Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing.
Which of the following actions is the nurse’s priority?
A. Call emergency services for the client.
Choice A is wrong because it does not address the immediate need of assessing the respiratory status and may cause unnecessary panic or delay in treatment.
B. Increase the oxygen flow to 3 L/min.
Choice B is wrong because it does not follow the guidelines for oxygen therapy for COPD, which require a prescription and monitoring of oxygen levels. Increasing the oxygen flow without assessing the oxygen level could cause oxygen toxicity or suppress the respiratory drive.
C. Have the client cough and expectorate secretions.
Choice C is wrong because it is not the most urgent action to take. Having the client cough and expectorate secretions may help clear the airway, but it may also increase the work of breathing and worsen hypoxia. Assessing the respiratory status should come first. Normal ranges for oxygen saturation are 95% to 100% for healthy individuals and 88% to 92% for most people with COPD. Normal ranges for blood gas tests vary depending on the laboratory, but generally, normal values for arterial blood gas are: pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, PaO2 80 to 100 mm Hg, HCO3 22 to 26 mEq/L.
D. Assess the client’s respiratory status.
This is the nurse’s priority because it will help determine the severity of the client’s difficulty breathing and guide the appropriate interventions. According to the Mayo Clinic, oxygen therapy for COPD is indicated when there is not enough oxygen in the blood, which can be measured by a pulse oximeter or a blood gas test. Increasing the oxygen flow without assessing the oxygen level could be harmful or ineffective. Having the client cough and expectorate secretions may help clear the airway, but it is not the first action to take. Calling emergency services may be necessary if the client’s condition is life threatening, but it should not be done before assessing the respiratory status.
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Full Explanation
This is the nurse’s priority because it will help determine the severity of the client’s difficulty breathing and guide the appropriate interventions. According to the Mayo Clinic, oxygen therapy for COPD is indicated when there is not enough oxygen in the blood, which can be measured by a pulse oximeter or a blood gas test. Increasing the oxygen flow without assessing the oxygen level could be harmful or ineffective. Having the client cough and expectorate secretions may help clear the airway, but it is not the first action to take. Calling emergency services may be necessary if the client’s condition is life threatening, but it should not be done before assessing the respiratory status.
Choice A is wrong because it does not address the immediate need of assessing the respiratory status and may cause unnecessary panic or delay in treatment.
Choice B is wrong because it does not follow the guidelines for oxygen therapy for COPD, which require a prescription and monitoring of oxygen levels.
Increasing the oxygen flow without assessing the oxygen level could cause oxygen toxicity or suppress the respiratory drive.
Choice C is wrong because it is not the most urgent action to take.
Having the client cough and expectorate secretions may help clear the airway, but it may also increase the work of breathing and worsen hypoxia.
Assessing the respiratory status should come first.
Normal ranges for oxygen saturation are 95% to 100% for healthy individuals and 88% to 92% for most people with COPD. Normal ranges for blood gas tests vary depending on the laboratory, but generally, normal values for arterial blood gas are: pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, PaO2 80 to 100 mm Hg, HCO3 22 to 26 mEq/L.
Similar Questions
A nurse is teaching about values to a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding?
A. “A nurse’s personal values are not considered when making ethical decisions.”
Choice A is wrong because “A nurse’s personal values are not considered when making ethical decisions.” This statement contradicts the ethical principle of integrity, which means that the nurse acts in accordance with their personal and professional values and standards.
B. “A nurse’s behaviors and actions are called values.”
Choice B is wrong because “A nurse’s behaviors and actions are called values.” This statement confuses values with morals, which are the judgments about behaviors and actions based on personal or societal beliefs.
C. “It is important that the nurse is aware of the client’s values.”
This statement indicates an understanding of the ethical principle of respect for autonomy, which means that the nurse respects the client’s right to make their own decisions about their care and respects their values and beliefs.
D. “Value clarification involves maintaining clinical competency.”.
Choice D is wrong because “Value clarification involves maintaining clinical competency.” This statement confuses value clarification with professionalism, which involves maintaining clinical competency, accountability, and responsibility. Value clarification is a process of self-exploration and reflection that helps the nurse identify their own values and understand how they affect their ethical decisions.
E. “Value clarification involves maintaining clinical competency.”.
Full Explanation
This statement indicates an understanding of the ethical principle of respect for autonomy, which means that the nurse respects the client’s right to make their own decisions about their care and respects their values and beliefs.
Choice A is wrong because “A nurse’s personal values are not considered when making ethical decisions.” This statement contradicts the ethical principle of integrity, which means that the nurse acts in accordance with their personal and professional values and standards.
Choice B is wrong because “A nurse’s behaviors and actions are called values.” This statement confuses values with morals, which are the judgments about behaviors and actions based on personal or societal beliefs.
Choice D is wrong because “Value clarification involves maintaining clinical competency.” This statement confuses value clarification with professionalism, which involves maintaining clinical competency, accountability, and responsibility. Value clarification is a process of self-exploration and reflection that helps the nurse identify their own values and understand how they affect their ethical decisions.
In individuals who have appendicitis, the pain will typically localize to McBurney’s point.
Which quadrant of the abdomen is McBurney’s point found?
A. Left lower quadrant.
Choice A is wrong because the left lower quadrant is where the sigmoid colon and part of the small intestine are located. These organs are not related to appendicitis.
B. Left upper quadrant.
Choice B is wrong because the left upper quadrant is where the stomach, spleen, and part of the pancreas are located. These organs are also not related to appendicitis.
C. Right upper quadrant.
Choice C is wrong because the right upper quadrant is where the liver, gallbladder, and part of the small intestine are located. These organs can cause pain in this area if they have problems, but not appendicitis.
D. Right lower quadrant.
McBurney’s point is located one-third of the distance from the right anterior superior iliac spine to the umbilicus. This is where the base of the appendix is attached to the cecum, which is part of the large intestine. When the appendix becomes inflamed or infected, it causes pain in this area.
Full Explanation
Choice A is wrong because the left lower quadrant is where the sigmoid colon and part of the small intestine are located.
These organs are not related to appendicitis.
Choice B is wrong because the left upper quadrant is where the stomach, spleen, and part of the pancreas are located.
These organs are also not related to appendicitis.
Choice C is wrong because the right upper quadrant is where the liver, gallbladder, and part of the small intestine are located. These organs can cause pain in this area if they have problems, but not appendicitis
While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins.
Which sentinel event is this action intended to prevent?
A. The lack of healing of the stump.
Choice A is wrong because the lack of healing of the stump is not a sentinel event. It is a possible complication of amputation that may be related to the natural course of the patient’s illness or underlying condition.
B. Ineffective control of the client’s pain.
Choice B is wrong because ineffective control of the client’s pain is not a sentinel event. It is a quality of care issue that may affect the patient’s comfort and recovery, but it does not result in death, permanent harm, or severe temporary harm.
C. The removal of the wrong arm.
This action is intended to prevent a sentinel event, which is a patient safety event that results in death, permanent harm, or severe temporary harm. A sentinel event is a serious adverse event that signals the need for immediate investigation and response. Removing the wrong arm would be a devastating and irreversible outcome for the patient and the health care provider.
D. The client being mildly sedated.
Choice D is wrong because the client being mildly sedated is not a sentinel event. It is a level of anesthesia that may be appropriate for some types of surgery, but it does not result in death, permanent harm, or severe temporary harm.
Full Explanation
This action is intended to prevent a sentinel event, which is a patient safety event that results in death, permanent harm, or severe temporary harm. A sentinel event is a serious adverse event that signals the need for immediate investigation and response. Removing the wrong arm would be a devastating and irreversible outcome for the patient and the health care provider.
Choice A is wrong because the lack of healing of the stump is not a sentinel event. It is a possible complication of amputation that may be related to the natural course of the patient’s illness or underlying condition.
Choice B is wrong because ineffective control of the client’s pain is not a sentinel event. It is a quality of care issue that may affect the patient’s comfort and recovery, but it does not result in death, permanent harm, or severe temporary harm.
Choice D is wrong because the client being mildly sedated is not a sentinel event. It is a level of anesthesia that may be appropriate for some types of surgery, but it does not result in death, permanent harm, or severe temporary harm.