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A nurse is providing discharge education to parents of preschooler who is prescribed tylenol 300mg every 4hr as needed. The liquid suspension that has been prescribed provides 120 mg/5mL. How many teaspoons should the nurse teach the parents to administer per dose? - Verified Answer: 2. Detailed Rationale: In this item, you need knowledge of basic mathematic skills and the formula used for this type of calculation. Based on your understanding of these concepts, you can determine the number of teaspoons the nurse should teach the parents to administer. This item requires critical thinking because you have to analyze the provided information to determine the dosage, select the formula, enter data into the formula, and then perform the needed calculations. STEP 1: What is the dose needed? Dose needed = Desired; 300 mg
STEP 2: What is the dose available? Dose available = Have; 120 mg STEP 3: Do the units of measurement need to be converted? No (mg = mg). STEP 4: What is the quantity of the dose available? 5 mL STEP 5: Set up an equation and solve: Desired x Quantity / Have = Amount to be given; 300 mg x 5 mL / 120 mg = x mL; x = 12.5 mL. Convert to tsp: Equivalents: 1 tsp = 5 mL; 5 mL / 1 tsp = 12.5 mL / x; 5x = 12.5; x = 2.5 tsp. A nurse is collecting date on a recently admitted patient. Which of the following techniques should the nurse use to measure tissue perfusion?
- Verified Answer: Obtaining the client's level of oxygen saturation Detailed Rationale: In this item, you need nursing knowledge related to what the term tissue perfusion means. Based on an understanding of this, you can identify which of the following findings is an indicator of adequate tissue 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.
This response by the nurse is appropriate and fosters the nurse-client relationship. A nurse preceptor is orienting a newly licensed nurse. Which of the following actions indicates a breach of confidentiality and requires intervention by nurse preceptor? - Verified Answer: Discussing changes in clients plan of care with friend who is a nurse on another unit Detailed Rationale: In this item, you need knowledge of legal requirements in regard to confidentiality. Based on this information, you can identify which option describes an action that indicates a breach of client confidentiality. This is a negatively worded item that asks you to select the option that indicates an intervention by the nurse preceptor is warranted. You will learn more about negatively worded items in Module 4. This item requires critical thinking because you have to analyze each action in order to interpret the one that results in a breach of confidentiality. HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. A nurse discussing changes in a client's plan of care with another nurse on another unit is a breach of confidentiality. Client information can only be shared with other health care professionals involved in that client's care. The nurse on the other unit should be directed to the client to request information about changes in the client's plan of care. This action is not appropriate and requires intervention by the nurse preceptor. When collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following
actions should the nurse take? - Verified Answer: Cover area with transparent wound barrier Detailed Rationale: In this item, you need knowledge of appropriate skin care interventions for clients who are immobile with indications of a stage I pressure ulcer. This item requires foundational thinking because you have to recall interventions that are appropriate for maintaining skin integrity in clients who are immobile. Damage to tissues caused by continuous pressure is described as a pressure ulcer. The risk for pressure ulcers can be complicated by factors such as immobility, inadequate nutrition, bowel and bladder incontinence, decreased mental status, reduced sensation, increasing age, and excessive body heat. Appropriate care of pressure ulcers is based on the characteristics and stage of the wound. A wound that manifests as a reddened area is a stage 1 pressure ulcer. A transparent wound barrier applied to reddened skin or a stage 1 pressure ulcer to prevent contamination and reduce friction to the area is an appropriate action by the nurse. A nurse is caring for a patient who diagnosed with urinary tract infection and is prescribed ciprofloxacin 250 mg PO two times daily. The amount is available is 100 mg/tablet. How many tablets should the nurse administer? - Verified Answer: 2. Detailed Rationale: In this item, you need knowledge of basic mathematic skills and the formula used for this type of calculation. Based on your understanding of these concepts, you can determine the number of tablets the nurse should administer. This item requires
Detailed Rationale: In this item, you need nursing knowledge related to the proper administration and storage of nitroglycerin. Based on an understanding of this information, you can identify which option describes a statement by the patient that does not reflect accurate understanding of the medication. This is a negatively worded item that asks you to select the option that indicates the patient needs further teaching. You will learn more about negatively worded items in Module
- This item requires foundational thinking because you have to recall knowledge related to the administration and storage of nitroglycerin. This statement by the client indicates a need for further teaching. Buying nitroglycerin in bulk quantities is not a safe practice. The chemical instability of the medication allows it to lose effectiveness over time. While some nitroglycerin tablets have a shelf life of 24 months, NitroQuick retains its effectiveness for only 8 to 10 months. Because of the shortened shelf life, the client should not buy the medication in bulk quantities, and the client should be instructed to date the bottle when it is first opened. 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? - Verified Answer:
Supine Detailed Rationale: To answer this item, you need knowledge of inserting an indwelling urinary catheter on a male client. This item requires foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. 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. 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 should be included? - Verified Answer: Prepare a healthy meal to serve at the end of class
additional teaching. You will learn more about negatively worded items in Module 4. This item requires foundational thinking because you have to recall knowledge related to the use of appropriate body mechanics. To prevent a lift injury when transferring the client from the bed to a chair, alignment of the back, neck, pelvis, and feet should be maintained to reduce the risk of injury to the lumbar vertebrae. This action by the newly licensed nurse is not appropriate and indicates a need for additional teaching. 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? - Verified Answer: Away from body Detailed Rationale: to answer this item, you need knowledge of sterile procedures. This item required foundational thinking because you only need to recall knowledge related to the implementation of a nursing procedure. 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. Which of the following solutions should the nurse use to clean a blood spill that occurred while inserting a catheter? - Verified Answer: Bleach Detailed Rationale: This item requires foundational thinking because you have to recall knowledge specific to disinfectants that are effective against bloodborne pathogens. Disinfectants are concentrated solutions that can be toxic to the skin and are typically used to destroy certain pathogens on inanimate objects. 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.
a nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? - Verified Answer: Deep red tongue Detailed Rationale: In this item, you need nursing knowledge of clinical findings that are associated with healthy nutrition. Based on an understanding of this information, you can identify which option describes an expected finding in clients who are properly nourished. This item requires foundational thinking because you only need to recall knowledge related to expected clinical findings. 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. A nurse is collecting data on a client who had received a preoperative dose of morphine. Which of the following indicated the client is experiencing an adverse effect of the medication? - Verified Answer: Urinary retention Detailed Rationale: In this item, you need nursing knowledge related to morphine to recall adverse effects associated with the medication. This item requires foundational thinking because you only need to recall knowledge related to adverse effects of morphine. Morphine is an
opioid used to treat moderate to severe pain, and can reduce anxiety, produce a sense of well-being, as well as cause drowsiness and mental clouding. Morphine has an agonist effect on opioid receptors in the CNS, causing many of the adverse effects associated with the medication. Urinary retention is an adverse effect of morphine. By increasing bladder sphincter and detrusor muscle tone and reducing awareness of bladder stimuli, morphine can cause urinary hesitancy, urinary retention, and urinary urgency. 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? - Verified Answer: q.d Detailed Rationale: In this item, you need knowledge of abbreviations that the Joint Commission has determined should not be used in documentation. This is a negatively-worded item that asks you to select the option that indicates the newly licensed nurse needs additional teaching. You will learn more about negatively-worded items in Module
- This item requires foundational thinking because you only need to recall knowledge related to the abbreviations that are not acceptable for use when charting. To reduce the occurrence of medical errors, the Joint Commission developed a list of do-not-use abbreviations that
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. A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider? - Verified Answer: Dimpling of the tissue in the upper outer quadrant Detailed Rationale: In this item, you need nursing knowledge related to data collection of the breasts and knowledge of deviations from the expected that are indicative of cancer. Based on an understanding of these concepts, you can identify which option describes a finding that is not within the expected range and can indicate a cancerous lesion. This item requires foundational thinking because you have to identify which finding is outside the expected range. Dimpling of the tissue in the upper outer quadrant should be considered an unexpected finding and reported to the provider. In fact, dimpling that is noted anywhere within the breast tissue should be reported. Dimpling makes the tissue appear
retracted in a particular area and can result from underlying scar tissue or an invasive tumor causing ligaments to pull the skin inward toward the tumor. This variation of the breast tissue is consistent with breast cancer. A nurse is assisting with the preparations of an education program regarding advance directives for new hires. Which of the following information should be included about living wills? - Verified Answer: Living wills detail treatment wished of a client in the event of terminal illness Detailed Rationale: In this item, you need knowledge of advance directives. Based on this information, you can select the option that would be appropriate to include when teaching staff about living wills. This is a foundational item because you have to recall knowledge specific to the content and purpose of a living will. 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.
enteral feedings. To prevent this, administration should be slowed or switched to continuous enteral feedings. Nurse Logic: Nursing Concept A beginning student nurse is providing client-centered care for an adolescent who was admitted for tests to determine if he has type 1 diabetes mellitus. Which of the following statements by the student indicates a need for further teaching? - Verified Answer: "I will keep my communication with the client to a minimum." The student should use knowledge and a variety of skills when providing client-centered care. These include the nursing process, therapeutic communication, cultural competence, and advocacy. Based on proper use of these skills, the student should communicate as necessary in order to obtain a thorough history of his present illness and identify needs as perceived by the client. Keeping communication with the client to a minimum indicates a need for further teaching. Obtaining a health assessment should be one of the first things the student does to establish the client's physical, cognitive, and psychological baseline and identify current alterations in health and client needs. Having the provider talk to the client about his fears and concerns is an appropriate example of client advocacy. And finally, since
the client's family is from Vietnam, the client may have cultural preferences in relation to food and health care. An advanced student nurse assigned to clinical in a rehabilitation setting is preparing to participate in a team meeting. Which of the following statements by the student indicates a need for further teaching? - Verified Answer: "The provider will not be at the meeting because she is not a member of the interdisciplinary team." The provider is a member of the interdisciplinary team. The statement that indicates the provider is not a member of the interdisciplinary team indicates a need for further teaching. The nurse, social worker, and physical therapist are all members of the interdisciplinary team and as such, should be expected to provide a client report at the team meeting. A student is developing a plan of care for a client who has been diagnosed with cancer of the pancreas. Which of the following would be an appropriate resource to use in the development of an evidencebased plan of care? - Verified Answer: CINAHL, MedlinePlus, and OVID
