1
NURS 221 Nurse logic Knowledge and clinical judgment
beginner
1.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?
a. mcg
b. q.d.
c. mL
d. PO
Answer is B-q.d. is the incorrect term. To indicate daily, you should use the
word "daily" when charting. Q.d. used to be confused for qid, which means
4x a day.
Ⓒ
2.A nurse is caring for a client who is diagnosed with anemia. Which of the
following skin color variations is caused by a reduced amount of
oxyhemoglobin?
a. Cyanosis
b. Jaundice
c. Erythema
d. Pallor
Answer is D-Pallor
-Oxyhemoglobin is the combined state of oxygen that is to be delivered to
peripheral tissues with the hemoglobin molecule that will carry it. In clients
who have anemia, the RBCs are reduced, by function or in number, to the
point that peripheral tissues are not receiving adequate oxygen because of a
decreased amount of circulating oxyhemoglobin. 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.
Ⓒ
Pallor
Paleness of the skin - Decrease in the coloring of the peripheral tissues. 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.
Oxyhemoglobin
the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin
molecule that will carry it.
Ⓒ
3.A nurse is collecting data on a recently admitted client. Which of the
following techniques should the nurse use to measure tissue perfusion?
a. Determining the client's respiratory rate
b. Measuring the client's chest diameter
c. Obtaining the client's level of oxygen saturation
d. Checking the client's depth of respirations
Answer is C-Obtaining the client's level of oxygen saturation
-Obtaining the client's level of oxygen saturation is an appropriate technique of measuring
perfusion.
, 2
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.
Oxygen saturation measures the percent of hemoglobin bound with oxygen
that
Ⓒ is being perfused through the arteries and into the tissues.
Foundational Thinking
Ability to recall and comprehend information and concepts
Ⓒ
Perfusion
delivery or pumping of arterial blood through tissues or an organ.
Ⓒ
Oxygen saturation
Measures the percent of hemoglobin bound with oxygen that is being perfused through the
arteries and into the tissues.
Ⓒ
4.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?
a. Isopropyl alcohol
b. Chlorhexidine gluconate (Hibiclens)
c. Chlorine (bleach)
d. Iodophor
Answer is C-Chlorine
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.
Ⓒ
, 3
5.A nurse is collecting nutritional data on an older adult client. Which of
the following findings is suggestive of a healthy nutritional status?
a. Spongy gums that are receding
b. Fissures at eyelid corners
c. Easily plucked hair
d. reddish-colored tongue
Answer is D-Reddish-colored tongue
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.
Ⓒ
6.A nurse is assisting with the preparation of an education program regarding
advance directives for newly hired staff. Which of the following information
should be included about living wills?
a. Living
wills require a written prescription from the provider to be legal.
b. Living
wills allow the client to designate a health care proxy.
c. Living
wills ensure hospitals provide emergency care regardless of health coverage.
d. Living
wills detail treatment wishes of the client in the event of terminal illness.
Answer is D-Living wills detail treatment wishes of the client in the event of terminal illness.
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.
Ⓒ
Advance directives
Include both living wills and durable powers of attorney for health care.
Ⓒ
Living Wills
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.
Ⓒ
7.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?
a. Dorsal recumbent
b. Orthopneic
c. Side-lying
d. Supine
Answer is D-Supine
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.
Ⓒ
8.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?
a. To the left
b. To the right
c. Away from the body
NURS 221 Nurse logic Knowledge and clinical judgment
beginner
1.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?
a. mcg
b. q.d.
c. mL
d. PO
Answer is B-q.d. is the incorrect term. To indicate daily, you should use the
word "daily" when charting. Q.d. used to be confused for qid, which means
4x a day.
Ⓒ
2.A nurse is caring for a client who is diagnosed with anemia. Which of the
following skin color variations is caused by a reduced amount of
oxyhemoglobin?
a. Cyanosis
b. Jaundice
c. Erythema
d. Pallor
Answer is D-Pallor
-Oxyhemoglobin is the combined state of oxygen that is to be delivered to
peripheral tissues with the hemoglobin molecule that will carry it. In clients
who have anemia, the RBCs are reduced, by function or in number, to the
point that peripheral tissues are not receiving adequate oxygen because of a
decreased amount of circulating oxyhemoglobin. 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.
Ⓒ
Pallor
Paleness of the skin - Decrease in the coloring of the peripheral tissues. 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.
Oxyhemoglobin
the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin
molecule that will carry it.
Ⓒ
3.A nurse is collecting data on a recently admitted client. Which of the
following techniques should the nurse use to measure tissue perfusion?
a. Determining the client's respiratory rate
b. Measuring the client's chest diameter
c. Obtaining the client's level of oxygen saturation
d. Checking the client's depth of respirations
Answer is C-Obtaining the client's level of oxygen saturation
-Obtaining the client's level of oxygen saturation is an appropriate technique of measuring
perfusion.
, 2
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.
Oxygen saturation measures the percent of hemoglobin bound with oxygen
that
Ⓒ is being perfused through the arteries and into the tissues.
Foundational Thinking
Ability to recall and comprehend information and concepts
Ⓒ
Perfusion
delivery or pumping of arterial blood through tissues or an organ.
Ⓒ
Oxygen saturation
Measures the percent of hemoglobin bound with oxygen that is being perfused through the
arteries and into the tissues.
Ⓒ
4.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?
a. Isopropyl alcohol
b. Chlorhexidine gluconate (Hibiclens)
c. Chlorine (bleach)
d. Iodophor
Answer is C-Chlorine
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.
Ⓒ
, 3
5.A nurse is collecting nutritional data on an older adult client. Which of
the following findings is suggestive of a healthy nutritional status?
a. Spongy gums that are receding
b. Fissures at eyelid corners
c. Easily plucked hair
d. reddish-colored tongue
Answer is D-Reddish-colored tongue
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.
Ⓒ
6.A nurse is assisting with the preparation of an education program regarding
advance directives for newly hired staff. Which of the following information
should be included about living wills?
a. Living
wills require a written prescription from the provider to be legal.
b. Living
wills allow the client to designate a health care proxy.
c. Living
wills ensure hospitals provide emergency care regardless of health coverage.
d. Living
wills detail treatment wishes of the client in the event of terminal illness.
Answer is D-Living wills detail treatment wishes of the client in the event of terminal illness.
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.
Ⓒ
Advance directives
Include both living wills and durable powers of attorney for health care.
Ⓒ
Living Wills
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.
Ⓒ
7.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?
a. Dorsal recumbent
b. Orthopneic
c. Side-lying
d. Supine
Answer is D-Supine
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.
Ⓒ
8.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?
a. To the left
b. To the right
c. Away from the body
