Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client diagnosed with esophageal varices has a Sengstaken-Blakemore tube. What is the most important safety intervention for this client?
A. Keeping scissors at the bedside
Reason: Keeping scissors at the bedside is the most important safety intervention for this client, as it allows for quick removal of the tube in case of airway obstruction or bleeding.
B. Providing good mouth care
Reason: Providing good mouth care is an important intervention for this client, but it is not the most important, as it helps to prevent oral infections and discomfort.
C. Deflating the balloon on a regular basis
Reason: Deflating the balloon on a regular basis is not an appropriate intervention for this client, as it may cause bleeding or displacement of the tube.
D. Monitoring IV fluid intake
Reason: Monitoring IV fluid intake is an important intervention for this client, but it is not the most important, as it helps to prevent fluid overload or dehydration.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 3. Take the full exam now
Full Explanation
Choice A Reason: Keeping scissors at the bedside is the most important safety intervention for this client, as it allows for quick removal of the tube in case of airway obstruction or bleeding.
Choice B Reason: Providing good mouth care is an important intervention for this client, but it is not the most important, as it helps to prevent oral infections and discomfort.
Choice C Reason: Deflating the balloon on a regular basis is not an appropriate intervention for this client, as it may cause bleeding or displacement of the tube.
Choice D Reason: Monitoring IV fluid intake is an important intervention for this client, but it is not the most important, as it helps to prevent fluid overload or dehydration.
Similar Questions
A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis?
A. Atropine sulfate
Reason: Atropine sulfate is the medication that the nurse should ensure is available to treat cholinergic crisis, as it blocks the effects of acetylcholine and reverses the symptoms of excessive parasympathetic stimulation.
B. Pyridostigmine bromide (Mestinon)
Reason: Pyridostigmine bromide (Mestinon) is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to treat myasthenia gravis by increasing acetylcholine levels and improving muscle strength.
C. Protamine sulfate
Reason: Protamine sulfate is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to reverse the effects of heparin and prevent bleeding.
D. Acetylcysteine (Mucomyst)
Reason: Acetylcysteine (Mucomyst) is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to treat acetaminophen overdose and prevent liver damage.
Full Explanation
Choice A Reason: Atropine sulfate is the medication that the nurse should ensure is available to treat cholinergic crisis, as it blocks the effects of acetylcholine and reverses the symptoms of excessive parasympathetic stimulation.
Choice B Reason: Pyridostigmine bromide (Mestinon) is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to treat myasthenia gravis by increasing acetylcholine levels and improving muscle strength.
Choice C Reason: Protamine sulfate is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to reverse the effects of heparin and prevent bleeding.
Choice D Reason: Acetylcysteine (Mucomyst) is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to treat acetaminophen overdose and prevent liver damage.
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?
A. Compress the nares.
Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.
B. Administer decongestant for postnasal drip.
Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.
C. Tilt the head back.
Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.
D. Collect the drainage.
Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.
Full Explanation
Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.
Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.
Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.
Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.
A nurse is collecting data from a client diagnosed with laryngeal cancer who is postoperative following a laryngectomy. Which of the following is a clinical manifestation of a hemorrhage?
A. Increased pain
Reason: Increased pain is not a specific sign of hemorrhage, but it may indicate inflammation, infection, or nerve damage.
B. Continuous swallowing
Reason: Continuous swallowing is a sign of hemorrhage, as it indicates that blood is accumulating in the throat or esophagus and stimulating the swallowing reflex.
C. Poor fluid intake
Reason: Poor fluid intake is not a sign of hemorrhage, but it may indicate difficulty swallowing, nausea, or dehydration.
D. Drooling
Reason: Drooling is not a sign of hemorrhage, but it may indicate impaired oral control, salivary gland damage, or infection.
Full Explanation
Choice A Reason: Increased pain is not a specific sign of hemorrhage, but it may indicate inflammation, infection, or nerve damage.
Choice B Reason: Continuous swallowing is a sign of hemorrhage, as it indicates that blood is accumulating in the throat or esophagus and stimulating the swallowing reflex.
Choice C Reason: Poor fluid intake is not a sign of hemorrhage, but it may indicate difficulty swallowing, nausea, or dehydration.
Choice D Reason: Drooling is not a sign of hemorrhage, but it may indicate impaired oral control, salivary gland damage, or infection.
