Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
After assessing the client, the nurse contacts the provider and completes an incident report.
Which of the following components of professionalism is the nurse demonstrating?
A. Accountability.
B. Confidence.
C. Fairness.
D. Advocacy.
This question is an excerpt from Nurse Dive's nursing test bank - ATI custom fundamentals final proctored exam fall 2023. Take the full exam now
Full Explanation
Similar Questions
A newly licensed nurse is applying prescribed wrist restraints on a client.
Which of the following actions should the nurse take?
A. Anticipate removing the restraints every 4 hr.
Anticipate removing the restraints every 4 hr. This is incorrect because restraints should be removed more frequently to assess the client's skin integrity, circulation, and overall need for continued restraint. Best practices typically suggest removing restraints every 2 hours for these checks.
B. Ensure four fingers fit under the restraints to prevent constriction.
Ensure four fingers fit under the restraints to prevent constriction. This is incorrect as well. The correct practice is to ensure that only two fingers can fit under the restraints. Allowing four fingers may lead to improper restraint, increasing the risk of injury or the restraint slipping off.
C. Secure the restraints using a quick-release tie.
Secure the restraints using a quick-release tie. This is correct because quick-release ties are designed to allow rapid removal of restraints in case of emergency, ensuring the client's safety while also maintaining restraint effectiveness.
D. Secure the restraints to the lowest bar of the side rail.
Secure the restraints to the lowest bar of the side rail. This is incorrect because restraints should never be secured to a movable part like the side rail, as it can cause injury if the rail is adjusted. Restraints should be secured to the bed frame, which is stable and stationary.
Full Explanation
The correct answer is Choice C. Secure the restraints using a quick-release tie.
Choice A rationale: Anticipate removing the restraints every 4 hr. This is incorrect because restraints should be removed more frequently to assess the client's skin integrity, circulation, and overall need for continued restraint. Best practices typically suggest removing restraints every 2 hours for these checks.
Choice B rationale: Ensure four fingers fit under the restraints to prevent constriction. This is incorrect as well. The correct practice is to ensure that only two fingers can fit under the restraints. Allowing four fingers may lead to improper restraint, increasing the risk of injury or the restraint slipping off.
Choice C rationale: Secure the restraints using a quick-release tie. This is correct because quick-release ties are designed to allow rapid removal of restraints in case of emergency, ensuring the client's safety while also maintaining restraint effectiveness.
Choice D rationale: Secure the restraints to the lowest bar of the side rail. This is incorrect because restraints should never be secured to a movable part like the side rail, as it can cause injury if the rail is adjusted. Restraints should be secured to the bed frame, which is stable and stationary.
A nurse is planning care for clients.
Which of the following tasks can the nurse delegate to an assistive personnel (AP)?
A. Providing tracheostomy care for a client.
Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).
B. Assessing a client who just returned from surgery.
Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.
C. Teaching a client who is preoperative how to use an incentive spirometer.
Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.
D. Obtaining a blood pressure for a client who is to be discharged later in the day.
Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.
Full Explanation
The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.
Choice A rationale:
Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).
Choice B rationale:
Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.
Choice C rationale:
Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.
Choice D rationale:
Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.
A nurse is caring for a client who is 3 hr postoperative following abdominal surgery.
Which of the following assessment data should the nurse report to the provider?
A. Serosanguineous drainage noted on the abdominal dressing.
Serosanguineous drainage noted on the abdominal dressing is a common finding in the early postoperative period. It is a mixture of clear and bloody drainage and is often seen after surgery. This does not typically require immediate reporting unless it becomes excessive or changes significantly. The nurse can continue to monitor and assess the situation.
B. Postoperative laboratory results are Hgb 15% and Hct 40%.
Postoperative laboratory results of Hgb 15% and Hct 40% are within the normal range for most adults, and there is no immediate need to report these results to the provider. These values suggest that the client's hemoglobin and hematocrit levels are within an acceptable range, indicating adequate oxygen-carrying capacity.
C. The client's urine output has been 50 mL since surgery.
The client's urine output has been 50 mL since surgery, which is significantly decreased and could indicate a potential issue with renal function or fluid balance. This should be reported to the provider, as it may be indicative of kidney impairment, dehydration, or other postoperative complications.
D. The client's pain level has decreased since the administration of morphine.
The client's pain level decreasing after the administration of morphine is an expected response to pain management interventions. There is no need to report this information to the provider unless the pain relief is inadequate or the client experiences adverse effects. Pain management is an essential part of postoperative care, and successful pain reduction is a positive outcome.
Full Explanation
Choice A rationale:
Serosanguineous drainage noted on the abdominal dressing is a common finding in the early postoperative period. It is a mixture of clear and bloody drainage and is often seen after surgery. This does not typically require immediate reporting unless it becomes excessive or changes significantly. The nurse can continue to monitor and assess the situation.
Choice B rationale:
Postoperative laboratory results of Hgb 15% and Hct 40% are within the normal range for most adults, and there is no immediate need to report these results to the provider. These values suggest that the client's hemoglobin and hematocrit levels are within an acceptable range, indicating adequate oxygen-carrying capacity.
Choice C rationale:
The client's urine output has been 50 mL since surgery, which is significantly decreased and could indicate a potential issue with renal function or fluid balance. This should be reported to the provider, as it may be indicative of kidney impairment, dehydration, or other postoperative complications.
Choice D rationale:
The client's pain level decreasing after the administration of morphine is an expected response to pain management interventions. There is no need to report this information to the provider unless the pain relief is inadequate or the client experiences adverse effects. Pain management is an essential part of postoperative care, and successful pain reduction is a positive outcome.