Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client has little use of the left side due to a stroke. To assist with ambulation for the first time, the nurse should walk:
A. directly in front of the client.
This is incorrect. Walking directly in front of the client may block their view and increase their risk of falling. The nurse should walk to the side and slightly behind the client to provide support and guidance³.
B. along the affected left side.
This is correct. Walking along the affected left side allows the nurse to assist the client with balance, weight shifting, and foot clearance. The nurse should also encourage the client to use the handrail on their strong side³.
C. directly behind the client.
This is incorrect. Walking directly behind the client may not allow the nurse to see the client's gait pattern or intervene quickly if the client loses balance. The nurse should walk to the side and slightly behind the client to monitor and assist them³.
D. along the unaffected right side.
This is incorrect. Walking along the unaffected right side may not provide adequate support or protection for the client's affected side. The nurse should walk along the affected left side to help the client with their hemiplegic gait³.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Nursing 200 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: This is incorrect. Walking directly in front of the client may block their view and increase their risk of falling. The nurse should walk to the side and slightly behind the client to provide support and guidance³.
Choice B reason: This is correct. Walking along the affected left side allows the nurse to assist the client with balance, weight shifting, and foot clearance. The nurse should also encourage the client to use the handrail on their strong side³.
Choice C reason: This is incorrect. Walking directly behind the client may not allow the nurse to see the client's gait pattern or intervene quickly if the client loses balance. The nurse should walk to the side and slightly behind the client to monitor and assist them³.
Choice D reason: This is incorrect. Walking along the unaffected right side may not provide adequate support or protection for the client's affected side. The nurse should walk along the affected left side to help the client with their hemiplegic gait³.
Similar Questions
The nurse should teach the client who is taking digoxin 0.125 mg PO daily to call the healthcare provider if which side effect is experienced?
A. Tinnitus
Tinnitus is not a common or serious side effect of digoxin, a drug that strengthens the contraction of the heart and regulates the heart rhythm. ¹ Tinnitus is a ringing or buzzing sound in the ears that can be caused by many factors, such as ear infections, loud noises, or medications. ² However, digoxin is not known to cause tinnitus, and it is not a reason to call the healthcare provider.
B. Constipation
Constipation is not a common or serious side effect of digoxin. Digoxin does not affect the bowel function, and it is not a reason to call the healthcare provider. Constipation can be caused by many factors, such as dehydration, lack of fiber, or medications. ³ The client should drink plenty of fluids, eat high-fiber foods, and exercise regularly to prevent or relieve constipation.
C. Visual disturbances
Visual disturbances are a common and serious side effect of digoxin, and they are a reason to call the healthcare provider. Digoxin can cause changes in vision, such as blurred vision, yellow or green halos around objects, or seeing spots or flashes. ¹ These are signs of digoxin toxicity, which is a potentially life-threatening condition that occurs when the level of digoxin in the blood is too high. The client should report any visual disturbances to the healthcare provider as soon as possible.
D. Vertigo
Vertigo is not a common or serious side effect of digoxin. Vertigo is a sensation of spinning or losing balance that can be caused by many factors, such as inner ear problems, head injuries, or medications. However, digoxin is not known to cause vertigo, and it is not a reason to call the healthcare provider.
Full Explanation
Choice A reason: Tinnitus is not a common or serious side effect of digoxin, a drug that strengthens the contraction of the heart and regulates the heart rhythm. ¹ Tinnitus is a ringing or buzzing sound in the ears that can be caused by many factors, such as ear infections, loud noises, or medications. ² However, digoxin is not known to cause tinnitus, and it is not a reason to call the healthcare provider.
Choice B reason: Constipation is not a common or serious side effect of digoxin. Digoxin does not affect the bowel function, and it is not a reason to call the healthcare provider. Constipation can be caused by many factors, such as dehydration, lack of fiber, or medications. ³ The client should drink plenty of fluids, eat high-fiber foods, and exercise regularly to prevent or relieve constipation.
Choice C reason: Visual disturbances are a common and serious side effect of digoxin, and they are a reason to call the healthcare provider. Digoxin can cause changes in vision, such as blurred vision, yellow or green halos around objects, or seeing spots or flashes. ¹ These are signs of digoxin toxicity, which is a potentially life-threatening condition that occurs when the level of digoxin in the blood is too high. The client should report any visual disturbances to the healthcare provider as soon as possible.
Choice D reason: Vertigo is not a common or serious side effect of digoxin. Vertigo is a sensation of spinning or losing balance that can be caused by many factors, such as inner ear problems, head injuries, or medications. However, digoxin is not known to cause vertigo, and it is not a reason to call the healthcare provider.
When caring for a client diagnosed with thrombocytopenia, the nurse should plan to:
A. encourage vigorous tooth brushing with a soft bristle toothbrush.
The nurse should not encourage vigorous tooth brushing with a soft bristle toothbrush. Thrombocytopenia is a condition where the blood has a low number of platelets, which are cells that help with clotting. ¹ Vigorous tooth brushing can cause bleeding of the gums, which can be hard to stop in a client with thrombocytopenia. The nurse should advise the client to use a soft sponge or swab to clean the teeth and mouth gently.
B. avoid needle sticks or other invasive procedures as much as possible.
The nurse should avoid needle sticks or other invasive procedures as much as possible. Needle sticks and other invasive procedures can cause bleeding, bruising, or infection in a client with thrombocytopenia. ¹ The nurse should use the smallest gauge needle possible, apply pressure for at least 10 minutes after the procedure, and monitor the site for any signs of bleeding or infection. The nurse should also avoid unnecessary blood draws or injections, and use non-invasive methods whenever possible.
C. hold all stool softeners and laxatives until otherwise ordered.
The nurse should not hold all stool softeners and laxatives until otherwise ordered. Stool softeners and laxatives can help prevent constipation and straining, which can cause hemorrhoids or anal fissures in a client with thrombocytopenia. ¹ The nurse should encourage the client to take stool softeners and laxatives as prescribed, drink plenty of fluids, and eat high-fiber foods to promote regular bowel movements.
D. obtain a low temperature every 8 hours.`
The nurse should not obtain a low temperature every 8 hours. A low temperature is not a relevant or accurate measurement for a client with thrombocytopenia. The nurse should obtain a normal temperature, which is around 98.6°F (37°C), using a non-invasive method, such as an oral or tympanic thermometer. ² The nurse should avoid using a rectal thermometer, as it can cause bleeding or infection in a client with thrombocytopenia.
Full Explanation
Choice A reason: The nurse should not encourage vigorous tooth brushing with a soft bristle toothbrush. Thrombocytopenia is a condition where the blood has a low number of platelets, which are cells that help with clotting. ¹ Vigorous tooth brushing can cause bleeding of the gums, which can be hard to stop in a client with thrombocytopenia. The nurse should advise the client to use a soft sponge or swab to clean the teeth and mouth gently.
Choice B reason: The nurse should avoid needle sticks or other invasive procedures as much as possible. Needle sticks and other invasive procedures can cause bleeding, bruising, or infection in a client with thrombocytopenia. ¹ The nurse should use the smallest gauge needle possible, apply pressure for at least 10 minutes after the procedure, and monitor the site for any signs of bleeding or infection. The nurse should also avoid unnecessary blood draws or injections, and use non-invasive methods whenever possible.
Choice C reason: The nurse should not hold all stool softeners and laxatives until otherwise ordered. Stool softeners and laxatives can help prevent constipation and straining, which can cause hemorrhoids or anal fissures in a client with thrombocytopenia. ¹ The nurse should encourage the client to take stool softeners and laxatives as prescribed, drink plenty of fluids, and eat high-fiber foods to promote regular bowel movements.
Choice D reason: The nurse should not obtain a low temperature every 8 hours. A low temperature is not a relevant or accurate measurement for a client with thrombocytopenia. The nurse should obtain a normal temperature, which is around 98.6°F (37°C), using a non-invasive method, such as an oral or tympanic thermometer. ² The nurse should avoid using a rectal thermometer, as it can cause bleeding or infection in a client with thrombocytopenia.
The client with pernicious anemia asks why vitamin B12 injections are necessary. What is the best response by the nurse?
A. Vitamin B12 contributes to the increased production of RBCs after significant blood loss.
Vitamin B12 does not contribute to the increased production of RBCs after significant blood loss. Vitamin B12 is a type of vitamin that is essential for the normal formation and maturation of red blood cells (RBCs), which carry oxygen throughout the body. ¹ However, vitamin B12 does not increase the production of RBCs in response to blood loss. That is the role of erythropoietin, a hormone that stimulates the bone marrow to produce more RBCs. ²
B. Vitamin B12 is needed to prevent excessive production of red blood cells.
Vitamin B12 is not needed to prevent excessive production of red blood cells. Vitamin B12 is needed for the normal production of red blood cells, not for the prevention of overproduction. Excessive production of red blood cells, also known as polycythemia, can cause the blood to become thick and viscous, increasing the risk of clotting and stroke. ³ Polycythemia can be caused by various factors, such as smoking, dehydration, or genetic mutations, but not by a lack of vitamin B12.
C. Vitamin B12 is needed to prevent RBCs from sticking together.
Vitamin B12 is not needed to prevent RBCs from sticking together. Vitamin B12 is needed for the normal formation and maturation of RBCs, not for the prevention of aggregation. RBCs can stick together and form clumps, also known as rouleaux, which can impair blood flow and oxygen delivery. Rouleaux can be caused by various factors, such as inflammation, infection, or cancer, but not by a lack of vitamin B12.
D. Your stomach does not provide a substance necessary for the absorption of vitamin B12.
Vitamin B12 is needed for the normal formation and maturation of RBCs, but it cannot be absorbed by the body without a substance called intrinsic factor. Intrinsic factor is a protein that is produced by the stomach and binds to vitamin B12, allowing it to be absorbed by the small intestine. ¹ Pernicious anemia is a type of anemia that occurs when the stomach does not produce enough intrinsic factor, leading to vitamin B12 deficiency. The only way to treat pernicious anemia is by giving vitamin B12 injections, which bypass the need for intrinsic factor.
Full Explanation
Choice A reason: Vitamin B12 does not contribute to the increased production of RBCs after significant blood loss. Vitamin B12 is a type of vitamin that is essential for the normal formation and maturation of red blood cells (RBCs), which carry oxygen throughout the body. ¹ However, vitamin B12 does not increase the production of RBCs in response to blood loss. That is the role of erythropoietin, a hormone that stimulates the bone marrow to produce more RBCs. ²
Choice B reason: Vitamin B12 is not needed to prevent excessive production of red blood cells. Vitamin B12 is needed for the normal production of red blood cells, not for the prevention of overproduction. Excessive production of red blood cells, also known as polycythemia, can cause the blood to become thick and viscous, increasing the risk of clotting and stroke. ³ Polycythemia can be caused by various factors, such as smoking, dehydration, or genetic mutations, but not by a lack of vitamin B12.
Choice C reason: Vitamin B12 is not needed to prevent RBCs from sticking together. Vitamin B12 is needed for the normal formation and maturation of RBCs, not for the prevention of aggregation. RBCs can stick together and form clumps, also known as rouleaux, which can impair blood flow and oxygen delivery. Rouleaux can be caused by various factors, such as inflammation, infection, or cancer, but not by a lack of vitamin B12.
Choice D reason: Vitamin B12 is needed for the normal formation and maturation of RBCs, but it cannot be absorbed by the body without a substance called intrinsic factor. Intrinsic factor is a protein that is produced by the stomach and binds to vitamin B12, allowing it to be absorbed by the small intestine. ¹ Pernicious anemia is a type of anemia that occurs when the stomach does not produce enough intrinsic factor, leading to vitamin B12 deficiency. The only way to treat pernicious anemia is by giving vitamin B12 injections, which bypass the need for intrinsic factor.
