Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client with diabetes has returned from the post-anesthesia care unit (PACU) after a below-the-knee amputation (BKA) of the left leg.
Which physician’s order should the nurse implement?
A. Administer morphine 2-4 mg IV prn for pain.
After a below-the-knee amputation (BKA), pain management is crucial. Administering morphine 2-4 mg IV prn for pain is an appropriate physician’s order to implement. Pain can be severe after amputation, and effective pain management can improve patient comfort, reduce anxiety, and aid in recovery.
B. Apply a figure of 8 pressure dressing starting day two post-operatively.
Applying a figure of 8 pressure dressing starting day two post-operativelyis not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.
C. Administer antibiotics as prescribed.
Administering antibiotics as prescribedis important, but it is not the first action to take. Pain management is the priority immediately after surgery.
D. Apply ice to the stump for 60-90 minutes.
Applying ice to the stump for 60-90 minutesis not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.
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Full Explanation
The correct answer is Choice A. After a below-the-knee amputation (BKA), pain management is crucial. Administering morphine 2-4 mg IV prn for pain is an appropriate physician’s order to implement. Pain can be severe after amputation, and effective pain management can improve patient comfort, reduce anxiety, and aid in recovery. Applying a figure of 8 pressure dressing starting day two post-operatively (Choice B) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact. Administering antibiotics as prescribed (Choice C) is important, but it is not the first action to take. Pain management is the priority immediately after surgery. Applying ice to the stump for 60-90 minutes (Choice D) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.
Similar Questions
A client is receiving heparin sodium 1000 units per hour via an infusion and warfarin sodium 2.5 mg PO for thrombophlebitis in the left leg.
The nurse educates the client that heparin and warfarin are prescribed together because:
A. Smaller doses of both drugs can be used with this method.
While it might seem that smaller doses of both drugs could be used when they are prescribed together, this is not the primary reason for using heparin and warfarin together. Both drugs have different mechanisms of action and are used for their unique therapeutic effects.
B. This combination facilitates the thrombolysis more quickly.
The combination of heparin and warfarin does not facilitate thrombolysis more quickly. Thrombolysis is the process of breaking down clots, and while these medications can prevent the formation of new clots, they do not actively break down existing ones.
C. The heparin provides anticoagulation until the warfarin becomes effective.
Heparin and warfarin are often used together in the treatment of thrombophlebitis because they provide different benefits. Heparin acts quickly to prevent further clotting and allows the body to naturally break down existing clots. Warfarin, on the other hand, takes several days to become effective. Therefore, heparin is used to provide immediate anticoagulation until the warfarin becomes effective.
D. This combination provides immediate anticoagulation.
While it’s true that the combination of heparin and warfarin provides immediate anticoagulation, this is primarily due to the action of heparin. Warfarin takes several days to become effective, so it does not contribute to the immediate anticoagulant effect.
Full Explanation
Choice A rationale
While it might seem that smaller doses of both drugs could be used when they are prescribed together, this is not the primary reason for using heparin and warfarin together. Both drugs have different mechanisms of action and are used for their unique therapeutic effects.
Choice B rationale
The combination of heparin and warfarin does not facilitate thrombolysis more quickly. Thrombolysis is the process of breaking down clots, and while these medications can prevent the formation of new clots, they do not actively break down existing ones.
Choice C rationale
Heparin and warfarin are often used together in the treatment of thrombophlebitis because they provide different benefits. Heparin acts quickly to prevent further clotting and allows the body to naturally break down existing clots. Warfarin, on the other hand, takes several days to become effective. Therefore, heparin is used to provide immediate anticoagulation until the warfarin becomes effective.
Choice D rationale
While it’s true that the combination of heparin and warfarin provides immediate anticoagulation, this is primarily due to the action of heparin. Warfarin takes several days to become effective, so it does not contribute to the immediate anticoagulant effect.
The nurse is caring for the following four clients on the nursing unit.
Which client is at the highest risk for the development of deep vein thrombosis?
A. 55-year-old man with a past medical history of a myocardial infarction.
While a past medical history of myocardial infarction does increase the risk of deep vein thrombosis (DVT), it is not the highest risk factor among the options provided. Other factors such as immobility, surgery, and certain medical conditions can pose a higher risk.
B. 45-year-old woman post laparoscopic knee replacement.
Postoperative patients, such as those who have had a laparoscopic knee replacement, are at an increased risk for DVT due to periods of immobility and changes in blood flow and clotting. However, the risk is not as high as in patients who have undergone major open abdominal surgery.
C. 65-year-old woman post major open abdominal surgery.
Patients who have undergone major open abdominal surgery are at the highest risk for the development of DVT among the options provided. The surgery itself, along with the postoperative period of immobility, significantly increases the risk of DVT34567.
D. 50-year-old man with a peptic ulcer.
While peptic ulcers can be associated with certain risk factors for DVT, such as age and immobility due to pain, they do not pose as high a risk as major open abdominal surgery.
Full Explanation
Choice A rationale
While a past medical history of myocardial infarction does increase the risk of deep vein thrombosis (DVT), it is not the highest risk factor among the options provided. Other factors such as immobility, surgery, and certain medical conditions can pose a higher risk.
Choice B rationale
Postoperative patients, such as those who have had a laparoscopic knee replacement, are at an increased risk for DVT due to periods of immobility and changes in blood flow and clotting.
However, the risk is not as high as in patients who have undergone major open abdominal surgery.
Choice C rationale
Patients who have undergone major open abdominal surgery are at the highest risk for the development of DVT among the options provided. The surgery itself, along with the postoperative period of immobility, significantly increases the risk of DVT34567.
Choice D rationale
While peptic ulcers can be associated with certain risk factors for DVT, such as age and immobility due to pain, they do not pose as high a risk as major open abdominal surgery.
A client has been taking glipizide for 6 months and reports to the nurse that their urine has become darker since starting the medication.
What should be the nurse’s initial action?
A. Review the results of liver function studies.
Dark urine can be a sign of liver dysfunction, which can be a side effect of glipizide. Therefore, reviewing the results of liver function studies would be an appropriate initial action to determine if the medication is affecting the client’s liver function.
B. Instruct the client to increase their water intake.
While increasing water intake can sometimes help with certain side effects of medications, it would not address the potential issue of liver dysfunction indicated by the dark urine.
C. Check the client’s weight.
Checking the client’s weight would not provide information related to the cause of the dark urine.
D. Test a sample of urine for the presence of occult blood.
Testing a sample of urine for the presence of occult blood could be useful if there was a suspicion of bleeding, but it would not address the potential issue of liver dysfunction indicated by the dark urine.
Full Explanation
Choice A rationale
Dark urine can be a sign of liver dysfunction, which can be a side effect of glipizide. Therefore, reviewing the results of liver function studies would be an appropriate initial action to determine if the medication is affecting the client’s liver function.
Choice B rationale
While increasing water intake can sometimes help with certain side effects of medications, it would not address the potential issue of liver dysfunction indicated by the dark urine.
Choice C rationale
Checking the client’s weight would not provide information related to the cause of the dark urine.
Choice D rationale
Testing a sample of urine for the presence of occult blood could be useful if there was a suspicion of bleeding, but it would not address the potential issue of liver dysfunction indicated by the dark urine.