NurseLogic 2.0 Nursing Concepts
Beginning Test
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? - ANS-Determine the
client's condition
The client is the immediate concern, and determining his condition is crucial to the delivery
of safe, effective care.
The content of this question emphasizes the concept of safety by following the appropriate
steps after a medication administration error. Safety in nursing practice is the minimization of
risk factors that can cause injury or harm while promoting quality care and maintaining a
secure environment for clients, self, and others. By ensuring clients remain the top priority in
the provision of care, nurses are able to assist in achieving National Patient Safety Goals,
preventing or minimizing physical injury. This is the first action the nurse should take when
discovering a medication error.
~Other answers (not most correct answer):
- Complete an Incident Report: This is not the first action the nurse should take when
discovering a medication error. While creating an incident report is important and should
typically occur within 24 hr of the incident, there is another action that better ensures the
safety of the client.
- Inform the Nurse Manager & Notify the Provider
\A nurse in a local Clinic is caring for a female client who is 35 years old. Which of the
following screening should the nurse recommend to the client? - ANS-Dermatologist
evaluation every three years to detect skin cancer
Men and women between the ages of 20 and 40 should have skin cancer screening by a
dermatologist every 3 years. Clients above the age of 40 should have annual evaluations
The content of this question emphasizes the concept of client-centered care through the
recommendation of age-appropriate health screenings. Client-centered care focuses on the
client and emphasizes the client's cultural, ethnic, and social values. By recommending
age-appropriate screenings, nurses facilitate the provision of individualized, high-quality
care. A dermatologist evaluation every 3 years is an appropriate screening to recommend to
a 35-year-old client.
- A mammogram every year is not an appropriate screening to recommend to a 35-year-old
client. Women ages 40 or older should have annual mammograms.
, - A colonoscopy every 10 years is not an appropriate screening to recommend to a
35-year-old client. Men and women ages 50 and older should have a colonoscopy every 10
years.
- A complete eye examination every year is not an appropriate screening to recommend to a
35-year-old client. Clients ages 40 or below should have a complete eye examination every
3 to 5 years. Clients between the ages of 40 and 64 should have a complete eye
examination every 2 years, and clients older than 65 should have a complete eye
examination annually.
\A nurse in a provider's office is orientating a newly licensed nurse on how to position a client
in a vaginal examination. The nurse include in the teaching to place a client in which
following position? - ANS-Lithotomy
The lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of
the female genitalia. The nurse should drape the client appropriately to minimize exposure
and embarrassment.
The content of this question emphasizes the concept of leadership by providing education to
a newly licensed nurse. Leadership is the process by which nurses use a set of skills that
directs and influences others in the provision of individualized, safe, quality client care.
Nurses assume various types of leadership roles in the provision of client care, including
delegator, coordinator, educator, advocate, and change agent. This is the appropriate
position for the nurse to place the client.
~ other answer (wrong/not most right) rationales:
- The dorsal recumbent position can be used as an alternative to the supine position when
assessing the head and neck, lungs, breasts, axillae, heart, and abdomen.
- The prone position is used to assess hip joint extension, skin, and buttocks.
- The lateral recumbent position is used to detect heart murmurs when assessing the heart.
\A nurse is caring for a client following a Bronchoscopy . Which of the following findings
requires immediate intervention? - ANS-Difficulty breathing
This finding can lead to hypoxia; therefore, immediate intervention is warranted. The
difficulty in breathing can be caused by edema in the larynx or trachea and is a serious
complication
The content of this question emphasizes the concept of priority setting by requiring the
determination of which finding requires immediate intervention. Priority setting is the use of
nursing judgment when making decisions about the rank order in which to take nursing
actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing
process, ABC, and safety and risk reduction, can be useful in determining the priority of
needed actions.
~ other answer (wrong/not most right) rationales:
Beginning Test
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? - ANS-Determine the
client's condition
The client is the immediate concern, and determining his condition is crucial to the delivery
of safe, effective care.
The content of this question emphasizes the concept of safety by following the appropriate
steps after a medication administration error. Safety in nursing practice is the minimization of
risk factors that can cause injury or harm while promoting quality care and maintaining a
secure environment for clients, self, and others. By ensuring clients remain the top priority in
the provision of care, nurses are able to assist in achieving National Patient Safety Goals,
preventing or minimizing physical injury. This is the first action the nurse should take when
discovering a medication error.
~Other answers (not most correct answer):
- Complete an Incident Report: This is not the first action the nurse should take when
discovering a medication error. While creating an incident report is important and should
typically occur within 24 hr of the incident, there is another action that better ensures the
safety of the client.
- Inform the Nurse Manager & Notify the Provider
\A nurse in a local Clinic is caring for a female client who is 35 years old. Which of the
following screening should the nurse recommend to the client? - ANS-Dermatologist
evaluation every three years to detect skin cancer
Men and women between the ages of 20 and 40 should have skin cancer screening by a
dermatologist every 3 years. Clients above the age of 40 should have annual evaluations
The content of this question emphasizes the concept of client-centered care through the
recommendation of age-appropriate health screenings. Client-centered care focuses on the
client and emphasizes the client's cultural, ethnic, and social values. By recommending
age-appropriate screenings, nurses facilitate the provision of individualized, high-quality
care. A dermatologist evaluation every 3 years is an appropriate screening to recommend to
a 35-year-old client.
- A mammogram every year is not an appropriate screening to recommend to a 35-year-old
client. Women ages 40 or older should have annual mammograms.
, - A colonoscopy every 10 years is not an appropriate screening to recommend to a
35-year-old client. Men and women ages 50 and older should have a colonoscopy every 10
years.
- A complete eye examination every year is not an appropriate screening to recommend to a
35-year-old client. Clients ages 40 or below should have a complete eye examination every
3 to 5 years. Clients between the ages of 40 and 64 should have a complete eye
examination every 2 years, and clients older than 65 should have a complete eye
examination annually.
\A nurse in a provider's office is orientating a newly licensed nurse on how to position a client
in a vaginal examination. The nurse include in the teaching to place a client in which
following position? - ANS-Lithotomy
The lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of
the female genitalia. The nurse should drape the client appropriately to minimize exposure
and embarrassment.
The content of this question emphasizes the concept of leadership by providing education to
a newly licensed nurse. Leadership is the process by which nurses use a set of skills that
directs and influences others in the provision of individualized, safe, quality client care.
Nurses assume various types of leadership roles in the provision of client care, including
delegator, coordinator, educator, advocate, and change agent. This is the appropriate
position for the nurse to place the client.
~ other answer (wrong/not most right) rationales:
- The dorsal recumbent position can be used as an alternative to the supine position when
assessing the head and neck, lungs, breasts, axillae, heart, and abdomen.
- The prone position is used to assess hip joint extension, skin, and buttocks.
- The lateral recumbent position is used to detect heart murmurs when assessing the heart.
\A nurse is caring for a client following a Bronchoscopy . Which of the following findings
requires immediate intervention? - ANS-Difficulty breathing
This finding can lead to hypoxia; therefore, immediate intervention is warranted. The
difficulty in breathing can be caused by edema in the larynx or trachea and is a serious
complication
The content of this question emphasizes the concept of priority setting by requiring the
determination of which finding requires immediate intervention. Priority setting is the use of
nursing judgment when making decisions about the rank order in which to take nursing
actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing
process, ABC, and safety and risk reduction, can be useful in determining the priority of
needed actions.
~ other answer (wrong/not most right) rationales:
