ATI Nurse Logic: Knowledge and Clinical Judgement

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? Discussing changes in a client's plan of care with his friend who is a nurse on another unit 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? Cover the area with a transparent wound barrier 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? 2.5 tsp A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion? Obtaining the client's level of 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? "Tell me more about your concerns." 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? 2.5 tablets 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? "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." 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? Supine 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? Prepare a healthy meal to serve at the end of class 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? Twisting at the waist and shoulders A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurses should first open the sterile package in which of the following directions? Away from the body 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? Chlorine (bleach) 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? Hyperglycemia A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? Deep reddish-colored tongue 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? Urinary retention 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? q.d. 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? Pallor 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? Dimpling of the tissue in the upper outer quadrant 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? Living wills detail treatment wishes of the client in the event of terminal illness 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? Reduce the rate of the feedings A school nurse has requested the school board remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following? Advocacy A nurse is providing education to the parent of an infant who is newly diagnosed with biliary atresia. The nurse should teach the parent that which of the following is a clinical manifestation associated with the illness? Dark Urine A nurse is reinforcing teaching about a new prescription for cromolyn sodium (Intal) metered-dose inhaler (MDI) to a school-age child who has asthma. Which of the following statements should indicate to the nurse that the child needs further teaching? "I will use my cromolyn nebulizer before using my albuterol inhaler." 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? Slurred speech 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? WBC 2,800/mm3