Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge intravenous (IV) catheter with normal saline is infusing at a rate of 150 mL/hour. Which intervention should the nurse implement first?
A. Establish a second IV site.
Incorrect- While a second IV site might be considered if the first one is causing significant discomfort, it's not the initial intervention. The nurse should first address the immediate concern of pain.
B. Stop the normal saline infusion.
Correct- Pain at the IV site during infusion might indicate infiltration or irritation. Stopping the infusion is the most immediate intervention to prevent further discomfort and potential complications like tissue damage.
C. Assess the IV for blood return. D. Discontinue the 24 gauge IV.
Incorrect- While assessing for blood return is important to ensure proper IV placement, it's not the initial intervention for managing pain caused by the infusion.
D. Discontinue the 24 gauge IV.
Incorrect- Discontinuing the IV might be considered if the pain is severe and unmanageable, but the nurse should initially try to address the discomfort without removing the IV.
This question is an excerpt from Nurse Dive's nursing test bank - HESI Exit LPN Proctored Exam 1. Take the full exam now
Full Explanation
A) Incorrect- While a second IV site might be considered if the first one is causing significant discomfort, it's not the initial intervention. The nurse should first address the immediate concern of pain.
B) Correct- Pain at the IV site during infusion might indicate infiltration or irritation. Stopping the infusion is the most immediate intervention to prevent further discomfort and potential complications like tissue damage.
C) Incorrect- While assessing for blood return is important to ensure proper IV placement, it's not the initial intervention for managing pain caused by the infusion.
D) Incorrect- Discontinuing the IV might be considered if the pain is severe and unmanageable, but the nurse should initially try to address the discomfort without removing the IV.
Similar Questions
A client receives a prescription for acetaminophen 1,000 mg by mouth every 8 hours as needed for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)
Full Explanation
Rationale: The nurse should calculate the dose based on the concentration of the medication. Since the suspension contains 500 mg of acetaminophen per 15 mL, a 1,000 mg dose requires 30 mL (2 tablespoons) of the suspension.
Patient Data
Which are the nurse's best responses? Select all that apply.
A. "Hyperglycemia often results in weight loss."
Incorrect - Hyperglycemia typically does not lead to weight loss. In fact, it can result in weight gain due to the body's inability to properly use glucose for energy.
B. "Hyperglycemia causes an increased sensation of being hungry."
Correct - Hyperglycemia can lead to an increased sensation of hunger as the body's cells are not effectively receiving the glucose they need for energy, causing the person to feel hungry.
C. "Hyperglycemia causes cool and clammy skin."
Incorrect - Cool and clammy skin are not typical symptoms of hyperglycemia. Hyperglycemia can lead to dry skin, but it does not cause cool and clammy skin.
D. "Hyperglycemia often presents as increased thirst and urination."
Correct - Hyperglycemia often leads to increased thirst and urination. Excess glucose in the blood can cause the kidneys to work harder to filter and eliminate the glucose, leading to increased fluid intake and subsequently increased urination.
E. "Hyperglycemia causes a headache and flushed, dry skin."
Hyperglycemia can cause dehydration, leading to dry, flushed skin and sometimes headaches due to electrolyte imbalances and reduced blood flow to the brain.
Full Explanation
A) Incorrect - Hyperglycemia typically does not lead to weight loss. In fact, it can result in weight gain due to the body's inability to properly use glucose for energy.
B) Correct - Hyperglycemia can lead to an increased sensation of hunger as the body's cells are not effectively receiving the glucose they need for energy, causing the person to feel hungry.
C) Incorrect - Cool and clammy skin are not typical symptoms of hyperglycemia. Hyperglycemia can lead to dry skin, but it does not cause cool and clammy skin.
D) Correct - Hyperglycemia often leads to increased thirst and urination. Excess glucose in the blood can cause the kidneys to work harder to filter and eliminate the glucose, leading to increased fluid intake and subsequently increased urination.
E) Hyperglycemia can cause dehydration, leading to dry, flushed skin and sometimes headaches due to electrolyte imbalances and reduced blood flow to the brain.
Patient Data
Which 3 responses should the diabetic nurse educator provide?
A. Drink between 8 to 10 cups (1.9 to 2.4 liters) of fluids daily.
Incorrect- While hydration is important, this response doesn't directly address the client's question about the content and timing of meals.
B. Choose complex carbohydrates that are high in fiber content.
Correct- Complex carbohydrates high in fiber content have a slower impact on blood glucose levels, promoting better glycemic control.
C. Eliminate the bedtime snack if heartburn develops after eating.
Correct- Bedtime snacks can be helpful to prevent nighttime hypoglycemia, but if heartburn develops, it may be necessary to modify the timing or content of the snack.
D. Increase the percentage of protein in the diet if anemia develops.
Incorrect- This response is not directly related to managing blood glucose levels or gestational diabetes.
E. Avoid foods high in refined sugars.
Correct- Refined sugars can cause rapid spikes in blood glucose levels, so avoiding them helps maintain stable glycemic control.
Full Explanation
A) Incorrect- While hydration is important, this response doesn't directly address the client's question about the content and timing of meals.
B) Correct- Complex carbohydrates high in fiber content have a slower impact on blood glucose levels, promoting better glycemic control.
C) Correct- Bedtime snacks can be helpful to prevent nighttime hypoglycemia, but if heartburn develops, it may be necessary to modify the timing or content of the snack.
D) Incorrect- This response is not directly related to managing blood glucose levels or gestational diabetes.
E) Correct- Refined sugars can cause rapid spikes in blood glucose levels, so avoiding them helps maintain stable glycemic control.