Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
A. Inform the unit manager of the incident.
Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speak with the AP about the incident.
Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Remove the restraints from the client's wrists.
Removing the restraints from the client's wrists is the first action to address theinappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Review the chart for nonrestraint alternatives for agitation,
Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.
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Full Explanation
A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.
Similar Questions
A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?
A. A client who has gestational diabetes and is receiving biweekly nonstress tests
A client with gestational diabetes receiving biweekly nonstress tests typically requires monitoring and assessment that align more closely with obstetric nursing knowledge and skills rather than medical-surgical nursing.
B. A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor
A multigravida client with preeclampsia receiving misoprostol for induction of labor needs specialized obstetric care due to the complexity of the condition and the induction process.
C. A client who is at 32 weeks of gestation and has premature rupture of membranes
A client at 32 weeks of gestation with premature rupture of membranes would require obstetric care expertise for monitoring and management.
D. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump
A primigravida client 1 day postoperative following a Cesarean section with a patient- controlled analgesia (PCA) pump requires specialized postoperative obstetric care,making this assignment suitable for the RN who floated from a medical-surgical unit due to their experience with postoperative care and pain management.
Full Explanation
A. A client with gestational diabetes receiving biweekly nonstress tests typically requires monitoring and assessment that align more closely with obstetric nursing knowledge and skills rather than medical-surgical nursing.
B. A multigravida client with preeclampsia receiving misoprostol for induction of labor needs specialized obstetric care due to the complexity of the condition and the induction process.
C. A client at 32 weeks of gestation with premature rupture of membranes would require obstetric care expertise for monitoring and management.
D. A primigravida client 1 day postoperative following a Cesarean section with a patient- controlled analgesia (PCA) pump requires specialized postoperative obstetric care,
making this assignment suitable for the RN who floated from a medical-surgical unit due to their experience with postoperative care and pain management.
A nurse is caring for a client who requests information about the prevalence of Tay-Sachs disease. Which of the following resources should the nurse use to obtain this information?
A. A collaborative, user-edited website
Collaborative, user-edited websites might contain varying levels of accuracy and reliability regarding medical information, making them less suitable for obtaining specific prevalence data.
B. An evidence-based nursing journal
An evidence-based nursing journal is a reliable source of information that often includes statistical data, prevalence rates, and updated research on various medical conditions, including Tay-Sachs disease.
C. The facility's case manager
The facility's case manager might have general information but may not provide specific prevalence rates for Tay-Sachs disease.
D. The client's health care provider
While the client's health care provider might have knowledge about Tay-Sachs disease, their primary focus during a clinical encounter might be the client's immediate care needs rather than providing statistics on disease prevalence.
Full Explanation
A. Collaborative, user-edited websites might contain varying levels of accuracy and reliability regarding medical information, making them less suitable for obtaining specific prevalence data.
B. An evidence-based nursing journal is a reliable source of information that often includes statistical data, prevalence rates, and updated research on various medical conditions, including Tay-Sachs disease.
C. The facility's case manager might have general information but may not provide specific prevalence rates for Tay-Sachs disease.
D. While the client's health care provider might have knowledge about Tay-Sachs disease, their primary focus during a clinical encounter might be the client's immediate care needs rather than providing statistics on disease prevalence.
A nurse is providing change-of-shift report for an oncoming nurse. Which of the following information should the nurse include in the report?
A. "The client is the president of a local bank,"
Mentioning that the client is the president of a local bank might not be pertinent to the client's current health status or care needs and is not typically included in a change-of- shift report unless relevant to the care plan.
B. "The client's partner came to visit him 2 hours ago."
The fact that the client's partner came to visit two hours ago might be important for emotional support or social interaction but might not be crucial information for the oncoming nurse unless relevant to the client's condition.
C. "The client has routine vital signs prescribed."
"The client has routine vital signs prescribed” is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.
D. "The client is in the radiology department for a chest x-ray."
This is critical information for the incoming nurse. It informs them that the client is currently away from the unit, which may affect the plan of care, including monitoring, medication administration, or any interventions needed during the client’s absence. It is important for the incoming nurse to be aware of the client's current status and whereabouts.
Full Explanation
A. Mentioning that the client is the president of a local bank might not be pertinent to the client's current health status or care needs and is not typically included in a change-of- shift report unless relevant to the care plan.
B. The fact that the client's partner came to visit two hours ago might be important for emotional support or social interaction but might not be crucial information for the oncoming nurse unless relevant to the client's condition.
C. The client has routine vital signs prescribed” is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.
D. This is critical information for the incoming nurse. It informs them that the client is currently away from the unit, which may affect the plan of care, including monitoring, medication administration, or any interventions needed during the client’s absence. It is important for the incoming nurse to be aware of the client's current status and whereabouts.