Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A case manager is preparing a discharge plan for a client following coronary artery bypass grafting surgery. Which of the following client issues should the nurse address first?
A. Inadequate food supply
Inadequate food supply is a basic physiological need that directly affects recovery, wound healing, and overall postoperative outcomes after coronary artery bypass grafting. Ensuring access to adequate nutrition is essential for physical recovery and takes priority in discharge planning.
B. Limited social support
Limited social support is important for long-term recovery and adherence to care but does not address an immediate physiological need. It is typically addressed after basic needs are secured.
C. Low pain tolerance
Low pain tolerance affects comfort and recovery experience but is managed through pain control strategies and does not take priority over essential survival needs like nutrition.
D. Decreased self-esteem
Decreased self-esteem is a psychosocial concern that, while important for holistic recovery, is addressed after physiological and safety needs have been met.
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Full Explanation
A. Inadequate food supply is a basic physiological need that directly affects recovery, wound healing, and overall postoperative outcomes after coronary artery bypass grafting. Ensuring access to adequate nutrition is essential for physical recovery and takes priority in discharge planning.
B. Limited social support is important for long-term recovery and adherence to care but does not address an immediate physiological need. It is typically addressed after basic needs are secured.
C. Low pain tolerance affects comfort and recovery experience but is managed through pain control strategies and does not take priority over essential survival needs like nutrition.
D. Decreased self-esteem is a psychosocial concern that, while important for holistic recovery, is addressed after physiological and safety needs have been met.
Similar Questions
A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?
A. Recommend that he take time to plan at the beginning of his shift.
Recommending that the newly licensed nurse take time to plan at the beginning of the shift can help improve focus and organization, allowing for better task completion.
B. Offer to provide care for his clients while he takes a break.
Offering to take over care while he takes a break might provide immediate relief but doesn't address the underlying issue of focus and task completion.
C. Advise him to complete less time-consuming tasks first.
Advising to complete less time-consuming tasks first might not necessarily address the root cause of the difficulty in focusing.
D. Ask other staff members to take over some of his tasks.
Asking other staff members to take over tasks doesn't encourage skill development or help the newly licensed nurse develop coping strategies for focus and task completion.
Full Explanation
A. Recommending that the newly licensed nurse take time to plan at the beginning of the shift can help improve focus and organization, allowing for better task completion.
B. Offering to take over care while he takes a break might provide immediate relief but doesn't address the underlying issue of focus and task completion.
C. Advising to complete less time-consuming tasks first might not necessarily address the root cause of the difficulty in focusing.
D. Asking other staff members to take over tasks doesn't encourage skill development or help the newly licensed nurse develop coping strategies for focus and task completion.
A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?
A. A newly admitted client who has diabetes mellitus and requires initial teaching on self- administration of insulin
Teaching a client about self-administration of insulin requires a more advanced level of nursing knowledge and is within the scope of practice for a licensed practical nurse (LPN) or a registered nurse (RN).
B. A client who is scheduled for an endoscopy later today and requires an enema
Administering an enema requires assessment skills and the ability to monitor the client's response, typically within the scope of an RN.
C. A newly admitted client who has sickle cell anemia and requires the development of an initial plan of care
Developing an initial plan of care for a client with sickle cell anemia requires a comprehensive understanding of the condition and its management, which typically falls within the scope of an RN.
D. A client who had a myocardial infarction and will be transferring to the unit from the CCU.
A client transferring from the Critical Care Unit (CCU) after a myocardial infarction would likely need closer monitoring and assessment, tasks generally within the RN's scope of practice.
Full Explanation
- A: This client requires initial teaching, which is typically the responsibility of a registered nurse due to the educational aspect and the need to assess the client's understanding.
- B: Administering an enema is a task that falls within the scope of practice for a licensed practical nurse and does not require the advanced assessment skills of a registered nurse.
- C: Developing an initial plan of care involves comprehensive assessment and critical thinking, which are responsibilities of a registered nurse.
- D: A client transferring from the CCU after a myocardial infarction would require close monitoring and assessment, which are beyond the scope of practice for a licensed practical nurse.
A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
A. Notify risk management before initiating treatment.
Notifying risk management before initiating treatment is not necessary in this emergent situation; patient care should take precedence.
B. Proceed with treatment without obtaining written consent.
In emergent situations where a patient lacks decision-making capacity and requiresimmediate treatment to prevent harm, consent for treatment can be assumed based on the principle of implied consent.
C. Contact the client's next of kin to obtain consent for treatment.
Contacting the client's next of kin for consent might delay necessary treatment for the disoriented and arrhythmic client, which could be harmful.
D. Have the client sign a consent for treatment.
Having the client sign a consent for treatment might not be feasible or appropriate if the client is disoriented and lacks decision-making capacity in an emergency situation.
Full Explanation
A. Notifying risk management before initiating treatment is not necessary in this emergent situation; patient care should take precedence.
B. In emergent situations where a patient lacks decision-making capacity and requires
immediate treatment to prevent harm, consent for treatment can be assumed based on the principle of implied consent.
C. Contacting the client's next of kin for consent might delay necessary treatment for the disoriented and arrhythmic client, which could be harmful.
D. Having the client sign a consent for treatment might not be feasible or appropriate if the client is disoriented and lacks decision-making capacity in an emergency situation.