Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 57-year-old female patient was admitted to the hospital with a left upper wound infection (methicillin-resistant Staphylococcus aureus [MRSA] and several gram-negative bacteria) and cellulitis 5 days ago.
Her wound is packed and requires a dressing change twice a day.
She is scheduled for discharge to home with her daughter to continue antibiotic therapy for another week.
What health teaching should the nurse include as part of the discharge instructions for the patient and her daughter?
Select all that apply.
A. Use a sterile technique when packing the wound and changing the dressing twice a day.
Using a sterile technique when packing the wound and changing the dressing twice a day is crucial to prevent further infection.
B. Stop taking the antibiotics when your arm feels better and is not reddened.
It is important to complete the full course of antibiotics, even if symptoms improve, to ensure the infection is fully treated and to prevent antibiotic resistance.
C. Notify your primary health care provider if your diarrhea gets worse.
Diarrhea can be a side effect of some antibiotics. If it gets worse, it could be a sign of an infection such as Clostridium difficile, which requires immediate medical attention.
D. Avoid strenuous activity and take frequent rest periods.
Rest is important for recovery. Strenuous activity could delay healing and increase the risk of complications.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Nur214 proctored exam. Take the full exam now
Full Explanation
Choice A rationale
Using a sterile technique when packing the wound and changing the dressing twice a day is crucial to prevent further infection.
Choice B rationale
It is important to complete the full course of antibiotics, even if symptoms improve, to ensure the infection is fully treated and to prevent antibiotic resistance.
Choice C rationale
Diarrhea can be a side effect of some antibiotics. If it gets worse, it could be a sign of an infection such as Clostridium difficile, which requires immediate medical attention.
Choice D rationale
Rest is important for recovery. Strenuous activity could delay healing and increase the risk of complications.
Similar Questions
Which of the following actions by the new nurse requires immediate intervention by the experienced nurse?
A. Does not let patient know that nurse is assessing respirations.
It is a common practice for nurses to assess a patient’s respirations without explicitly stating so. This is because patients may alter their breathing pattern if they know it’s being observed.
B. Auscultating heart sounds using bell of stethoscope.
Auscultating heart sounds using the bell of the stethoscope is a standard practice in nursing. The bell of the stethoscope is used specifically to listen to low-frequency sounds such as heart murmurs.
C. Assessing both carotid pulse sites at the same time.
Assessing both carotid pulse sites at the same time is dangerous and should be avoided. This action can lead to reduced blood flow to the brain, possibly causing the patient to faint or experience a decrease in cerebral blood flow.
D. Cleaning stethoscope between patient assessments.
Cleaning the stethoscope between patient assessments is a recommended practice to prevent the spread of infections.
Full Explanation
Choice A rationale
It is a common practice for nurses to assess a patient’s respirations without explicitly stating so. This is because patients may alter their breathing pattern if they know it’s being observed.
Choice B rationale
Auscultating heart sounds using the bell of the stethoscope is a standard practice in nursing. The bell of the stethoscope is used specifically to listen to low-frequency sounds such as heart murmurs.
Choice C rationale
Assessing both carotid pulse sites at the same time is dangerous and should be avoided. This action can lead to reduced blood flow to the brain, possibly causing the patient to faint or experience a decrease in cerebral blood flow.
Choice D rationale
Cleaning the stethoscope between patient assessments is a recommended practice to prevent the spread of infections.
Which of the following actions by the nurse best supports patient autonomy?
A. The nurse explains interventions prior to performing them.
Explaining interventions prior to performing them is a key aspect of patient autonomy. It allows patients to understand what is happening to them and gives them the opportunity to ask questions or refuse treatment if they wish.
B. Patient information is kept private.
While keeping patient information private is important and is part of the ethical principle of confidentiality, it does not directly support patient autonomy.
C. The nurse brings back medication at the time stated previously.
Bringing back medication at the stated time supports the principle of beneficence (doing good) and reliability but does not directly support patient autonomy.
D. All patients are given equal care.
Providing equal care to all patients is part of the ethical principle of justice, not autonomy.
Full Explanation
Choice A rationale
Explaining interventions prior to performing them is a key aspect of patient autonomy. It allows patients to understand what is happening to them and gives them the opportunity to ask questions or refuse treatment if they wish.
Choice B rationale
While keeping patient information private is important and is part of the ethical principle of confidentiality, it does not directly support patient autonomy.
Choice C rationale
Bringing back medication at the stated time supports the principle of beneficence (doing good) and reliability but does not directly support patient autonomy.
Choice D rationale
Providing equal care to all patients is part of the ethical principle of justice, not autonomy.
The nurse is assessing the apical pulse. Where should the stethoscope be placed?
A. Between the fourth and fifth intercostal space.
The apical pulse is located at the fifth intercostal space at the left midclavicular line.
B. Between the third and fourth intercostal space.
C. Between the second and third intercostal space.
D. Between the first and second intercostal space.
Full Explanation
Choice A rationale
The apical pulse is located at the fifth intercostal space at the left midclavicular line.