and Clinical Judgement
A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly
licensed nurse indicates a breach of confidentiality and requires intervention by the nurse preceptor?
Discussing changes in a client's plan of care with his friend who is a nurse on another unit
While 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? Cover the area with a transparent
wound barrier
A nurse is providing discharge education to the parents of a preschooler who is prescribed
acetaminophen (Tylenol) 300 mg every 4 hr as needed. The acetaminophen liquid suspension that has
been prescribed provides 120 mg/5 mL. How many teaspoons should the nurse teach the parents to
administer per dose? 2.5 tsp
A nurse is collecting data on a recently admitted client. Which of the following techniques should the
nurse use to measure tissue perfusion? Obtaining the client's level of oxygen saturation
A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, "I don't think I'm
going to have the surgery. Everybody has to die sometime." Which of the following responses by the
nurse is appropriate? "Tell me more about your concerns."
A nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribed
ciprofloxacin (Cipro) 250 mg PO two times daily. The amount available is 100 mg/tablet. How many
tablets should the nurse administer with each dose? 2.5 tablets
A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is
diagnosed with angina. Which of the following statements by the client indicates a need for further
teaching? "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities."
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? Supine
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 activities should be included as a learning strategy in
the program? Prepare a healthy meal to serve at the end of class
A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a
chair. Which of the following actions by the new nurse indicates a need for further teaching to
prevent lift injuries? Twisting at the waist and shoulders
A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing
to insert the catheter, the nurses should first open the sterile package in which of the following
directions? Away from the body
A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled
on the floor. Which of the following solutions should the nurse use to clean the spill? Chlorine
(bleach)
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