Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client has a history of gastric bypass surgery within the past year. She presents to her primary care office for a check-up and states she has been troubled by several seemingly unrelated ailments: a sore tongue, tingling in her fingers, and “almost” falling several times due to lack of balance. The nurse notes that she is pale and slightly tachycardic.
Which type of anemia does the nurse suspect?
A. Folic acid deficiency anemia.
Choice A is wrong because folic acid deficiency anemia is caused by the lack of folic acid in the diet or increased demand for folic acid, such as during pregnancy. Folic acid is also needed for red blood cell production, but it does not cause nerve symptoms.
B. Aplastic anemia.
Choice B is wrong because aplastic anemia is caused by the failure of the bone marrow to produce enough blood cells. It is not related to gastric bypass surgery or nutrient deficiency. It can be caused by infections, drugs, radiation, or autoimmune diseases.
C. Vitamin B12 deficiency anemia.
This type of anemia is caused by the reduced absorption of vitamin B12 in the small intestine after gastric bypass surgery. Vitamin B12 is needed for the production of healthy red blood cells and nerve function. The symptoms of vitamin B12 deficiency anemia include sore tongue, tingling in the fingers, and balance problems.
D. Acquired anemia.
Choice D is wrong because acquired anemia is a general term for any type of anemia that is not inherited or present at birth. It can have many causes, such as blood loss, infection, inflammation, or chronic disease. It does not specify the type of anemia or the underlying mechanism. Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women. Normal ranges for vitamin B12 are 200 to 900 pg/mL.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Sp23 N144 FINAL Proctored Exam. Take the full exam now
Full Explanation
This type of anemia is caused by the reduced absorption of vitamin B12 in the small intestine after gastric bypass surgery. Vitamin B12 is needed for the production of healthy red blood cells and nerve function. The symptoms of vitamin B12 deficiency anemia include sore tongue, tingling in the fingers, and balance problems.
Choice A is wrong because folic acid deficiency anemia is caused by the lack of folic acid in the diet or increased demand for folic acid, such as during pregnancy.
Folic acid is also needed for red blood cell production, but it does not cause nerve symptoms.
Choice B is wrong because aplastic anemia is caused by the failure of the bone marrow to produce enough blood cells.
It is not related to gastric bypass surgery or nutrient deficiency. It can be caused by infections, drugs, radiation, or autoimmune diseases.
Choice D is wrong because acquired anemia is a general term for any type of anemia that is not inherited or present at birth.
It can have many causes, such as blood loss, infection, inflammation, or chronic disease.
It does not specify the type of anemia or the underlying mechanism. Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women. Normal ranges for vitamin B12 are 200 to 900 pg/mL.
Similar Questions
The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?
A. Patient will exhibit O2 saturation > 92% by discharge.
Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge. The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.
B. Teach pursed-lip breathing prior to discharge.
Choice B is wrong because it is not a goal statement, but an intervention. A goal statement should describe the expected outcome of the intervention, not the intervention itself.
C. Patient will state 2 ways to decrease chance of reinfection by the end of shift.
This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.
D. Patient will demonstrate pursed-lip breathing.
Choice D is wrong because it is not measurable or time-bound. A goal statement should have a clear indicator of how and when the outcome will be achieved.
Full Explanation
This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.
Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.
The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.
Choice B is wrong because it is not a goal statement, but an intervention.
A goal statement should describe the expected outcome of the intervention, not the intervention itself.
Choice D is wrong because it is not measurable or time-bound.
A goal statement should have a clear indicator of how and when the outcome will be achieved.
The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?
A. Provide a walker.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
B. Place a chair on either side of the bed.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
C. Provide a cane.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
D. Place a fall risk wrist band on the client.
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Full Explanation
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?
A. Instruct the client to use pursed-lip breathing.
Pursed-lip breathing is a technique that helps to slow down the breathing rate and keep the airways open longer. This improves gas exchange and reduces the work of breathing. Pursed-lip breathing also helps to prevent air trapping and hyperinflation of the lungs, which are common complications of COPD.
B. Plan to have the client lay down for 1 hr after meals.
Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.
C. Restrict the client’s fluid intake to less than 1 L/day.
Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.
D. Encourage the client to use the upper chest for respiration.
Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress. It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing. Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.
Full Explanation
Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.
Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.
Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.
It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.
Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.