Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community.
In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
A. A client who is receiving heparin for deep-vein thrombosis.
wrong because a client who is receiving heparin for deep-vein thrombosis (DVT) needs close monitoring of their blood levels and clotting factors. Heparin is a blood thinner that prevents the clots from getting bigger or breaking loose and traveling to the lungs, which can cause a life-threatening condition called pulmonary embolism (PE). This client is not a good candidate for early discharge.
B. A client who is 1 day postoperative following a vertebroplasty.
A client who is 1 day postoperative following a vertebroplasty. A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
C. A client who has cancer and a sealed implant for radiation therapy.
wrong because a client who has cancer and a sealed implant for radiation therapy needs to be isolated in a special room to prevent exposure of others to radiation. A sealed implant is a small holder that contains a radioactive source that is placed inside or near the tumor to deliver high doses of radiation. This type of internal radiation therapy, also called brachytherapy, can last from several minutes to several days, depending on the type and dose of the radioactive source.
D. A client who has COPD and a respiratory rate of 44/min.
wrong because a client who has COPD and a respiratory rate of 44/min has signs of respiratory distress and possible hypoxemia (low oxygen levels in the blood). COP
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is choice B. A client who is 1 day postoperative following a vertebroplasty. A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
Therefore, this client is most likely to be stable and ready for early discharge.
Choice A is wrong because a client who is receiving heparin for deep-vein thrombosis (DVT) needs close monitoring of their blood levels and clotting factors. Heparin is a blood thinner that prevents the clots from getting bigger or breaking loose and traveling to the lungs, which can cause a life-threatening condition called pulmonary embolism (PE).
This client is not a good candidate for early discharge.
Choice C is wrong because a client who has cancer and a sealed implant for radiation therapy needs to be isolated in a special room to prevent exposure of others to radiation. A sealed implant is a small holder that contains a radioactive source that is placed inside or near the tumor to deliver high doses of radiation. This type of internal radiation therapy, also called brachytherapy, can last from several minutes to several days, depending on the type and dose of the radioactive source.
This client is not a good candidate for early discharge.
Choice D is wrong because a client who has COPD and a respiratory rate of 44/min has signs of respiratory distress and possible hypoxemia (low oxygen levels in the blood).
COP
Similar Questions
A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis.
A. “We can review some information to help you select a safe alternative practitioner.”.
This statement shows respect for the client’s interest in alternative therapies and offers guidance on how to choose a reliable and qualified provider. Alternative therapies can provide some benefits for people with rheumatoid arthritis, such as reducing pain, inflammation, and stiffness, but they should be used as a complement to conventional treatments and not as a substitute.
B. “If there are therapies available to you, your provider will tell you about them.”.
because it implies that the client has no role in deciding their own treatment plan and that alternative therapies are not worth considering. This may discourage the client from sharing their preferences and concerns with the provider.
C. “I’m sure you can find alternative remedies through an online support group.”.
wrong because it suggests that online support groups are a reliable source of information about alternative remedies, which may not be true. Online sources may contain inaccurate, misleading, or harmful information that could jeopardize the client’s health and safety.
D. “Feel free to try whatever therapies that fit within your personal belief system.”.
is wrong because it encourages the client to try any therapy that fits their personal belief system, without considering the evidence, effectiveness, or potential risks of such therapies. Some alternative therapies may interact with medications, cause side effects, or worsen the condition.
Full Explanation
The correct answer is choice A: “We can review some information to help you select a safe alternative practitioner.” This statement shows respect for the client’s interest in alternative therapies and offers guidance on how to choose a reliable and qualified provider. Alternative therapies can provide some benefits for people with rheumatoid arthritis, such as reducing pain, inflammation, and stiffness, but they should be used as a complement to conventional treatments and not as a substitute.
Choice B is wrong because it implies that the client has no role in deciding their own treatment plan and that alternative therapies are not worth considering.
This may discourage the client from sharing their preferences and concerns with the provider.
Choice C is wrong because it suggests that online support groups are a reliable source of information about alternative remedies, which may not be true.
Online sources may contain inaccurate, misleading, or harmful information that could jeopardize the client’s health and safety.
Choice D is wrong because it encourages the client to try any therapy that fits their personal belief system, without considering the evidence, effectiveness, or potential risks of such therapies. Some alternative therapies may interact with medications, cause side effects, or worsen the condition.
Normal ranges for rheumatoid arthritis are not applicable in this question, as it is not asking about laboratory values or disease activity measures. However, some common tests used to diagnose and monitor rheumatoid arthritis include erythrocyte sedimentation rate (ESR), Creactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, and joint ultrasound or X-ray.
The normal ranges for these tests may vary depending on the laboratory and the method used.
A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes.
A. “Why are you interested in seeing your therapist’s notes?”.
Why are you interested in seeing your therapist’s notes?” is wrong because it implies that the client has no valid reason to request their records and may discourage them from expressing their concerns or needs.
B. “I don’t think you will benefit from reviewing your therapist’s notes right now.”.
“I don’t think you will benefit from reviewing your therapist’s notes right now.” is wrong because it dismisses the client’s request and assumes that the nurse knows what is best for the client without consulting them.
C. “Are you not happy with your treatment?”.
Are you not happy with your treatment?” is wrong because it deflects the client’s request and may imply that the therapist has something to hide or that the client is dissatisfied with the therapy.
D. “We can provide a copy of your records, but the therapist’s notes are not included.”.
“We can provide a copy of your records, but the therapist’s notes are not included.” This response respects the client’s right to access their own records, but also protects the confidentiality of the therapist’s notes, which are not considered part of the official record.
A nurse is preparing to administer a medication that is available in a glass ampule.
Which of the following actions should the nurse plan to take?
A. The nurse should use a filter needle to withdraw the medication.
This is because glass ampules can leave small shards of glass in the solution, which can be harmful if injected into the client. A filter needle has a small mesh that traps any glass particles and prevents them from entering the syringe.
B. The nurse should break the neck of the ampule toward their body.
because the nurse should break the neck of the ampule away from their body to avoid injury from the glass.
C. The nurse should use the same needle to draw up and inject the client.
is wrong because the nurse should use a different needle to inject the client after withdrawing the medication with a filter needle. This is to prevent contamination and reduce pain for the client.
D. The nurse should dispose of the ampule in the trash can.
wrong because the nurse should dispose of the ampule in a sharps container, not in the trash can. This is to prevent injury and infection from the broken glass.
Full Explanation
This is because glass ampules can leave small shards of glass in the solution, which can be harmful if injected into the client. A filter needle has a small mesh that traps any glass particles and prevents them from entering the syringe.
Choice B is wrong because the nurse should break the neck of the ampule away from their body to avoid injury from the glass.
Choice C is wrong because the nurse should use a different needle to inject the client after withdrawing the medication with a filter needle. This is to prevent contamination and reduce pain for the client.
Choice D is wrong because the nurse should dispose of the ampule in a sharps container, not in the trash can. This is to prevent injury and infection from the broken glass.