Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some "heart damage." The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client's history, which nursing problem has the highest priority?
A. Sleep deprivation.
Sleep deprivation:While sleep is important for overall well-being, it may not be the top priority in this case. Fluid volume excess, given the client's cardiac history, poses a more immediate threat to health.
B. Fluid volume excess
Fluid volume excess:Clients with heart damage are prone to heart failure, and managing fluid balance is crucial. Excess fluid can worsen cardiac function, making this the priority concern.
C. Nausea and vomiting
Nausea and vomiting: While nausea and vomiting are significant concerns, they might not be as directly related to the client's cardiac history as fluid volume excess. However, if severe, it could contribute to fluid imbalance.
D. Risk for infection.
Risk for infection:Infection is a concern for postpartum clients, but in this case, the client's history of rheumatic fever and heart damage takes precedence. The priority is to prevent complications related to heart failure.
This question is an excerpt from Nurse Dive's nursing test bank - Samuel Merrit University Oaklands Hesi Maternity (Labor and Delivery) Proctored Exam. Take the full exam now
Full Explanation
A. Sleep deprivation:
While sleep is important for overall well-being, it may not be the top priority in this case. Fluid volume excess, given the client's cardiac history, poses a more immediate threat to health.
B. Fluid volume excess:
Clients with heart damage are prone to heart failure, and managing fluid balance is crucial. Excess fluid can worsen cardiac function, making this the priority concern.
C. Nausea and vomiting:
While nausea and vomiting are significant concerns, they might not be as directly related to the client's cardiac history as fluid volume excess. However, if severe, it could contribute to fluid imbalance.
D. Risk for infection:
Infection is a concern for postpartum clients, but in this case, the client's history of rheumatic fever and heart damage takes precedence. The priority is to prevent complications related to heart failure.
Similar Questions
A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?
A. Chromosomal abnormalities
Chromosomal abnormalities:While an ultrasound can sometimes identify structural abnormalities, it's not the primary tool for detecting chromosomal abnormalities. Genetic testing or procedures like amniocentesis are more specific for this purpose.
B. Sex and size of the infant
Sex and size of the infant:An ultrasound is indeed used to determine the sex of the baby and assess its size and growth.
C. Lecithin-sphingomyelin ratio
Lecithin-sphingomyelin ratio: The lecithin-sphingomyelin ratio is typically assessed in tests related to fetal lung maturity, which is not the primary purpose of a routine ultrasound.
D. Fetal growth and gestational age.
Fetal growth and gestational age:This is one of the primary purposes of a routine ultrasound during pregnancy. It helps evaluate the baby's growth and ensures it aligns with the expected gestational age.
Full Explanation
A. Chromosomal abnormalities:
While an ultrasound can sometimes identify structural abnormalities, it's not the primary tool for detecting chromosomal abnormalities. Genetic testing or procedures like amniocentesis are more specific for this purpose.
B. Sex and size of the infant:
An ultrasound is indeed used to determine the sex of the baby and assess its size and growth.
C. Lecithin-sphingomyelin ratio:
The lecithin-sphingomyelin ratio is typically assessed in tests related to fetal lung maturity, which is not the primary purpose of a routine ultrasound.
D. Fetal growth and gestational age:
This is one of the primary purposes of a routine ultrasound during pregnancy. It helps evaluate the baby's growth and ensures it aligns with the expected gestational age.
The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump?
(Enter numerical value only.)
Full Explanation
- To calculate the infusion rate, use the formula:
(mL of solution / grams of drug) x (grams ordered / minutes to infuse) x 60
- In this case, the formula becomes: (500 mL / 20 g) x (6 g / 20 min) x 60
- Simplify and solve: (25 mL / g) x (0.3 g / min) x 60
- The answer is 450 mL/hour
- The nurse should set the infusion pump at 450 mL/hour
A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. The nurse would be correct in stating that the purpose for using the ointment is to
A. dilate the pupil so the red reflex can be visualized
Dilate the pupil so the red reflex can be visualized:This statement is not accurate regarding the purpose of the eye ointment. The eye ointment is not used to dilate the pupil but serves a different purpose.
B. prevent herpes infection.
Prevent herpes infection:While eye ointment can help prevent certain eye infections, it's not specifically administered to prevent herpes infection.
C. prevent eye infections
Prevent eye infections: This is the correct answer. The eye ointment typically contains an antibiotic and is applied to prevent infections, particularly those that could be transmitted during childbirth.
D. clear the infant's vision
Clear the infant's vision:The eye ointment is not used to clear the infant's vision. Its primary purpose is to prevent infections rather than affect vision.
Full Explanation
A. Dilate the pupil so the red reflex can be visualized:
This statement is not accurate regarding the purpose of the eye ointment. The eye ointment is not used to dilate the pupil but serves a different purpose.
B. Prevent herpes infection:
While eye ointment can help prevent certain eye infections, it's not specifically administered to prevent herpes infection.
C. Prevent eye infections:
This is the correct answer. The eye ointment typically contains an antibiotic and is applied to prevent infections, particularly those that could be transmitted during childbirth.
D. Clear the infant's vision:
The eye ointment is not used to clear the infant's vision. Its primary purpose is to prevent infections rather than affect vision.