NurseLogic Knowledge and Clinical Judgment Advanced
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?
A. Rapid weight gain
B. Tar-colored stools
C. Lethargy
D. Dark urine - correct answer Dark urine
In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the
pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical
manifestation the parent should be taught is associated with biliary atresia. This item requires
critical thinking because you have to evaluate each finding in relation to the pathophysiology of
biliary atresia. Biliary atresia is a progressive process that leads to destruction of the biliary tree.
The biliary tree begins as many small ducts that join together into one main common bile duct,
similar to the joining of branches to a tree trunk. Bilirubin, created from the breakdown of
heme in RBCs and the main pigment in bile, travels to the liver where the liver cells, known as
hepatocytes, secretes it into bile. The bile then passes into the small ducts and then travels to
the small intestine where bacteria break it down into urobilinogen to be excreted in the feces.
Dark urine is a clinical sign of biliary atresia because of conjugated bilirubin escaping from the
liver and being excreted in the urine. The nurse should teach the parent that dark urine is a
clinical manifestation associated with the illness.
A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and
has requested no resuscitative mesasures be taken in the event of respiratory or cardiac arrest.
Which of the following is necessary to legally change the client's code status to do-not-
resuscitate (DNR)?
A. A written prescription from the provider
B. Signed documentation from the client
C. Family support of the decision
, D. Admission to hospice for palliative care - correct answer A written prescription from the
provider
In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on
your knowledge of this concept, you can select the option that describes requirements to
legally change the code status of a client to a DNR. This item requires foundational thinking
because you have to recall legalities associated with initiating a DNR. A DNR is typically
instituted at the request of a client or family member and should be a written order instead of a
verbal prescription. Until a DNR prescription exists, every attempt to revive the client should be
made in the event of respiratory or cardiac arrest. A written prescription from the provider is
necessary to legally change the client's code status to a DNR.
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?
A. Place the child on the affected side for several minutes upon completion of instillation.
B. Warm refrigerated drops to room temperature prior to instillation.
C. Pull the pinna of the ear upward and back during instillation.
D. Massage the area posterior to the ear after instillation. - correct answer Warm refrigerated
drops to room temperature prior to instillation.
This item requires knowledge of appropriate techniques for administering ear drops. Based on
your understanding of this concept, you can select the appropriate nursing action. This item
requires foundational thinking because you have to recall knowledge of a specific nursing skill
to appropriately administer ear drops. This is an appropriate action by the nurse when
administering ear drops. Ear drops are topically administered medications, which are slowly
absorbed through the skin and primarily provide local results. Because of the anatomy of
internal ear structures, it is important to remember that the ear is sensitive to extremes in
temperature. Ear drops should be warmed to room temperature prior to instillation to reduce
the risk of painful stimuli.
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?
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?
A. Rapid weight gain
B. Tar-colored stools
C. Lethargy
D. Dark urine - correct answer Dark urine
In this item, you need knowledge of the anatomy of the biliary tree, as well as knowledge of the
pathophysiology of biliary atresia. Based on this knowledge, you can identify a clinical
manifestation the parent should be taught is associated with biliary atresia. This item requires
critical thinking because you have to evaluate each finding in relation to the pathophysiology of
biliary atresia. Biliary atresia is a progressive process that leads to destruction of the biliary tree.
The biliary tree begins as many small ducts that join together into one main common bile duct,
similar to the joining of branches to a tree trunk. Bilirubin, created from the breakdown of
heme in RBCs and the main pigment in bile, travels to the liver where the liver cells, known as
hepatocytes, secretes it into bile. The bile then passes into the small ducts and then travels to
the small intestine where bacteria break it down into urobilinogen to be excreted in the feces.
Dark urine is a clinical sign of biliary atresia because of conjugated bilirubin escaping from the
liver and being excreted in the urine. The nurse should teach the parent that dark urine is a
clinical manifestation associated with the illness.
A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and
has requested no resuscitative mesasures be taken in the event of respiratory or cardiac arrest.
Which of the following is necessary to legally change the client's code status to do-not-
resuscitate (DNR)?
A. A written prescription from the provider
B. Signed documentation from the client
C. Family support of the decision
, D. Admission to hospice for palliative care - correct answer A written prescription from the
provider
In this item, you need specific knowledge of legal issues regarding a DNR code status. Based on
your knowledge of this concept, you can select the option that describes requirements to
legally change the code status of a client to a DNR. This item requires foundational thinking
because you have to recall legalities associated with initiating a DNR. A DNR is typically
instituted at the request of a client or family member and should be a written order instead of a
verbal prescription. Until a DNR prescription exists, every attempt to revive the client should be
made in the event of respiratory or cardiac arrest. A written prescription from the provider is
necessary to legally change the client's code status to a DNR.
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?
A. Place the child on the affected side for several minutes upon completion of instillation.
B. Warm refrigerated drops to room temperature prior to instillation.
C. Pull the pinna of the ear upward and back during instillation.
D. Massage the area posterior to the ear after instillation. - correct answer Warm refrigerated
drops to room temperature prior to instillation.
This item requires knowledge of appropriate techniques for administering ear drops. Based on
your understanding of this concept, you can select the appropriate nursing action. This item
requires foundational thinking because you have to recall knowledge of a specific nursing skill
to appropriately administer ear drops. This is an appropriate action by the nurse when
administering ear drops. Ear drops are topically administered medications, which are slowly
absorbed through the skin and primarily provide local results. Because of the anatomy of
internal ear structures, it is important to remember that the ear is sensitive to extremes in
temperature. Ear drops should be warmed to room temperature prior to instillation to reduce
the risk of painful stimuli.
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?
