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(Answered) Nurse Logic 2.0: Knowledge and Clinical Judgement - Advanced Test

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Nurse Logic 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)? 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 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? 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? 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? 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? 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? 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? 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 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? 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 nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precautions? 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? 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? A nurse is collecting data on a newborn who was delivered 30 min ago at the gestational age of 37 weeks. Which of the following findings requires further intervention? A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective? A nurse is collecting data on a client who is diagnosed with schizophrenia and is taking clozapine (Clozaril). Which of the following findings indicates the client is experiencing an adverse effect of the medication? A nurse is caring for a client who is postoperative following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. The client reports a burning pain in his chest. Which of the following actions by the nurse is appropriate? A nurse is caring for a client who is pregnant with a single fetus and has a body mass index (BMI) of 23. When asked by the client how much weight she should gain during the pregnancy, which of the following responses by the nurse is appropriate? A nurse is caring for a client who is experiencing night sweats and hemoptysis and is suspected to have active pulmonary tuberculosis. Which of the following tests is used to confirm this diagnosis?

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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)?
- 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?
- 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?
- "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?
- 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?
- Headache

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