NURS 221 Nurse logic Knowledge and clinical judgment beginner

NURS 221 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 -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 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. 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. 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. 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 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. 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 1tsp = 5 mL 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.