Other options:
1. Autonomy - Autonomy refers to the right of individuals to make decisions about their own
lives and actions without interference from others. While the school nurse's actions may
indirectly support the autonomy of the students by promoting their safety, the primary focus is
on advocating for changes to protect their well-being rather than respecting their autonomy.
2. Delegation - Delegation involves assigning tasks or responsibilities to others who are
competent and qualified to perform them. The school nurse's request to remove the playground
equipment is not an example of delegation, as it does not involve assigning tasks to others but
rather advocating for a policy change to address safety concerns.
3. Quality improvement - Quality improvement refers to systematic efforts to enhance the quality
and effectiveness of services or processes. While removing the playground equipment may
contribute to improving safety standards within the school environment, the nurse's actions in
this scenario primarily align with advocacy for the protection of students rather than a formal
quality improvement initiative.
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?
Answer: Dark urine
Rationale:
Dark urine can be a clinical manifestation of biliary atresia due to the obstruction of bile flow
from the liver to the gallbladder and intestines. In biliary atresia, the bile ducts become inflamed,
narrowed, or blocked, leading to impaired bile flow and the accumulation of bilirubin in the
bloodstream. Bilirubin is a yellow pigment produced by the liver and excreted in bile. When bile
flow is obstructed, bilirubin is not properly eliminated from the body, resulting in its
accumulation in the bloodstream and subsequent excretion in the urine, causing it to appear dark
or tea-colored. Therefore, educating the parent about the association between dark urine and
biliary atresia can help them recognize this clinical manifestation and seek timely medical
evaluation and treatment for their infant.
Other options:
1. Hypertension - Hypertension, or high blood pressure, is not typically associated with biliary
atresia. Biliary atresia primarily affects the liver and bile ducts, leading to manifestations such as
jaundice, dark urine, and pale stools, rather than hypertension.
2. Bradycardia - Bradycardia, or a slow heart rate, is not a typical clinical manifestation of biliary
atresia. Biliary atresia primarily affects the liver and bile ducts, resulting in manifestations such
as jaundice, dark urine, and hepatomegaly, rather than changes in heart rate.
3. Increased appetite - Increased appetite is not typically associated with biliary atresia. In fact,
infants with biliary atresia may have poor feeding tolerance and failure to thrive due to liver
dysfunction and impaired nutrient absorption. Therefore, increased appetite would not be
considered a characteristic clinical manifestation of this condition.
A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metereddose 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?
Answer: "I will use my cromolyn nebulizer before using my albuterol inhaler."
Rationale:
Cromolyn sodium (Intal) is a mast cell stabilizer that helps prevent asthma attacks by reducing
inflammation and hypersensitivity in the airways. It is typically used as a maintenance
medication to prevent asthma symptoms, rather than as a rescue medication for acute symptoms.
Therefore, the statement indicating the use of cromolyn nebulizer before using the albuterol
inhaler suggests a misunderstanding of the purpose and timing of medication administration.
Albuterol is a short-acting bronchodilator used for quick relief of asthma symptoms during acute
exacerbations or as needed. The child should be instructed to use the albuterol inhaler for
immediate relief of symptoms, as directed by their healthcare provider, and to use the cromolyn
sodium inhaler regularly for long-term control of asthma symptoms.
Other options:
1. "I will shake the cromolyn inhaler well before each use." - This statement indicates an
understanding of the proper technique for using the cromolyn sodium (Intal) inhaler. Shaking the
inhaler well before each use helps ensure an even distribution of the medication and optimal
delivery to the lungs.
2. "I will rinse my mouth with water after using the cromolyn inhaler to prevent throat irritation."
- This statement indicates an understanding of the potential side effects of using the cromolyn
sodium (Intal) inhaler, such as throat irritation or dryness. Rinsing the mouth with water after
inhaler use helps minimize these side effects and maintain oral hygiene.
3. "I will use my cromolyn inhaler even when I'm feeling well to prevent asthma symptoms." This statement indicates an understanding of the preventive nature of cromolyn sodium (Intal)
inhaler therapy. Using the inhaler regularly, even when asthma symptoms are not present, helps
maintain control of inflammation in the airways and prevent asthma exacerbations.
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?
Answer: Slurred speech
Rationale:
Slurred speech is indicative of neurological involvement and may suggest a cerebral vascular
accident (stroke), a serious complication of sickle cell anemia. Stroke is a life-threatening
condition that requires immediate medical intervention to minimize brain damage and prevent
further complications. Therefore, the highest priority is to assess and manage the client's
neurological status promptly. Prompt interventions may include notifying the healthcare
provider, initiating neurological assessments, and preparing for emergency treatment such as
blood transfusion or medication administration to improve blood flow and oxygenation to the
brain.
Other options:
1. Pain in the extremities - Pain in the extremities is a common manifestation of vaso-occlusive
crisis in sickle cell anemia. While it is important to assess and manage the client's pain, slurred
speech indicating neurological compromise takes priority due to the potential for serious
complications such as stroke.
2. Low-grade fever - A low-grade fever may be present during a vaso-occlusive crisis as a result
of inflammation and tissue damage. While fever should be monitored and managed, slurred
speech indicating neurological involvement takes precedence in terms of priority.
3. Decreased urine output - Decreased urine output may indicate dehydration or renal
impairment, which can occur during a vaso-occlusive crisis. While assessing urinary output is
important for monitoring hydration status and kidney function, slurred speech indicating
neurological compromise takes priority due to the potential for serious neurological
complications such as stroke.
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?
Answer: WBC 2,800/mm3
Rationale:
A white blood cell (WBC) count of 2,800/mm3 indicates leukopenia, which is a potential adverse
effect of clozapine (Clozaril). Clozapine can suppress bone marrow function, leading to a
decrease in the production of white blood cells, particularly neutrophils. Leukopenia increases
the risk of infection and can potentially progress to agranulocytosis, a severe and life-threatening
condition characterized by a dangerously low level of white blood cells. Therefore, monitoring
of WBC counts is essential during clozapine therapy, and any significant decrease in WBC count
should be promptly reported to the healthcare provider for further evaluation and management.
Other options:
1. Dry mouth - Dry mouth is a common side effect of clozapine (Clozaril) and many other
antipsychotic medications. While uncomfortable, it is not typically considered a serious adverse
effect that requires immediate intervention. Dry mouth can often be managed with measures
such as frequent oral hydration, sugar-free gum, or saliva substitutes.
2. Weight gain - Weight gain is a common side effect of clozapine (Clozaril) and many other
antipsychotic medications. While significant weight gain may increase the risk of metabolic
complications such as diabetes and cardiovascular disease, it is not typically considered an
immediate adverse effect that requires urgent intervention unless it is severe or accompanied by
other concerning symptoms.
3. Sedation - Sedation is a common side effect of clozapine (Clozaril) and many other
antipsychotic medications, particularly during the initial stages of treatment. While sedation can
impair daily functioning and quality of life, it is not typically considered a serious adverse effect
that requires immediate intervention unless it is severe or significantly impacts the client's ability
to function safely.
A nurse is caring for a client who weighs 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?
Answer: 2.5 mL
Rationale:
First, calculate the total daily dose of gentamicin:
132 lb × (1 kg/2.2 lb) = 60 kg (approx.)
5 mg/kg/day × 60 kg = 300 mg/day
Since the total daily dose is to be divided into three equal doses, each dose would be:
300 mg/3 doses = 100 mg/dose
Next, calculate the volume of gentamicin solution needed for each dose:
100 mg/(40 mg/mL) = 2.5 mL
Therefore, the nurse should add 2.5 mL of the gentamicin solution to the 50 mL of 0.9% sodium
chloride solution for each dose.
Other options:
1. 1.5 mL
2. 3 mL
3. 4 mL
Rationale:
1. Incorrect. 1.5 mL would not provide the prescribed dose of 100 mg of gentamicin per dose.
2. Incorrect. 3 mL would provide a higher dose than the prescribed 100 mg of gentamicin per
dose.
3. Incorrect. 4 mL would provide a higher dose than the prescribed 100 mg of gentamicin per
dose.
A nursing supervisor is determining bed placement for four clients. Which of the following
clients should be placed on droplet precautions?
Answer: A client who has rubella
Rationale:
Rubella, also known as German measles, is transmitted via droplets from the respiratory tract of
an infected individual. Therefore, placing a client with rubella on droplet precautions is
necessary to prevent the spread of the virus to others. Droplet precautions include measures such
as wearing a mask and maintaining a distance of at least three feet from the infected individual to
reduce the risk of transmission through respiratory droplets.
Other options:
1. A client who has tuberculosis (TB) - Tuberculosis is transmitted via airborne particles, not
droplets. Therefore, this client should be placed on airborne precautions rather than droplet
precautions.
2. A client who has scabies - Scabies is transmitted through direct skin-to-skin contact or by
sharing contaminated items, not through respiratory droplets. Therefore, droplet precautions are
not indicated for a client with scabies.
3. A client who has Clostridium difficile (C. difficile) infection - Clostridium difficile infection is
transmitted through the fecal-oral route or via contact with contaminated surfaces or objects.
Therefore, standard precautions, including hand hygiene and the use of gloves, are sufficient for
preventing transmission of C. difficile, and droplet precautions are not indicated.
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?
Answer: 25-35 lb
Rationale:
The recommended weight gain during pregnancy depends on the pre-pregnancy BMI of the
mother. A BMI of 23 falls within the normal weight category. According to the Institute of
Medicine (IOM) guidelines, the recommended weight gain range for pregnant individuals with a
normal pre-pregnancy BMI (18.5-24.9) is 25-35 pounds. Therefore, advising the client to gain
between 25-35 pounds during the pregnancy is appropriate based on her BMI.
Other options:
1. 11-20 lb - This weight gain range is more appropriate for individuals with an underweight prepregnancy BMI (<18.5). A BMI of 23 falls within the normal weight category, so the
recommended weight gain range would be higher.
2. 15-25 lb - This weight gain range is also more appropriate for individuals with an underweight
pre-pregnancy BMI (<18.5). A BMI of 23 falls within the normal weight category, so the
recommended weight gain range would be higher.
3. 28-40 lb - This weight gain range is more appropriate for individuals with an overweight prepregnancy BMI (25-29.9). A BMI of 23 falls within the normal weight category, so the
recommended weight gain range would be lower.
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?
Answer: NG tube to suction
Rationale:
NG (Nasogastric) tube suctioning involves the removal of gastric contents from the stomach,
which can lead to the loss of electrolytes, including potassium. Since potassium is a major
intracellular ion found in the gastric fluid, prolonged or excessive NG tube suctioning can result
in the depletion of potassium levels in the body, leading to hypokalemia. Therefore, clients with
NG tubes to suction are at an increased risk for hypokalemia, and close monitoring of potassium
levels and supplementation may be necessary to prevent or correct hypokalemia.
Other options:
1. Chest tube - Chest tube drainage typically involves the removal of air or fluid from the pleural
space, which does not directly affect potassium levels in the body. Therefore, clients with chest
tubes are not at increased risk for hypokalemia due to tube drainage.
2. Hemovac drain - Hemovac drains are used to remove excess blood or fluid from surgical sites
or wounds. While excessive drainage can result in fluid and electrolyte loss, it is not specific to
potassium depletion, and clients with Hemovac drains are not at increased risk for hypokalemia
compared to other drainage tubes.
3. Jackson-Pratt drain - Jackson-Pratt drains are also used for wound drainage following surgery.
Similar to Hemovac drains, excessive drainage from Jackson-Pratt drains can lead to fluid and
electrolyte loss but is not specific to potassium depletion. Therefore, clients with Jackson-Pratt
drains are not at increased risk for hypokalemia due to tube drainage.
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?
Answer: "What part of your mother's care concerns you?"
Rationale:
This response is appropriate because it encourages the daughter to express her specific concerns
or areas of uncertainty regarding her mother's colostomy care. By addressing the daughter's
specific concerns, the nurse can provide tailored education and support to help alleviate her
worries and ensure that she feels confident in caring for her mother's colostomy. Open-ended
questions like this one facilitate communication and allow the nurse to assess the daughter's
knowledge, address misconceptions, and provide targeted teaching to promote effective
caregiving.
Other options:
1. "Don't worry, it's not as difficult as it seems." - This response dismisses the daughter's
concerns without addressing them and may not effectively address her specific questions or
uncertainties about caring for her mother's colostomy. It's important to acknowledge and address
the daughter's concerns rather than downplaying them.
2. "You'll get the hang of it eventually." - This response may come across as dismissive or
minimizing of the daughter's concerns and may not provide the immediate support or guidance
she needs in caring for her mother's colostomy. Encouragement is important, but it should be
combined with practical education and assistance to address specific concerns.
3. "Let me show you how to care for the colostomy." - While demonstrating colostomy care is
important, this response does not directly address the daughter's expressed concerns or
uncertainties. Starting with an open-ended question allows the nurse to assess the daughter's
knowledge and concerns before proceeding with education and demonstration.
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?
Answer: 0.75 mEq/L
Rationale:
A serum lithium level of 0.75 mEq/L falls within the therapeutic range for maintenance therapy
in the treatment of bipolar disorder. Lithium is a mood stabilizer commonly used to manage
bipolar disorder, and maintaining serum lithium levels within the therapeutic range is crucial for
its effectiveness while minimizing the risk of toxicity. For maintenance therapy, therapeutic
lithium levels typically range from 0.6 to 1.2 mEq/L. Therefore, a serum lithium level of 0.75
mEq/L indicates that the client's dosage is appropriate for maintenance therapy.
Other options:
1. 0.2 mEq/L - A serum lithium level of 0.2 mEq/L is below the therapeutic range and may
indicate subtherapeutic dosing. Inadequate lithium levels may result in insufficient control of
bipolar symptoms, necessitating a dosage adjustment.
2. 1.5 mEq/L - A serum lithium level of 1.5 mEq/L is above the upper limit of the therapeutic
range. Elevated lithium levels increase the risk of toxicity, which can manifest with symptoms
such as nausea, vomiting, tremors, confusion, and even seizures or cardiac arrhythmias.
Therefore, a level of 1.5 mEq/L is not appropriate for maintenance therapy and may require
dosage adjustment or closer monitoring to avoid toxicity.
3. 2.0 mEq/L - A serum lithium level of 2.0 mEq/L is significantly above the therapeutic range
and poses a high risk of lithium toxicity. Toxic levels of lithium can lead to serious adverse
effects, including neurological symptoms, renal impairment, and cardiac complications.
Therefore, a level of 2.0 mEq/L is not appropriate for maintenance therapy and requires
immediate intervention, such as withholding further doses and supportive care to manage
toxicity.
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?
Answer: Headache
Rationale:
After a lumbar puncture, the client may experience a headache due to leakage of cerebrospinal
fluid (CSF) through the puncture site. This headache is typically positional, worsening when the
client sits or stands and improving when lying down. It is thought to be caused by decreased
CSF pressure and traction on pain-sensitive structures.
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?
Answer: Assist the client to a side-lying position
Rationale:
Positioning the client in a side-lying position can help alleviate the burning pain by promoting
drainage of fluid or air from the pleural space. This position change can facilitate movement of
fluid or air away from the site of irritation, potentially reducing discomfort.
Other options:
• Administering pain medication: While pain relief may be necessary, it is important to address
the underlying cause of the burning pain. Positioning can help relieve discomfort without the
need for additional medication.
• Assessing the chest tube: While assessing the chest tube is important, it may not directly
address the client's immediate discomfort. Positioning should be prioritized to provide relief.
• Encouraging deep breathing exercises: Deep breathing exercises are important for lung
expansion and prevention of complications, but they may not directly address the client's burning
chest pain. Positioning should be prioritized for immediate relief.
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?
Answer: Toast with peanut butter
Rationale:
Toast with peanut butter is a suitable food choice for a client with dumping syndrome following
a gastrectomy. Foods high in protein and fat, like peanut butter, help slow down gastric
emptying, which can reduce the symptoms of dumping syndrome. Additionally, toast provides
carbohydrates without adding excessive sugar, which can exacerbate symptoms.
Other options:
• Orange juice: Orange juice is high in simple sugars and can exacerbate symptoms of dumping
syndrome due to its rapid absorption into the bloodstream, leading to a surge in blood glucose
levels and subsequent symptoms such as nausea, sweating, and palpitations.
• Rice with honey: Honey is a concentrated source of simple sugars and can contribute to rapid
gastric emptying and symptoms of dumping syndrome. While rice is easily digestible, the
addition of honey may not be appropriate for managing dumping syndrome.
• Boiled potatoes: Boiled potatoes are a good source of carbohydrates, but they are low in protein
and fat. For managing dumping syndrome, it is important to include foods that slow gastric
emptying, such as those higher in protein and fat, to help mitigate symptoms.
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 a respiratory or cardiac arrest.
Which of the following is necessary to legally change the client's code status to do-notresuscitate (DNR)?
Answer: A written prescription from the provider
Rationale:
In order to change a client's code status to do-not-resuscitate (DNR), a written prescription from
the provider is necessary. This prescription serves as a legal document that specifies the client's
wishes regarding resuscitative measures. It ensures that healthcare providers are aware of and
adhere to the client's preferences in the event of cardiac or respiratory arrest.
Other options:
• Verbal consent from the client: While verbal consent is important in the decision-making
process, it may not be sufficient to legally change the client's code status to DNR. Written
documentation is necessary to ensure clarity and accountability in healthcare decision-making.
• Family agreement: While family input and agreement can be valuable in discussions about endof-life care, the ultimate decision regarding code status rests with the competent client. Written
documentation from the provider is required to legally change the code status to DNR.
• Advance directive on file: Advance directives, such as living wills or healthcare proxies, may
express the client's wishes regarding resuscitative measures. However, a specific written
prescription from the provider is needed to formally change the code status to DNR within the
healthcare setting.
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?
Answer: Sputum culture for acid-fast bacillus
Rationale:
A sputum culture for acid-fast bacillus is used to confirm the diagnosis of active pulmonary
tuberculosis. Acid-fast bacilli are characteristic of Mycobacterium tuberculosis, the bacterium
that causes tuberculosis. Culturing the sputum allows for the growth and identification of these
bacteria, confirming the presence of tuberculosis infection.
Other options:
• Chest X-ray: While a chest X-ray may reveal abnormalities consistent with tuberculosis, such
as infiltrates or cavitations, it cannot confirm the diagnosis on its own. Further testing, such as
sputum culture, is necessary for confirmation.
• Mantoux tuberculin skin test (TST): The Mantoux tuberculin skin test can detect exposure to
tuberculosis but cannot differentiate between active and latent infection. A positive TST indicates
exposure to tuberculosis but does not confirm active disease.
• Polymerase chain reaction (PCR) assay: PCR assays can detect the presence of Mycobacterium
tuberculosis DNA in sputum samples, providing a rapid and sensitive method for diagnosis.
However, sputum culture remains the gold standard for confirmation of active pulmonary
tuberculosis due to its ability to isolate live bacteria for further testing and drug susceptibility
testing.
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?
Answer: A client who is recovering from a cardiac catheterization
Rationale:
Performing an electronic blood pressure measurement would be appropriate for a client who is
recovering from a cardiac catheterization. Electronic blood pressure monitors are often preferred
in situations where accurate and frequent blood pressure measurements are needed, such as
during cardiac procedures or in critical care settings. These monitors provide continuous or
automated readings, which can be particularly useful for detecting changes in blood pressure
quickly and accurately in clients recovering from cardiac interventions.
Other options:
• A client who is receiving continuous intravenous (IV) vasopressor medications: Electronic
blood pressure measurement may be suitable for this client due to the need for frequent and
accurate blood pressure monitoring to titrate vasopressor medications and maintain
hemodynamic stability.
• A client with a history of atrial fibrillation: While electronic blood pressure measurement may
be appropriate for this client, it is not specifically indicated based solely on the history of atrial
fibrillation. Other factors, such as the client's current condition and need for frequent monitoring,
would determine the choice of blood pressure measurement method.
• A client who is in the immediate postoperative period following abdominal surgery: While
electronic blood pressure measurement may be suitable for this client, the specific indication
would depend on factors such as the client's hemodynamic stability, presence of comorbidities,
and clinical status. Other methods of blood pressure measurement, such as auscultation with a
sphygmomanometer, may also be appropriate depending on the clinical context.
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?
Answer: Abdominal distension
Rationale:
Abdominal distension in a newborn could indicate several potential issues, including
gastrointestinal obstruction, bowel perforation, or other abdominal pathology. In the immediate
postnatal period, abdominal distension can be concerning and may require further evaluation and
intervention to rule out serious conditions and ensure the newborn's well-being.
Other options:
• Respiratory rate of 60 breaths per minute: A respiratory rate of 60 breaths per minute is within
the normal range for a newborn. Newborns typically have a higher respiratory rate compared to
older children and adults.
• Pink mucous membranes: Pink mucous membranes indicate adequate oxygenation, which is a
positive finding in a newborn. Cyanosis or pale mucous membranes would be concerning for
hypoxemia and would require further intervention.
• Temperature of 36.8°C (98.2°F): A temperature of 36.8°C (98.2°F) is within the normal range
for a newborn. Newborns may have slightly lower temperatures immediately after birth but
should stabilize within the normal range shortly thereafter.
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?
Answer: Warm refrigerated drops to room temperature prior to instillation
Rationale:
Warming refrigerated ear drops to room temperature before instillation is appropriate when
administering benzocaine (Americaine) ear drops to a toddler with acute otitis media. Cold drops
can cause discomfort or dizziness when instilled into the ear canal. Warming the drops to room
temperature can help prevent these sensations and improve the comfort of the toddler during
administration.
Other options:
• Administering the drops immediately after removal from the refrigerator: Administering cold
drops directly from the refrigerator can cause discomfort or dizziness when instilled into the ear
canal. Warming the drops to room temperature before administration is recommended to improve
the comfort of the toddler.
• Diluting the drops with saline solution: Diluting the drops with saline solution is not necessary
and may alter the concentration of the medication, potentially reducing its effectiveness in
providing pain relief.
• Placing the toddler in a supine position during administration: Placing the toddler in a supine
position during administration is not specifically indicated for administering ear drops. The
toddler can be positioned comfortably for ear drop administration, but warming the drops to
room temperature is a more appropriate action to enhance comfort during instillation.
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?
Answer: Assigning staff members on each shift the same password for accessing medical
records
Rationale:
Assigning staff members on each shift the same password for accessing medical records
compromises confidentiality and poses a risk of unauthorized access to confidential client
information. Each staff member should have their own unique login credentials to access
medical records, and passwords should be regularly changed to enhance security and protect
client privacy.
Other options:
• Storing client records in a locked cabinet: Storing client records in a locked cabinet is a
protective measure that helps maintain confidentiality and prevent unauthorized access to client
information. This practice aligns with confidentiality requirements and does not indicate a need
for intervention.
• Requiring staff to sign confidentiality agreements upon hire: Requiring staff to sign
confidentiality agreements upon hire is a standard practice to ensure that employees understand
their responsibility to protect client information. This practice supports confidentiality
requirements and does not indicate a need for intervention.
• Encrypting electronic client data: Encrypting electronic client data is a security measure that
helps protect client information from unauthorized access or disclosure. This practice aligns with
confidentiality requirements and does not indicate a need for intervention.
