NurseLogic 2.0: Knowledge and Clinical Judgement - Advanced Test
A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and
has requested no resuscitative measures 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)? - correct answer A written prescription from the provider
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 attempts 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? - correct answer Warm refrigerated drops to
room temperature prior to instillation.
Because of the anatomy of internal ear structures, it is important to remember that the ear is
sensitive to extremes in temp. Ear drops should be warmed to room temp prior to instillation to
reduce the risk of painful stimuli
A nurse is caring for a client who has a new colostomy. The client is being discharged and plans
to live with her daughter. Which of the following responses by the nurse is appropriate when
the daughter states that she doesn't know how she is going to care for her mother's colostomy?
- correct answer "What part of your mother's care concerns you?"
A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium
(Lithane). Which of the following serum lithium levels indicates the client's dosage is
appropriate for maintenance therapy? - correct answer 0.75 mEq/L
Lithium is a mood-stabilizing medication used in the treatment of bipolar I acute and recurrent
manic and depressive episodes. To achieve a therapeutic range, give 300 mg to 600 mg of
lithium during the active phase. The therapeutic serum lithium level is between 0.8 mEq/L and
1.4 mEq/L. Maintenance levels of 0.4 to 1.3 mEq/L are then achieved for clients who are
prescribed lithium for long-term therapy. Because small increments of dosage separate
therapeutic, maintenance, and toxic levels of lithium, knowledge of these levels is essential to
,ensure safe, quality care. This serum lithium level indicates the client's dosage is appropriate for
maintenance therapy.
A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach
the client that which of the following is a post-procedure complication? - correct answer
Headache
A headache is a manifestation experienced by 15 to 30% of clients following a lumbar puncture
that results from cerebrospinal fluid leakage at the puncture site. These headaches are
managed primarily with analgesics, hydration, and bed rest
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? - correct answer "I will use
my cromolyn inhaler before using my albuterol inhaler."
When both cromolyn and albuterol are prescribed, albuterol should be inhaled first to open the
airways because it is a bronchodilator. After waiting a few minutes, the cromolyn can then be
inhaled and will reach further into the lungs because of the dilatory effects of albuterol.
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? - correct answer A
client who is recovering from a cardiac catheterization
Electronic blood pressure measurement is attained through a sensor that detects vibrations
caused by blood rushing through the arteyr, is appropriate for use when the blood pressure
must be monitored frequently, and should not be taken on clients with conditions that can
result in an inaccurate reading. A client who is recovering from a cardiac cath requires frequent
blood pressure measurements. It is appropriate to perform an electronic blood pressure
measurement on this client.
A nurse is caring for a client who weighs 132 lb and has been prescribed gentamicin
(Garamycin) 5mg/kg/day by IV bolus in three equal doses. Available on hand is 40 mg/mL that is
to be added to 50 mL 0.9% sodium chloride. How many mL should the nurse add to the solution
per dose? - correct answer 2.5 mL
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? - correct answer Dark urine
, 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 administrator is reviewing policies and procedures of the facility she works in to ensure
confidentiality requirements are being met. Which of the following indicates that intervention
is needed to prevent the release of confidential client information? - correct answer Assigning
staff members on each shift the same password for accessing medical records
If all staff members on each shift have the same password, limitations exist is tracking who is
accessing those records, increasing the possibility that someone not involved in the care of a
client could access records out of curiosity. This procedure is not appropriate and requires
intervention to prevent the release of confidential information.
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? - correct answer Advocacy
Advocacy is supporting or seeking a specific course of action for the benefit and on behalf of a
person, group, or community. The nurse made the request to remove the playground
equipment on behalf of and to benefit the children of the school. This is an example of
advocacy.
A nursing supervisor is determining bed placement for four clients. Which of the following
clients should be placed on droplet precautions? - correct answer A client who has rubella
A nurse is assigned to care for four clients. The client with which of the following drainage tubes
is at an increased risk for hypokalemia? - correct answer NG tube to suction
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?c -
correct answer Slurred speech
Slurred speech can indicate a cerebrovascular accident (CVA), which is a severe complication of
sickle cell anemia. The blockage of blood vessels in the brain by sickled cells results in cerebral
infarction, which leads to neurological impairment. Because a CVA threatens the life of the
client, this is highest priority finding.
A nurse is caring for a client who has terminal pancreatic cancer. The client is competent and
has requested no resuscitative measures 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)? - correct answer A written prescription from the provider
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 attempts 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? - correct answer Warm refrigerated drops to
room temperature prior to instillation.
Because of the anatomy of internal ear structures, it is important to remember that the ear is
sensitive to extremes in temp. Ear drops should be warmed to room temp prior to instillation to
reduce the risk of painful stimuli
A nurse is caring for a client who has a new colostomy. The client is being discharged and plans
to live with her daughter. Which of the following responses by the nurse is appropriate when
the daughter states that she doesn't know how she is going to care for her mother's colostomy?
- correct answer "What part of your mother's care concerns you?"
A nurse is caring for a client who is diagnosed with bipolar disorder and is taking lithium
(Lithane). Which of the following serum lithium levels indicates the client's dosage is
appropriate for maintenance therapy? - correct answer 0.75 mEq/L
Lithium is a mood-stabilizing medication used in the treatment of bipolar I acute and recurrent
manic and depressive episodes. To achieve a therapeutic range, give 300 mg to 600 mg of
lithium during the active phase. The therapeutic serum lithium level is between 0.8 mEq/L and
1.4 mEq/L. Maintenance levels of 0.4 to 1.3 mEq/L are then achieved for clients who are
prescribed lithium for long-term therapy. Because small increments of dosage separate
therapeutic, maintenance, and toxic levels of lithium, knowledge of these levels is essential to
,ensure safe, quality care. This serum lithium level indicates the client's dosage is appropriate for
maintenance therapy.
A nurse is caring for a client who is scheduled for a lumbar puncture. The nurse should teach
the client that which of the following is a post-procedure complication? - correct answer
Headache
A headache is a manifestation experienced by 15 to 30% of clients following a lumbar puncture
that results from cerebrospinal fluid leakage at the puncture site. These headaches are
managed primarily with analgesics, hydration, and bed rest
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? - correct answer "I will use
my cromolyn inhaler before using my albuterol inhaler."
When both cromolyn and albuterol are prescribed, albuterol should be inhaled first to open the
airways because it is a bronchodilator. After waiting a few minutes, the cromolyn can then be
inhaled and will reach further into the lungs because of the dilatory effects of albuterol.
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? - correct answer A
client who is recovering from a cardiac catheterization
Electronic blood pressure measurement is attained through a sensor that detects vibrations
caused by blood rushing through the arteyr, is appropriate for use when the blood pressure
must be monitored frequently, and should not be taken on clients with conditions that can
result in an inaccurate reading. A client who is recovering from a cardiac cath requires frequent
blood pressure measurements. It is appropriate to perform an electronic blood pressure
measurement on this client.
A nurse is caring for a client who weighs 132 lb and has been prescribed gentamicin
(Garamycin) 5mg/kg/day by IV bolus in three equal doses. Available on hand is 40 mg/mL that is
to be added to 50 mL 0.9% sodium chloride. How many mL should the nurse add to the solution
per dose? - correct answer 2.5 mL
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? - correct answer Dark urine
, 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 administrator is reviewing policies and procedures of the facility she works in to ensure
confidentiality requirements are being met. Which of the following indicates that intervention
is needed to prevent the release of confidential client information? - correct answer Assigning
staff members on each shift the same password for accessing medical records
If all staff members on each shift have the same password, limitations exist is tracking who is
accessing those records, increasing the possibility that someone not involved in the care of a
client could access records out of curiosity. This procedure is not appropriate and requires
intervention to prevent the release of confidential information.
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? - correct answer Advocacy
Advocacy is supporting or seeking a specific course of action for the benefit and on behalf of a
person, group, or community. The nurse made the request to remove the playground
equipment on behalf of and to benefit the children of the school. This is an example of
advocacy.
A nursing supervisor is determining bed placement for four clients. Which of the following
clients should be placed on droplet precautions? - correct answer A client who has rubella
A nurse is assigned to care for four clients. The client with which of the following drainage tubes
is at an increased risk for hypokalemia? - correct answer NG tube to suction
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?c -
correct answer Slurred speech
Slurred speech can indicate a cerebrovascular accident (CVA), which is a severe complication of
sickle cell anemia. The blockage of blood vessels in the brain by sickled cells results in cerebral
infarction, which leads to neurological impairment. Because a CVA threatens the life of the
client, this is highest priority finding.
