Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A diabetic client presents to the acute care facility for the amputation of two gangrenous digits on her left foot.
Which type of perfusion issue has caused this condition?
A. Arterial insufficiency.
This means that the blood flow to the affected area is reduced due to narrowed or blocked arteries. This can cause tissue death or gangrene. Diabetes can damage the blood vessels and affect blood flow, increasing the risk of gangrene.
B. Stasis.
Stasis is wrong because it refers to a condition where blood pools in the veins of the legs, causing swelling and skin changes. It does not cause gangrene by itself.
C. Venous insufficiency.
Venous insufficiency is wrong because it refers to a condition where the veins in the legs have problems sending blood back to the heart, causing swelling and skin ulcers. It does not cause gangrene by itself.
D. Varicose veins.
Varicoseveins are wrong because they are enlarged veins that may cause pain or discomfort, but do not cause gangrene by themselves.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Sp23 N144 FINAL Proctored Exam. Take the full exam now
Full Explanation
damage the blood vessels and affect blood flow, increasing the risk of gangrene. Choice B. Stasis is wrong because it refers to a condition where blood pools in the veins of the legs, causing swelling and skin changes. It does not cause gangrene by itself.
Choice C. Venous insufficiency is wrong because it refers to a condition where the veins in the legs have problems sending blood back to the heart, causing swelling and skin ulcers. It does not cause gangrene by itself.
Choice D. Varicose veins are wrong because they are enlarged veins that may cause pain or discomfort, but do not cause gangrene by themselves.
Similar Questions
A nurse is discussing the reporting of elder abuse with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “Reporting is voluntary for health care workers.”
Choice A is wrong because reporting is not voluntary for health care workers.
B. “If suspicion of abuse exists then reporting is mandatory.”
If suspicion of abuse exists then reporting is mandatory. According to the National Institute on Aging, health care providers play an important role in recognizing and reporting elder abuse. They have a legal and ethical obligation to report any suspected cases of abuse to the appropriate authorities. Reporting is not voluntary for health care workers.
C. “Civil liability can result if the abuse can’t be proven.”
Choice C is wrong because civil liability cannot result if the abuse can’t be proven. Health care providers are protected by immunity laws when they report suspected abuse in good faith.
D. “Evidence of abuse must be collected prior to reporting.”.
Choice D is wrong because evidence of abuse does not need to be collected prior to reporting. Health care providers should report any signs or symptoms of abuse, even if they are not conclusive.
Full Explanation
According to the National Institute on Aging, health care providers play an important role in recognizing and reporting elder abuse. They have a legal and ethical obligation to report any suspected cases of abuse to the appropriate authorities. Reporting is not voluntary for health care workers.
Choice A is wrong because reporting is not voluntary for health care workers. Choice C is wrong because civil liability cannot result if the abuse can’t be proven. Health care providers are protected by immunity laws when they report suspected abuse in good faith.
Choice D is wrong because evidence of abuse does not need to be collected prior to reporting. Health care providers should report any signs or symptoms of abuse, even if they are not conclusive.
The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?
A. Encouraging the client to increase intake of foods that contain high fat to increase GI motility.
Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.
B. Encouraging the client to increase solid food intake to promote peristalsis.
Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.
C. Encouraging the client to increase intake of foods that contain fiber.
Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.
D. Withholding food and oral fluids until intestinal mobility has returned.
Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.
Full Explanation
Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.
Giving food and fluids to a client with POI may worsen the condition and cause complications.
Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.
Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.
Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.
Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.
The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD).
Which medication does the nurse anticipate to decrease this client’s risk for developing a respiratory infection?
A. An influenza vaccine.
This is because people with COPD are more likely to catch respiratory infections such as colds, flu and pneumonia, which can worsen their symptoms and cause further lung damage. An influenza vaccine can help prevent flu and reduce the risk of complications.
B. A broad-spectrum antibiotic.
A broad-spectrum antibiotic is wrong because antibiotics are only effective against bacterial infections, not viral ones. Antibiotics are usually prescribed for COPD exacerbations caused by bacterial infections, but not for prevention.
C. A bronchodilator.
A bronchodilator is wrong because bronchodilators are medications that relax the muscles around the airways and make breathing easier. They are used to treat the symptoms of COPD, but they do not prevent respiratory infections.
D. A corticosteroid.
A costeroid is wrong because corticosteroids are anti inflammatory drugs that reduce swelling and mucus production in the airways. They are also used to treat the symptoms of COPD, but they do not prevent respiratory infections. In fact, long-term use of corticosteroids may increase the risk of infections by suppressing the immune system.
Full Explanation
This is because people with COPD are more likely to catch respiratory infections such as colds, flu and pneumonia, which can worsen their symptoms and cause further lung damage. An influenza vaccine can help prevent flu and reduce the risk of complications.
Choice B. A broad-spectrum antibiotic is wrong because antibiotics are only effective against bacterial infections, not viral ones. Antibiotics are usually prescribed for COPD exacerbations caused by bacterial infections, but not for prevention.
Choice C. A bronchodilator is wrong because bronchodilators are medications that relax the muscles around the airways and make breathing easier. They are used to treat the symptoms of COPD, but they do not prevent respiratory infections.
Choice D. A corticosteroid is wrong because corticosteroids are anti inflammatory drugs that reduce swelling and mucus production in the airways. They are also used to treat the symptoms of COPD, but they do not prevent respiratory infections. In fact, long-term use of corticosteroids may increase the risk of infections by suppressing the immune system.