Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?
A. Auscultates bowel sounds for 3 to 5 min
Auscultating bowel sounds for 3 to 5 minutes is appropriate if sounds are not initially heard.
B. Clamps the NG tube during auscultation
Clamping the NG tube prevents false bowel sounds from the tube.
C. Performs auscultation between meals
Performing auscultation between meals ensures accurate assessment of bowel sounds.
D. Palpates the abdomen prior to performing auscultation.
Palpating the abdomen prior to auscultation can alter bowel sounds, making it important to auscultate before palpation.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg pharm comprehensive proctored exam. Take the full exam now
Full Explanation
Rationale:
A. Auscultating bowel sounds for 3 to 5 minutes is appropriate if sounds are not initially heard.
B. Clamping the NG tube prevents false bowel sounds from the tube.
C. Performing auscultation between meals ensures accurate assessment of bowel sounds.
D. Palpating the abdomen prior to auscultation can alter bowel sounds, making it important to auscultate before palpation.
Similar Questions
A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?
A. A client with diabetes mellitus who has a leg ulcer
A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent client who has a leg fracture and has been using crutches for the past 2 days
An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult client who is confused and has urinary frequency
An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A client who is 1 day postoperative and has a nursing assistant helping him out of bed
A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.
Full Explanation
A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.
A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?
A. A client who is being discharged to a long-term care facility
The float nurse may not be familiar with discharge planning specific to long-term care facilities.
B. A client who is postoperative following a lobectomy and has a chest tube
A nurse from the PACU is highly experienced with postoperative care and monitoring of clients with chest tubes, making this the most appropriate assignment.
C. A client who needs teaching about insulin self-administration
Teaching about insulin self-administration requires specific education techniques which the float nurse might not be most familiar with.
D. A client who needs teaching prior to initiating cardiac rehabilitation activities
Teaching for cardiac rehabilitation involves specialized knowledge that might be outside the float nurse’s expertise.
Full Explanation
Rationale:
A. The float nurse may not be familiar with discharge planning specific to long-term care facilities.
B. A nurse from the PACU is highly experienced with postoperative care and monitoring of clients with chest tubes, making this the most appropriate assignment.
C. Teaching about insulin self-administration requires specific education techniques which the float nurse might not be most familiar with.
D. Teaching for cardiac rehabilitation involves specialized knowledge that might be outside the float nurse’s expertise.
A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
A. "Yes, you are free to move around as you wish."
Allowing free movement could increase the risk of falls due to dizziness.
B. "We will have to get a prescription from your provider.
While involving the provider is important, immediate safety measures should be communicated directly.
C. "No, you are on strict bedrest and must not be up."
Strict bedrest is not typically necessary, and movement can help prevent complications like blood clots.
D. "Please ring for assistance when you wish to get out of bed."
Assisting the client when they wish to get out of bed ensures safety by preventing falls, which are a significant risk for those with Ménière's disease due to vertigo.
Full Explanation
A. Allowing free movement could increase the risk of falls due to dizziness.
B. While involving the provider is important, immediate safety measures should be communicated directly.
C. Strict bedrest is not typically necessary, and movement can help prevent complications like blood clots.
D. Assisting the client when they wish to get out of bed ensures safety by preventing falls, which are a significant risk for those with Ménière's disease due to vertigo.