Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client has suffered a partial thickness second-degree burn injury of the chest, abdomen, and upper legs and is scheduled for hydrotherapy and debridement.
Which of these actions should the nurse take to effectively assist the patient?
A. Medicate the client 30 minutes before the procedure.
Medicate the client 30 minutes before the procedure. This is the correct action. Administering pain medication 30 minutes before the procedure allows the medication to take effect and provides pain control during the procedure.
B. Reassure the client that the procedure is not painful.
Reassure the client that the procedure is not painful. This is not accurate. Debridement and hydrotherapy can be painful, so it’s important to manage the client’s pain effectively.
C. Utilize meditation and imagery.
Utilize meditation and imagery. While these techniques can be helpful adjuncts to pain management, they should not replace pharmacological pain management in this situation.
D. Administer pain medication around the clock.
Administer pain medication around the clock. While it’s important to manage pain effectively, this does not specifically address the client’s needs during the hydrotherapy and debridement procedure.
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Full Explanation
Choice A rationale
Medicate the client 30 minutes before the procedure. This is the correct action. Administering pain medication 30 minutes before the procedure allows the medication to take effect and provides pain control during the procedure.
Choice B rationale
Reassure the client that the procedure is not painful. This is not accurate. Debridement and hydrotherapy can be painful, so it’s important to manage the client’s pain effectively.
Choice C rationale
Utilize meditation and imagery. While these techniques can be helpful adjuncts to pain management, they should not replace pharmacological pain management in this situation.
Choice D rationale
Administer pain medication around the clock. While it’s important to manage pain effectively, this does not specifically address the client’s needs during the hydrotherapy and debridement procedure.
Similar Questions
A nurse leader is discussing possible continuing education opportunities with other staff members.
Which of the following actions should the nurse leader recommend to maintain clinical competence?
A. Discussing facility policies with coworkers.
Discussing facility policies with coworkers. While understanding facility policies is important, it does not necessarily contribute to maintaining clinical competence.
B. Attending a professional conference.
Attending a professional conference. This is the correct answer. Professional conferences often provide opportunities for continuing education, learning about the latest research and best practices, and networking with other professionals in the field.
C. Joining a nurses’ union.
Joining a nurses’ union. While a union can provide support and advocacy for nurses, joining a union does not directly maintain clinical competence.
D. Removing expired supplies from the storage area.
Removing expired supplies from the storage area. This is an important task for maintaining a safe and effective work environment, but it does not contribute to maintaining clinical competence.
Full Explanation
Choice A rationale
Discussing facility policies with coworkers. While understanding facility policies is important, it does not necessarily contribute to maintaining clinical competence.
Choice B rationale
Attending a professional conference. This is the correct answer. Professional conferences often provide opportunities for continuing education, learning about the latest research and best practices, and networking with other professionals in the field.
Choice C rationale
Joining a nurses’ union. While a union can provide support and advocacy for nurses, joining a union does not directly maintain clinical competence.
Choice D rationale
Removing expired supplies from the storage area. This is an important task for maintaining a safe and effective work environment, but it does not contribute to maintaining clinical competence.
A nurse is planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administered twice daily.
When should the nurse plan to administer the medication?
A. At the time the client takes a proton-pump inhibitor.
At the time the client takes a proton-pump inhibitor. Sucralfate and proton pump inhibitors should not be taken at the same time. Sucralfate can interfere with the absorption of other medications.
B. At the time the client takes an antacid.
At the time the client takes an antacid. Sucralfate and antacids should not be taken at the same time. Sucralfate can interfere with the absorption of other medications.
C. One hour before breakfast and the evening meal.
One hour before breakfast and the evening meal. This is the correct answer. Sucralfate is most effective when taken on an empty stomach. Taking it one hour before meals allows it to form a protective coating on the ulcer before food is introduced into the stomach.
D. Thirty minutes after breakfast and the evening meal.
Thirty minutes after breakfast and the evening meal. Sucralfate should not be taken immediately after meals. It is most effective when taken on an empty stomach.
Full Explanation
Choice A rationale
At the time the client takes a proton-pump inhibitor. Sucralfate and proton pump inhibitors should not be taken at the same time. Sucralfate can interfere with the absorption of other medications.
Choice B rationale
At the time the client takes an antacid. Sucralfate and antacids should not be taken at the same time. Sucralfate can interfere with the absorption of other medications.
Choice C rationale
One hour before breakfast and the evening meal. This is the correct answer. Sucralfate is most effective when taken on an empty stomach. Taking it one hour before meals allows it to form a protective coating on the ulcer before food is introduced into the stomach.
Choice D rationale
Thirty minutes after breakfast and the evening meal. Sucralfate should not be taken immediately after meals. It is most effective when taken on an empty stomach.
A patient arrives at the emergency department with a stab wound to the chest.
The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity.
Where should the nurse place the system?
A. Attached to the foot of the bed.
Attaching the chest tube system to the foot of the bed is not recommended. This position could potentially cause the system to tip over or become disconnected, which could lead to complications such as pneumothorax or hemothorax.
B. Below the level of the patient’s chest.
The chest tube system should be placed below the level of the patient’s chest. This allows for gravity-assisted drainage of air and fluid from the thoracic cavity, which is crucial for the patient’s recovery. The system works on a water seal that prevents air or fluid from entering the pleural space. Placing the system below the chest level ensures that the water seal is maintained, preventing backflow of fluid or air into the pleural space.
C. Along the side of the patient’s knee.
Placing the system along the side of the patient’s knee is not appropriate. This position does not facilitate effective drainage of air and fluid from the thoracic cavity. It could also lead to discomfort and potential dislodgement of the system.
D. At the level of the patient’s clavicle.
Placing the system at the level of the patient’s clavicle is not recommended. This position is too high and could disrupt the water seal, leading to ineffective drainage and potential complications.
Full Explanation
Choice A rationale
Attaching the chest tube system to the foot of the bed is not recommended. This position could potentially cause the system to tip over or become disconnected, which could lead to complications such as pneumothorax or hemothorax.
Choice B rationale
The chest tube system should be placed below the level of the patient’s chest. This allows for gravity-assisted drainage of air and fluid from the thoracic cavity, which is crucial for the patient’s recovery. The system works on a water seal that prevents air or fluid from entering the pleural space. Placing the system below the chest level ensures that the water seal is maintained, preventing backflow of fluid or air into the pleural space.
Choice C rationale
Placing the system along the side of the patient’s knee is not appropriate. This position does not facilitate effective drainage of air and fluid from the thoracic cavity. It could also lead to discomfort and potential dislodgement of the system.
Choice D rationale
Placing the system at the level of the patient’s clavicle is not recommended. This position is too high and could disrupt the water seal, leading to ineffective drainage and potential complications.