Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client with a terminal illness asks the nurse, “If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?” Which of the following statements should the nurse provide to explain a DNR prescription?
A. “A DNR prescription means you will only receive pain medication for your treatments.”.
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
B. “A DNR prescription will limit your current treatment regimen.”.
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
C. “A DNR prescription will allow you to continue with your current treatment regimen.”.
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
D. “A DNR prescription will limit your ability to receive invasive procedures.”. .
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Lpn Med Surg Proctored Exam 1. Take the full exam now
Full Explanation
Choice A rationale
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
Choice B rationale
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
Choice C rationale
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
Choice D rationale
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.
Similar Questions
A nurse is assisting with the care of a client.
- At 1600, the nurse administered an antibiotic as prescribed.
- At 1630, the nurse noted that the client’s bilateral breath sounds were clear and present throughout.
- The client reports itching on the chest and has urticaria over the chest and trunk.
- The client states they are having difficulty swallowing and feel as if there is a lump in their throat.
- The nurse hears bilateral breath sounds with scattered wheezing throughout.
What should the nurse do next?
A. Stop the antibiotic infusion immediately and notify the healthcare provider.
Stop the antibiotic infusion immediately and notify the healthcare provider.Explanation: This is the correct first action. The client is showing signs of a severe allergic reaction, possibly anaphylaxis. Stopping the antibiotic prevents further exposure to the allergen, and notifying the provider ensures prompt medical intervention.
B. Apply a cool compress to the itchy areas and monitor for further reactions.
Apply a cool compress to the itchy areas and monitor for further reactions.Explanation: While a cool compress may help with itching, it does not address the serious symptoms of anaphylaxis, such as difficulty swallowing and wheezing. Immediate action is required beyond just symptom management.
C. Administer diphenhydramine (Benadryl) as a first-line treatment.
Administer diphenhydramine (Benadryl) as a first-line treatment. Explanation: While antihistamines like diphenhydramine are helpful in treating mild allergic reactions, this case suggests anaphylaxis, which requires epinephrine as the first-line treatment. Administering diphenhydramine alone is not sufficient for airway compromise.
D. Assess the client’s throat for swelling and encourage them to drink water.
Assess the client’s throat for swelling and encourage them to drink water.Explanation: Assessing for throat swelling is important, but encouraging oral intake is not appropriate when a client has difficulty swallowing, as this could worsen airway obstruction. The priority is stopping the medication and seeking emergency intervention.
Full Explanation
A. Stop the antibiotic infusion immediately and notify the healthcare provider.
- Explanation: This is the correct first action. The client is showing signs of a severe allergic reaction, possibly anaphylaxis. Stopping the antibiotic prevents further exposure to the allergen, and notifying the provider ensures prompt medical intervention.
B. Apply a cool compress to the itchy areas and monitor for further reactions.
- Explanation: While a cool compress may help with itching, it does not address the serious symptoms of anaphylaxis, such as difficulty swallowing and wheezing. Immediate action is required beyond just symptom management.
C. Administer diphenhydramine (Benadryl) as a first-line treatment.
- Explanation: While antihistamines like diphenhydramine are helpful in treating mild allergic reactions, this case suggests anaphylaxis, which requires epinephrine as the first-line treatment. Administering diphenhydramine alone is not sufficient for airway compromise.
D. Assess the client’s throat for swelling and encourage them to drink water.
- Explanation: Assessing for throat swelling is important, but encouraging oral intake is not appropriate when a client has difficulty swallowing, as this could worsen airway obstruction. The priority is stopping the medication and seeking emergency intervention.
A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness.
Which method should the nurse use to elicit a response from a painful stimulus?
A. Press down on the orbital area of the eye.
Pressing down on the orbital area of the eye is not typically used as it can cause injury to the eye.
B. Pinch the trapezius muscle.
Pinching the trapezius muscle is a common method used to elicit a response from a painful stimulus in an unresponsive patient. It is considered safe and effective.
C. Use a 25 gauge needle.
Using a 25 gauge needle to elicit a response is not typically recommended as it can cause unnecessary harm to the patient.
D. Elicit a reflex with a reflex hammer.
Eliciting a reflex with a reflex hammer is not typically used to assess responsiveness to painful stimuli. Reflex hammers are primarily used to test reflexes, not responsiveness.
Full Explanation
Choice A rationale
Pressing down on the orbital area of the eye is not typically used as it can cause injury to the eye.
Choice B rationale
Pinching the trapezius muscle is a common method used to elicit a response from a painful stimulus in an unresponsive patient. It is considered safe and effective.
Choice C rationale
Using a 25 gauge needle to elicit a response is not typically recommended as it can cause unnecessary harm to the patient.
Choice D rationale
Eliciting a reflex with a reflex hammer is not typically used to assess responsiveness to painful stimuli. Reflex hammers are primarily used to test reflexes, not responsiveness.
A nurse is preparing to administer heparin subcutaneously to a client.
Which action by the nurse is appropriate?
A. Inject the medication into the abdomen above the level of the iliac crest.
The abdomen is a common site for subcutaneous injections because it allows for consistent absorption. The area above the iliac crest is often used because it is easy to access and usually has enough subcutaneous tissue for the injection.
B. Use a 1-inch needle to inject the medication.
A 1-inch needle is typically too long for a subcutaneous injection. A shorter needle (usually 1/2 to 5/8 inch) is usually used to ensure the medication is delivered to the subcutaneous tissue.
C. Use a 22-gauge needle to inject the medication.
A 22-gauge needle is typically too large for a subcutaneous injection. Smaller gauge needles (usually 25-27 gauge) are usually used for subcutaneous injections.
D. Massage the injection site after administration of the medication.
Massaging the injection site after administration of heparin is not recommended. It can cause the medication to be absorbed too quickly and can also lead to bruising.
Full Explanation
Choice A rationale
The abdomen is a common site for subcutaneous injections because it allows for consistent absorption. The area above the iliac crest is often used because it is easy to access and usually has enough subcutaneous tissue for the injection.
Choice B rationale
A 1-inch needle is typically too long for a subcutaneous injection. A shorter needle (usually 1/2 to 5/8 inch) is usually used to ensure the medication is delivered to the subcutaneous tissue.
Choice C rationale
A 22-gauge needle is typically too large for a subcutaneous injection. Smaller gauge needles (usually 25-27 gauge) are usually used for subcutaneous injections.
Choice D rationale
Massaging the injection site after administration of heparin is not recommended. It can cause the medication to be absorbed too quickly and can also lead to bruising.