1 Nurse logic Knowledge and clinical judgment beginner
1. 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? a. mcg b. q.d. c. mL d. PO Answer is B-q.d. is the incorrect term. To indicate daily, you should use the word "daily" when charting. Q.d. used to be confused for qid, which means 4x a day.
2. 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? a. Cyanosis b. Jaundice c. Erythema d. Pallor Answer is D-Pallor
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-Oxyhemoglobin is the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin molecule that will carry it. In clients who have anemia, the RBCs are reduced, by function or in number, to the point that peripheral tissues are not receiving adequate oxygen because of a decreased amount of circulating oxyhemoglobin. The reduced oxygen supply to the tissues causes changes to the client's skin color. Pallor is caused by a reduced amount of oxyhemoglobin. Pallor is a decrease in the coloring of the peripheral tissues that is caused by an overall reduction in the blood flow or by a decrease in the number of RBCs that contain oxyhemoglobin, which reduces the visibility of oxyhemoglobin.
Pallor Paleness of the skin - Decrease in the coloring of the peripheral tissues. Is caused by an overall reduction in the blood flow or by a decrease in the number of RBCs that contain oxyhemoglobin, which reduces the visibility of oxyhemoglobin.
Oxyhemoglobin the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin molecule that will carry it.
3. A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion? a. Determining the client's respiratory rate b. Measuring the client's chest diameter c. Obtaining the client's level of oxygen saturation d. Checking the client's depth of respirations Answer is C-Obtaining the client's level of oxygen saturation -Obtaining the client's level of oxygen saturation is an appropriate technique of measuring perfusion.
This item requires foundational thinking because you only need to identify which of the following options describes a technique for measuring tissue perfusion.
Perfusion is the delivery or pumping of arterial blood through tissues or an organ. Oxygen saturation measures the percent of hemoglobin bound with oxygen that is being perfused through the arteries and into the tissues.
Foundational Thinking Ability to recall and comprehend information and concepts
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Perfusion delivery or pumping of arterial blood through tissues or an organ.
Oxygen saturation Measures the percent of hemoglobin bound with oxygen that is being perfused through the arteries and into the tissues.
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4. 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?
a. Isopropyl alcohol b. Chlorhexidine gluconate (Hibiclens) c. Chlorine (bleach) d. Iodophor Answer is C-Chlorine Chlorine is a disinfectant that is effective against bacteria, tuberculosis, spores, fungi, and viruses, and is specifically recommended for cleaning blood spills. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. Chlorine should be used to clean the spill.
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2 5. A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? a. Spongy gums that are receding b. Fissures at eyelid corners c. Easily plucked hair d. reddish-colored tongue Answer is D-Reddish-colored tongue Deep reddish-colored tongue is suggestive of a healthy nutritional status. The tongue should be a healthy pink to a deep, reddish color with surface papillae present, without swelling or lesions.
6. 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? a. Living wills require a written prescription from the provider to be legal. b. Living wills allow the client to designate a health care proxy. c. Living wills ensure hospitals provide emergency care regardless of health coverage. d. Living wills detail treatment wishes of the client in the event of terminal illness. Answer is D-Living wills detail treatment wishes of the client in the event of terminal illness. Advance directives include both living wills and durable powers of attorney for health care. The living will details treatment wishes of the client in the event of terminal illness or persistent vegetative state. This information is accurate and should be included in the teaching about living wills.
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Advance directives Include both living wills and durable powers of attorney for health care. Living Wills Details treatment wishes of the client in the event of terminal illness or persistent vegetative state. This information is accurate and should be included in the teaching about living wills.
7. 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? a. Dorsal recumbent b. Orthopneic c. Side-lying d. Supine Answer is D-Supine
Indwelling urinary catheters are indicated in numerous situations, such as relief of bladder distension, strict measurement of urinary output, need for bladder irrigations, and surgery. A prescription from the provider is required for urethral catheterization. When preparing to implement this procedure, it is important to ensure client privacy by draping nonessential body parts and positioning the client for optimal visualization while still maintaining comfort. A male client should be positioned in the supine position for insertion of an indwelling urinary catheter. This position allows for optimal visualization, which reduces trauma and increases success of insertion.
8. 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? a. To the left b. To the right c. Away from the body d. Toward the body Answer is C-Away from the body
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Sterile packages are resistant to pathogens and are used for specific techniques or procedures to prevent contamination. During such procedures, any sterile item that comes into contact with an unsterile object is considered contaminated. To prevent contamination of the sterile field, nurses follow certain steps when opening sterile packages and creating a sterile field. Opening the sterile package away from the body first allows a nurse to open the remaining flaps without reaching over the sterile field, which could result in contamination. This is the appropriate direction to open the sterile package.
1tsp = 5 mL
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9. 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 is 2.5 teaspoons
10. 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? a. Watch a video discussing healthy meal preparation. b. Prepare a healthy meal to serve at the end of class. c. Read pamphlets about preparing a healthy meal. d. Discuss healthy meal preparation as a class. Answer is B-Prepare a healthy meal to serve at the end of class.
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3 Tactile learners are hands on. They learn best by touching and doing; therefore, having the participants prepare a healthy meal to serve at the end of class is a learning strategy appropriate for tactile learners.
11. 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? a. Hypomagnesemia b. Hyperglycemia c. Hyponatremia d. Hyperkalemia Answer is B-Hyperglycemia Dexamethasone, a glucocorticoid, is a powerful anti-inflammatory and immunosuppressant and is indicated for the treatment of multiple disorders, including rheumatoid arthritis. Adverse effects of dexamethasone increase with the dosage and duration of treatment and can include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing's syndrome among others. Hyperglycemia, an elevated blood glucose level, is an adverse effect of dexamethasone. Both hyperglycemia and glycosuria can be manifested in clients who are taking dexamethasone because of its effect on the production and use of glucose.
12. 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?
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a. "I'll make sure that the medication container is kept tightly sealed." b. "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." c. "I'll keep my pills in the medicine cabinet when I'm home." d. "I'll go to the emergency room if my chest pain doesn't go away." Answer is B-"I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities."
Buying nitroglycerin in bulk quantities is not a safe practice. The chemical instability of the medication allows it to lose effectiveness over time. While some nitroglycerin tablets have a shelf life of 24 months, NitroQuick retains its effectiveness for only 8 to 10 months. Because of the shortened shelf life, the client should not buy the medication in bulk quantities, and the client should be instructed to date the bottle when it is first opened.
13. 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? a. Chill formula prior to administration. b. Verify feeding tube placement. c. Reduce the rate of the feedings. d. Place the client supine during feedings. Answer is C-Reduce the rate of feeding.
Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food. Complications of enteral tube feedings include feeding tube regurgitation and aspiration of feedings, delayed gastric emptying, and malabsorption among others. Reducing the rate of feedings is an appropriate action by the nurse to prevent diarrhea after subsequent feedings. A client receiving intermittent enteral tube feedings can experience diarrhea because of the administration of hyperosmolar enteral feedings. To prevent this, administration should be slowed or switched to continuous enteral feedings.
14. 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? a. Urinary retention b. Rapid respirations c. Dilated pupils d. Diarrhea Answer is A-Urinary retention
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In this item, you need nursing knowledge related to morphine to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of morphine. Morphine is an opioid used to treat moderate to severe pain, and can reduce anxiety, produce a sense of wellbeing, as well as cause drowsiness and mental clouding. Morphine has an agonist effect on opioid receptors in the CNS, causing many of the adverse effects associated with the medication. Urinary retention is an adverse effect of morphine. By increasing bladder sphincter and detrusor muscle tone and reducing awareness of bladder stimuli, morphine can cause urinary hesitancy, urinary retention, and urinary urgency.
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15. 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? a. Reposition the client every 4 hr. b. Cover the area with a transparent wound barrier. c. Massage areas surrounding the redness. d. Wash the area with hot water every 8 hr. Answer is B-Cover the area with a transparent wound barrier
In this item, you need knowledge of appropriate skin care interventions for clients who are immobile with indications of a stage I pressure ulcer. Damage to tissues caused by continuous pressure is described as a pressure ulcer. The risk for pressure ulcers can be complicated by factors such as immobility, inadequate nutrition, bowel and bladder incontinence, decreased mental status, reduced sensation, increasing age, and excessive body heat. Appropriate care of pressure ulcers is based on the characteristics and stage of the wound. A wound that manifests as a reddened area is a stage 1
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4 pressure ulcer. A transparent wound barrier applied to reddened skin or a stage 1 pressure ulcer to prevent contamination and reduce friction to the area is an appropriate action by the nurse.
16. 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? a. Twisting at the waist and shoulders b. Standing with feet in a wide stance c. Positioning self close to the client d. Using arms and legs to lift Answer is A-Twisting at the waist and shoulders To prevent a lift injury when transferring the client from the bed to a chair, alignment of the back, neck, pelvis, and feet should be maintained to reduce the risk of injury to the lumbar vertebrae. This action by the newly licensed nurse is not appropriate and indicates a need for additional teaching.
17. 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? a. Faxing laboratory results to a client's provider b. Discussing changes in a client's plan of care with his friend who is a nurse on another unit c. Describing a client's level of independence to the case manager arranging home health services d. Remaining in the room with the client while he reviews his own medical records Answer is B-Discussing changes in a client's plan of care with his friend who is a nurse on another unit.
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HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. A nurse discussing changes in a client's plan of care with another nurse on another unit is a breach of confidentiality. Client information can only be shared with other health care professionals involved in that client's care. The nurse on the other unit should be directed to the client to request information about changes in the client's plan of care. This action is not appropriate and requires intervention by the nurse preceptor. 18. 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? a. "Clients having this surgery are always scared." b. "Why have you changed your mind about the surgery?" c. "You shouldn't worry, everything will be fine." d. "Tell me more about your concerns." Answer is D-"Tell me more about your concerns."
The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Giving a general lead encourages the client to openly share feelings and concerns in a non-threatening environment, which will assist in establishing a meaningful nurse-client relationship. This response by the nurse is appropriate and fosters the nurse-client relationship.
19. 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 is 2.5 tablets per dose
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? a. Silver-colored striae b. Unilateral nipple inversion present since menarche c. Dimpling of the tissue in the upper outer quadrant d. Visible symmetrical venous patterns Answer is C-Dimpling of the tissue in the upper outer quadrant
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Dimpling of the tissue in the upper outer quadrant should be considered an unexpected finding and reported to the provider. In fact, dimpling that is noted anywhere within the breast tissue should be reported. Dimpling makes the tissue appear retracted in a particular area and can result from underlying scar tissue or an invasive tumor causing ligaments to pull the skin inward toward the tumor. This variation of the breast tissue is consistent with breast cancer.
Nurse logic nursing concepts beginner
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1. A nurse is caring for an older adult client, who has an allergy to Sulfa, is taking valproic acid (Depakote) for seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help with my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following? A. Celecoxib is contraindicated in clients with an allergy to sulfonamide. B. Celecoxb is contraindicatated in clients taking valproic acid C. Calecoxib is contraindicated in clients with a seizure disorders D. Calecoxib is contraindicated in older adults
Answer is A -Rationale: - Celecoxib is a nonsteroidal anti-inflammatory, cyclooxygenase inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. However, since it contains a sulfa molecule; it cannot be given to a client who has allergies to sulfa.
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5 2. A nurse is working with the information 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? A. Placement of computer systems in restricted areas B. Installation of firewall software on each computer C. Ability of staff access electronic health records of clients throughout the facility D. Occurrence of an automatic log-off after a period of inactivity Answer is C Rationale: - The ability of staff to access electronic health records of clients through the facility allows viewing confidential information on clients the staff might not directly be involved in care of. The majority of the staff should only be allowed to access the electronic health health records of clients on the unit where he or she works only.
3. 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? A. Acupunctur is loosely regulated by the federal gov't B. Acupuncture has been discredited by scientific research. C. Acupuncture is thought to be effective only as a placebo D. Acupuncture has been proven to reduce pain and increase function. Answer is D Rationale: - because of emphasized evidence based practice
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4. A nurse discovers that a client who is diagnosed with dementia received the wrong meds. Which of the following should be the nurse's first action? A. Inform the nurse manager B. Determine the client's condition C. Notify the provider D. Complete an incident Report Answer is B Rationale: - because the client is our top priority, we need to assess his condition and everything else follows. 5. A nurse is reinforcing teaching about transdermal nitroglycerin to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective? A. I should leave the patch on for 16 to 20 hours each day B. I will apply a new patch in the same location each day C. The patch should be effective within an hour of being applied. D. The medication is o absorbed well when placed on the abdomen. Answer is C Rationale: Medication becomes effective after 20-60 min and last till the patch is removed
6. A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following info is appropriate for the nurse to include? A. Meds will eliminate HIV in most adults B. Adolescents are at a lower risk for developing HIV C. Initial HIV symptoms are often similar to the flu D. Using condoms ensures the prevention of HIV during sexual intercourse Answer is C Rationale: - This question emphasized on patient education, pt generally has flu like symptoms during the first or primary infection stage.
7. 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? A. Blood glucose 150 mg/dL B. Potassium 2.5 mEq/L C. Total protein 5.2 g/dL D. Urine specific gravity 1.040 Answer is B Rationale: - This requires immediate action, while the rest can still wait and is not life threatening at the moment. The potassium level is below the expected reference range. Hypokalemia can lead to arrhythmias or cardiac arrest.
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8. A nurse is caring for an older adult client who was admitted 3 days ago with fracture ribs and bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse's priority goal? A. Support the client's relationships with his caregivers B. Encourage the client to express his feeling C. Determine who is responsible for the abuse D. Protect the client from further abuse Answer is D Rationale: - This question emphasizes safety. Safety in nursing practice is the minimization of risk factors that can cause injury or harm, while promoting quality care. Must advocate care and maintain a secure environment for the clients. 9. A nurse in 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? A. Mammogram every year to detect breast cancer B. Colonoscopy every 10 years to detect colon cancer C. Dermatologist evaluation every 3 years to detect skin cancer D. Complete eye examination every year to detect eye disorders Answer is C Rationale: - recommendation of age- appropriate health screenings for adults between 20-40. Mammogram is recommended every year for women 40 years or older.
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