ATI Nursing Logic
Knowledge and Clinical Judgement
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
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?
"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?
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?
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?
, 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?
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?
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?
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?
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. 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 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?
Abdominal distension
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?
Toast with peanut butter
Dumping syndrome results from rapid emptying of the stomach into the small intestine after eating, and manifests as
a group of vasomotor symptoms, such as vertigo, tachycardia, syncope, sweating, pallor, and palpitations.
Additionally, abdominal distension occurs because of the shift of fluid into the intestines. A diet that restricts some
foods and includes others as appropriate food choices reduces the occurrence and severity of dumping syndrome.
Peanut butter and toast are allowed or encouraged foods for a client who has dumping syndrome.
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?
WBC 2,800/mm3
Adverse effects of clozapine include tachycardia, weight gain, sedation, and agranulocytosis. Agranulocytosis,
which is a decrease in one of the WBCs called neutrophils, reduces the ability to fight infection and can be fatal.
Because of the potential for agranulocytosis, clients who are taking clozapine are monitored frequently for a
decrease in WBC count below 3,000/mm3. The client's WBC and absolute neutrophil count is monitored weekly
during the first 6 months of therapy, then every 2 weeks during the next 6 months. A WBC level of 2,800/mm3
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?
Assist the client to a side-lying position.
Knowledge and Clinical Judgement
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
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?
"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?
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?
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?
, 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?
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?
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?
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?
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. 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 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?
Abdominal distension
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?
Toast with peanut butter
Dumping syndrome results from rapid emptying of the stomach into the small intestine after eating, and manifests as
a group of vasomotor symptoms, such as vertigo, tachycardia, syncope, sweating, pallor, and palpitations.
Additionally, abdominal distension occurs because of the shift of fluid into the intestines. A diet that restricts some
foods and includes others as appropriate food choices reduces the occurrence and severity of dumping syndrome.
Peanut butter and toast are allowed or encouraged foods for a client who has dumping syndrome.
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?
WBC 2,800/mm3
Adverse effects of clozapine include tachycardia, weight gain, sedation, and agranulocytosis. Agranulocytosis,
which is a decrease in one of the WBCs called neutrophils, reduces the ability to fight infection and can be fatal.
Because of the potential for agranulocytosis, clients who are taking clozapine are monitored frequently for a
decrease in WBC count below 3,000/mm3. The client's WBC and absolute neutrophil count is monitored weekly
during the first 6 months of therapy, then every 2 weeks during the next 6 months. A WBC level of 2,800/mm3
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?
Assist the client to a side-lying position.
