B- ATI Nursing Logic Critical and clinical thinking – Flashcards
Unlock all answers in this set
Unlock answersquestion
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.In this item, you need nursing knowledge of dexamethasone 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 dexamethasone. 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.
question
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
In this item, you need knowledge of appropriate skin care interventions for clients who are immobile with indications of a stage I pressure ulcer. This item requires foundational thinking because you have to recall interventions that are appropriate for maintaining skin integrity in clients who are immobile. 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 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.
question
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
In this item, you need knowledge of abbreviations that the Joint Commission has determined should not be used in documentation. This is a negatively-worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively-worded items in Module 4. This item requires foundational thinking because you only need to recall knowledge related to the abbreviations that are not acceptable for use when charting. To reduce the occurrence of medical errors, the Joint Commission developed a list of do-not-use abbreviations that should be avoided in health care settings. The abbreviation "q.d." was previously used to indicate every day, which can be mistaken as the abbreviation for "four times daily (qid)," resulting in medical errors. The Joint Commission has recommended the use of "daily" to indicate every day. This is not an acceptable abbreviation; therefore, additional teaching is needed.
question
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
Bleach
question
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
question
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: Sterile packages are resistant to pathogens and are used for specific techniques or procedures to prevent contamination.
question
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
question
To Transfer a client from a chair to a bed
answer
Twisting at the waist and shoulders
question
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 Desired xQuantity / Have= 250 x 1 tablet /100 = 2.5
question
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
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 well-being, 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. Urinary retention
question
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 clients level of oxygen saturation
question
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
question
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
In this item, you need nursing knowledge of clozapine to recall adverse effects associated with the medication. Based on an understanding of this information, you can identify which is the correct option. This item requires foundational thinking because you have to recall knowledge related to adverse effects of clozapine. Clozapine is a second-generation antipsychotic used to relieve symptoms of schizophrenia and to reduce suicidal behaviors in clients who have schizophrenia or schizoaffective disorder. Adverse effects of clozapine include tachycardia, weight gain, sedation, and agranulocytosis. Agranulocytosis, which is a decrease in one of the WBCs called neutrophils, reduces the ability to fight infection and can be fatal. Because of the potential for agranulocytosis, clients who are taking clozapine are monitored frequently for a decrease in WBC count below 3,000/mm3. The client's WBC and absolute neutrophil count is monitored weekly during the first 6 months of therapy, then every 2 weeks during the next 6 months. A WBC level of 2,800/mm3 indicates the client is experiencing an adverse effect of the medication.
question
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
question
what are the clinical manifistation of biliary atresia
answer
Dark urine
question
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
question
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?
answer
Lithotomy
question
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 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 my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following
answer
Celecoxib is contraindicated in clients with allergy to sulfonamide
question
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
answer
Demonstrating independent performance of the procedure
question
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?
answer
Speech pathologist
question
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?
answer
Ability of staff to access electronic health records of clients throughout the facility
question
A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action?
answer
Determine the clients condition
question
A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis and is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol?
answer
Loss of color and discrimination
question
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?
answer
Autonomy
question
A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention?
answer
Difficulty Breathing
question
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 advice?
answer
Discuss the risks of leaving the facility
question
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 advice?
answer
Stop the infusion
question
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?
answer
Supine with head of the bed elevated 45 degrees
question
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?
answer
Reduce bleeding time
question
A nurse is caring for a client who has a urinary tract infection 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?
answer
Determine respiratory status
question
nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis?
answer
Elevated temp
question
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 charge nurse to assign?
answer
An adolescent who is two days postoperative following happendectomy
question
A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching
answer
Its the responsibility of the provider to obtain express consent
question
A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)
answer
Lethargy
question
A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis?
answer
Elevated temp
question
A nurse is conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider?
answer
Digoxin 3.0 ng/ml
question
A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle
answer
1 1/2 INCH
question
A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which statement indicates a need for further teaching?
answer
"im lucky i have a prescription plan that allows me to buy pills in bulk"-Shelf life 8-10 months, instruct to date the bottle when first opened.
question
A nurse is caring for a client who is in the immediate postoperative period following a tracheotomy. Which of the following is the nurse's priority action?
answer
Maintaining a patent airway
question
A nurse is collecting data on four clients. Which of the following finding is the most urgent?
answer
Warmth and pain in the calf.
question
A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?
answer
Place the client in the orthopneic position.
question
A nurse is collecting data on four clients. Which of following is the highest priority finding by the nurse?
answer
Diarrhea
question
A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention?
answer
Platelets 95,000 mm3
question
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?
answer
Check the leg for warmth and edema.
question
A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first?
answer
A client who had abdominal surgery 10 days ago and reports feeling his incision pop
question
A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions?
answer
Place the infant in a supine position when sleeping.
question
A newly hired nurse is reviewing the facility's emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide priority care to clients who are which of the following categories during a disaster?
answer
Immediate
question
A nurse is preparing to administer oral medications to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse?
answer
Have the client position the head with the chin down while swallowing.
question
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?
answer
Obtain an ECG.
question
A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first?
answer
Assist client to cough effectively.
question
A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for a fluid volume deficit?
answer
Check the heart rate and blood pressure.
question
A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first?
answer
Determine the mobility status of each client
question
A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first?
answer
Hypoxic
question
A nurse in a provider's office has collected data on 4 clients. Which of the following clients should be the nurse's priority concern?
answer
A client who is having a nosebleed associated with hypertension.
question
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?
answer
Check on the client.
question
A nurse is caring for a client who has a urinary tract infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first?
answer
Move the client to a room near the nurses' station.
question
A nurse is caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client?
answer
Creating meaningful social relationships
question
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?
answer
Partial thickness skin loss
question
Lyme disease is transmitted
answer
By Vector
question
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?
answer
Stand close to the client
question
A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?
answer
Sims postion
question
A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should be elicited over areas of consolidation during percussion?
answer
Dullness
question
A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should be elicited over areas of consolidation during percussion?
answer
3/4 cup of canned tomato juice is correct. Sodium-restricted diets are frequently prescribed to clients to treat hypertension and weight loss. This beverage selection has approximately 820 mg of sodium; therefore, this food selection is not appropriate for the client who is prescribed a 2,000 mg sodium-restricted diet. This selection indicates that further teaching is required by the nurse.
