Nurse Logic Testing and Remediation Advanced Test

A nurse is caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the clients TPN is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations?

Shakiness and diaphoresis

These are manifestations of hypoglycemia, which can occur if there is a sudden interruption in the delivery of TPN, resulting in the client receiving below the prescribed amount.

A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching?

"This illness will not recur because my child has now had it"

It is possible for rheumatic fever to recur, so prophylactic treatment with monthly IM injections of benzathine penicillin G, or daily oral doses of penicillin or sulfadiazine, will be needed.

A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse?

Place the client in a knee-chest position

Placing the client in a knee-chest position will aid in keeping the pressure of the presenting part of the fetus off the cord. Using the ABC priority setting framework, the greatest risk is the cessation of circulation to the fetus; therefore, this is the priority action the nurse should take. BUT wrapping the umbilical cord in the 0.9% sodium chloride solution is also CORRECT but not priority i guess..

A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril?

Aspirin (Bayer)

Aspirin and other NSAIDS can reduce the antihypertensive effects of captopril, which is an ACE inhibitor. The nurse should reinforce to the client that aspirin has the potential to reduce the antihypertensive effect of captopril and should be avoided.

A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following clinical findings should be immediately reported to the provider?

Slurred speech

lurred speech is an early clinical finding associated with lithium toxicity and can precipitate the onset of seizures or coma. Using the safety and risk reduction priority setting framework, this finding jeopardizes the immediate physiological safety of the client and should be reported to the provider immediately.

A nurse is reviewing the electronic fetal heart rate tracing of a client who is in labor. Which of the following images exhibits variable decelerations?

*Variable decelerations are caused from cord compression.

Late decelerations are caused from uteroplacental insufficiency.

Prolonged decelerations are a decrease in the fetal heart rate of 15/min below baseline. Prolonged decelerations last more than 2 min but less than 10 min. This can result from maternal hypotension, umbilical cord prolapsed, placental rupture, placental hemorrhage, and tetanic contraction.

Early decelerations are caused from head compression.

A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching?

"I should eat low carbohydrate foods" is correct. Clients who are experiencing nausea should eat foods high in carbohydrates, such as crackers, yogurt, toast, bananas, and sherbet. This is not an appropriate statement by the client and indicates a need for further teaching

A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching?

Soybeans

Food sources of complete proteins contain sufficient quantities of all nine essential amino acids to support body growth and maintenance. Soybeans are a source of complete protein and should be included in the teaching.

A nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching? (Select all that apply.)

Urinary Tract, Surgical Wounds, Respiratory Tract, an Blood Stream are all correct

Urinary tract is correct. Health care associated infections are caused from health care delivery in a health care facility. These result from prescribed antibiotic administration, presence of multi-medication resistant organisms, breeches in infection control practices, and invasive procedures. The urinary tract is a common site for health care associated infections. ***(UTIs and CAUTIs from caths)

Surgical wound is correct. ***(any open wound can contract bacteria if not properly cleaned/maintained)

Musculoskeletal system is INCORRECT. While injuries can occur in the health care setting that affect the musculoskeletal system, this is not a common site for health care associated infections.

Respiratory tract is correct. ***( droplet and airborne precautions are a must, TB, pertussis, rubella etc..)

Blood stream is correct. ***(any open wound again, any time an IV is placed or injected etc. hard line to the blood stream and cause for sepsis)

A nurse is caring for an infant who has been prescribed a one-time dose of ceftriaxone (Rocephin) 50 mg/kg IM. The infant weighs 17.6 lb. Available is 500 mg/mL. How many mL should the nurse administer?

0.8mL

STEP 1: Determine the infant's weight in kg: 2.2 lb / x kg = weight in lb / 1 kg; 2.2 lb / x kg = 17.6 lb / 1 kg. Cross multiply and x = 8 kg

STEP 2: Find total of one-time dose: Amount prescribed x kg weight (mg x kg) = total daily dose; 50 mg x 8 kg = 400 mg

STEP 3: What is the dose needed? Dose needed = Desired; Desired = 400 mg

STEP 4: What is the dose available? Dose available = Have; Have = 500 mg

STEP 5: Do the units of measure need to be converted? No (mg = mg)

STEP 6: What is the quantity of the dose available? Quantity = 1 mL

STEP 7: Set up an equation using knowledge about basic equivalents. Desired x Quantity / Have = Amount to be given; 400 mg x 1 mL / 500 mg = x mL; 400 x 1 = 400 ÷ 500 = 0.8 mL

STEP 8: Reassess to determine if the amount to be given seems plausible. If there are 500 mg in 1 mL and the prescribed dose is 400 mg, it makes sense to administer 0.8 mL. The nurse should administer 0.8 mL ceftriaxone IM.

A nurse is caring for a client who is admitted with acute alcohol withdrawal. Which of the following findings should the nurse report to the provider?

Tachycardia

Symptoms of acute alcohol withdrawal include tachycardia, hypertension, diaphoresis, disorientation, and hand tremors. These can progress to visual or tactile hallucinations, paranoid delusions, agitation, hyperthermia, and grand mal seizures. Acute alcohol is a medical emergency and can cause death if not treated with the appropriate interventions.

A nurse is collecting data on a client who has appendicitis. Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's point.

SIte A

This is the site the nurse should palpate. McBurney's point is located in the lower right quadrant midway between the anterior iliac crest and the umbilicus. Pressure over this point will elicit pain in the later stages of appendicitis. Remember, the screen is not a mirror image; you had to identify the client's right side.

A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Which of the following clinical findings are associated with the illness? (Select all that apply.)

Drooling is correct. Drooling is a clinical finding associated with epiglottitis.

Stridor is correct. Stridor is a clinical finding associated with epiglottitis.

Difficulty swallowing is correct. Difficulty swallowing is a clinical finding associated with epiglottitis.

Croupy cough is incorrect. Croupy cough is a clinical finding associated with acute spasmodic laryngitis, and acute tracheitis, but it is not a clinical finding associated with epiglottitis.

High-grade fever is correct. High-grade fever is a clinical finding associated with epiglottitis.

A nurse in a rehabilitation center is caring for a client who has just had a cerebrovascular accident. Based on a review of the client's medical record, which of the following findings should be immediately reported to the provider?

Temperature 37.6° C (99.8° F)

Sore throat, malaise, mouth sores, and fever are clinical findings associated with agranulocytosis, a potentially dangerous blood dyscrasia that is an adverse effect of clozapine. Using the urgent versus nonurgent priority setting framework, this is the priority finding and should be reported immediately to the provider.

A nurse is a caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder?

Unstable interpersonal relationships

Borderline personality disorder is characterized by unstable interpersonal relationships, emotional instability, impulsivity, unstable mood, and self image distortions.

A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles is the nurse functioning?

Advocate

A nurse advocate acts as a liaison between clients and providers in order to improve or maintain the quality of care that clients receive. The nurse is functioning in the role of the nurse advocate for the clients during the prenatal period.

A nurse is reviewing the laboratory results of four clients. Which of the following should be immediately reported to the provider?

A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L

This value is clearly abnormal and indicates that the client has hypokalemia, or decreased potassium. This is a common complication with the use of loop diuretics, such as furosemide. The nurse should also note that the client receives digoxin. Hypokalemia places the client at increased risk for digoxin toxicity, so this is the client who is at immediate risk for injury and whose laboratory findings should be reported to the provider.

Normal Potassium range is 3.5-5 mEq/L

Digoxin levels therapeutic range is 0.5-0.9 ng/ml. Toxic is greater than 2.0 ng/ml

A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak?

Oliguria is correct. When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death. Oliguria, or decreased urine production, is a finding consistent with peritonitis and can indicate the client is experiencing an anastomotic leak.

A nurse is caring for a client who is from a culture different than his own. Which of the following actions by the nurse is most important in the provision of culturally competent care?

Identify one's own beliefs and values is correct.

To provide culturally competent care, it is essential to identify one's own cultural background, values, and beliefs, especially those that are related to health and health care. This is the most important action by the nurse.

A nurse in a pediatric provider's office is conducting telephone triage and receives a call from a client regarding her 4-day-old newborn who was circumcised 2 days ago. Listen to the audio clip and determine which of the following responses by the nurse is appropriate.

"i was changing my baby diaper and there was a yellow crust around his penis, what do i do?"

"Do not attempt to remove it"

Yellow exudate covers the penis 24 hr after the circumcision and will persist for 2 to 3 days. This is an expected finding and should not be removed. The nurse should provide teaching to the client regarding circumcision care.