Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?
A. Keep the four side rails up on beds at night.
Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B. Institute rounds every 2 hr during the day to offer toileting
Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C. Accompany residents older than 85 years of age during ambulation
Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D. Apply vest restraints on residents who are confused.
Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.
E. Apply vest restraints on residents who are confused.
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Full Explanation
A. Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B. Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C. Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D. Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.
Similar Questions
A nurse is receiving a verbal prescription from the provider for a client who is having increased pain. The nurse should transcribe which of the following prescriptions in the client's medical record?
A. MSO4 10 mg IVP q4° prn for pain
"MSO4 10 mg IVP q4° prn for pain" lacks clarity in abbreviation and dosing instructions.
B. MS 10 mg IV every 4 pm for pain
"MS 10 mg IV every 4 pm for pain" contains an unclear frequency and timing.
C. Morphine sulfate 10 mg IV q4h IV pm for pain
"Morphine sulfate 10 mg IV q4h IV pm for pain" contains redundant dosing information and unclear timing.
D. Morphine sulfate 10 mg every 4 hours IV prn for pain
"Morphine sulfate 10 mg every 4 hours IV prn for pain" provides clear and appropriate information regarding medication, dosage, route, frequency, and indication.
Full Explanation
A. "MSO4 10 mg IVP q4° prn for pain" lacks clarity in abbreviation and dosing instructions.
B. "MS 10 mg IV every 4 pm for pain" contains an unclear frequency and timing.
C. "Morphine sulfate 10 mg IV q4h IV pm for pain" contains redundant dosing information and unclear timing.
D. "Morphine sulfate 10 mg every 4 hours IV prn for pain" provides clear and appropriate information regarding medication, dosage, route, frequency, and indication.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
A. Generalized rash over trunk
A generalized rash over the trunk might indicate various conditions but might not be an immediate concern in the context of meningitis.
B. Increased temperature
An increased temperature is an expected finding in meningitis and should bemonitored but might not necessitate immediate reporting unless exceptionally high or coupled with other concerning symptoms.
C. Report of photophobia
Photophobia, or sensitivity to light, is a common symptom in meningitis but alone might not necessitate immediate reporting if the client's other symptoms are stable.
D. Decreased level of consciousness
Decreased level of consciousness can indicate neurological deterioration and requires immediate attention as it could signal worsening of the client's condition.
Full Explanation
A. A generalized rash over the trunk might indicate various conditions but might not be an immediate concern in the context of meningitis.
B. An increased temperature is an expected finding in meningitis and should be
monitored but might not necessitate immediate reporting unless exceptionally high or coupled with other concerning symptoms.
C. Photophobia, or sensitivity to light, is a common symptom in meningitis but alone might not necessitate immediate reporting if the client's other symptoms are stable.
D. Decreased level of consciousness can indicate neurological deterioration and requires immediate attention as it could signal worsening of the client's condition.
A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia.Which of the following actions by the AP should the nurse identify as correct technique?
A. Providing a 10 min rest period prior to meals
Providing a rest period prior to meals might be beneficial for some individuals but isn't directly related to correct feeding technique for someone with dysphagia.
B. Elevating the head of the client's bed to 30° during mealtime
Elevating the head of the client's bed to 30° during mealtime helps prevent aspiration and promotes safer swallowing for someone with dysphagia.
C. Withholding fluids until the end of the meal
Withholding fluids until the end of the meal is not appropriate as it can increase the risk of aspiration and dehydration.
D. Instructing the client to place her chin toward her chest when swallowing
Instructing the client to place her chin toward her chest when swallowing is not a recommended technique for someone with dysphagia as it can increase the risk of
Full Explanation
A: Providing a 10-minute rest period prior to meals can be beneficial for some clients, but it is not specifically related to the prevention of aspiration in clients with dysphagia. Rest periods do not directly facilitate safer swallowing processes.
B: Elevating the head of the client's bed to 30° during mealtime is the correct technique for a client with dysphagia. This position helps prevent aspiration, which can occur if food or liquids enter the lungs instead of going down the esophagus. The semi-upright position aids in the proper alignment of the esophagus and reduces the risk of choking.
C: Withholding fluids until the end of the meal is not an appropriate technique for a client with dysphagia. Fluids are often needed to help swallow and clear the mouth of food particles. Additionally, providing fluids throughout the meal can help prevent dehydration.
D: Instructing the client to place her chin toward her chest when swallowing can help prevent aspiration in clients with dysphagia. However, this technique should be used in conjunction with other methods, such as the correct positioning of the bed, to ensure safety and effectiveness.