Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
A. Hold the client's arms and legs from moving.
Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.
B. Place the client back in bed.
Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the floor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.
C. Place the client on his side.
Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.
D. Insert a tongue blade in the client's mouth.
Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.
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Full Explanation
Placing the client on his side is an essential action to take during a seizure, as it can prevent airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.
Holding the client's arms and legs from moving is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.
Placing the client back in bed is not necessary, as it can cause harm or delay care. The client should be left on the floor, unless it is unsafe or uncomfortable, and padded with pillows or blankets to protect from injury.
Inserting a tongue blade in the client's mouth is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.
Similar Questions
A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?
A. "A headache is an indication of an allergy to the medication."
"A headache is an indication of an allergy to the medication." is not correct, as a headache is not a sign of an allergic reaction to nitroglycerin. An allergic reaction would manifest as rash, itching, swelling, or difficulty breathing.
B. "A headache indicates tolerance to the medication."
"A headache indicates tolerance to the medication." is not accurate, as a headache does not indicate tolerance to nitroglycerin. Tolerance would manifest as reduced or absent relief from anginal pain.
C. "A headache is likely due to the anxiety about the chest pain."
"A headache is likely due to the anxiety about the chest pain." is not plausible, as a headache is not likely due to the anxiety about the chest pain. Anxiety would manifest as nervousness, restlessness, palpitations, or sweating.
D. "A headache is an expected adverse effect of the medication."
A headache is a common and expected adverse effect of nitroglycerin, due to its vasodilating action. The client can take an over-the-counter analgesic to relieve the headache, unless contraindicated.
Full Explanation
A headache is a common and expected adverse effect of nitroglycerin, due to its vasodilating action. The client can take an over-the-counter analgesic to relieve the headache, unless contraindicated.
"A headache is an indication of an allergy to the medication." is not correct, as a headache is not a sign of an allergic reaction to nitroglycerin. An allergic reaction would manifest as rash, itching, swelling, or difficulty breathing.
"A headache indicates tolerance to the medication." is not accurate, as a headache does not indicate tolerance to nitroglycerin. Tolerance would manifest as reduced or absent relief from anginal pain.
"A headache is likely due to the anxiety about the chest pain." is not plausible, as a headache is not likely due to the anxiety about the chest pain. Anxiety would manifest as nervousness, restlessness, palpitations, or sweating.
A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?
A. "Limit your alcohol consumption to three drinks a day."
Alcohol should be limited to no more than one drink per day for women and two for men; three drinks a day exceeds recommended limits.
B. "Plan to lower saturated fats to 10 percent of your daily calorie intake."
Reducing saturated fat intake to around 10 percent of daily calories helps manage hypertension and supports overall cardiovascular health.
C. "Diuretics are the first type of medication to control hypertension."
Diuretics are commonly prescribed for hypertension, but medication choice depends on the client’s individual needs and risk factors; it is not universally the first-line option.
D. "Reaching your goal blood pressure will occur within 2 months."
Achieving goal blood pressure varies among clients and may take longer than 2 months; it cannot be guaranteed within a specific timeframe.
Full Explanation
A. Alcohol should be limited to no more than one drink per day for women and two for men; three drinks a day exceeds recommended limits.
B. Reducing saturated fat intake to around 10 percent of daily calories helps manage hypertension and supports overall cardiovascular health.
C. Diuretics are commonly prescribed for hypertension, but medication choice depends on the client’s individual needs and risk factors; it is not universally the first-line option.
D. Achieving goal blood pressure varies among clients and may take longer than 2 months; it cannot be guaranteed within a specific timeframe.
A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?
A. Instruct the client to perform range-of-motion exercises to his lower extremities.
Instructing the client to perform range-of-motion exercises to his lower extremities is not appropriate, as it can increase the risk of bleeding or dislodging the arterial sheath or closure device. The client should keep the affected leg straight and avoid bending or lifting it for several hours after the procedure, or as directed by the provider.
B. Restrict the client's fluid intake.
Restricting the client's fluid intake is not necessary, as fluid intake can help prevent dehydration and contrast- induced nephropathy following a cardiac catheterization. The client should be encouraged to drink fluids, unless contraindicated.
C. Perform neurovascular checks with vital signs.
Performing neurovascular checks with vital signs is an important action to take following a cardiac catheterization accessed through the femoral artery, as it can help monitor for complications such as bleeding, hematoma, infection, thrombosis, or embolism. The nurse should assess the color, temperature, sensation, movement, and pulses of the affected leg, as well as the blood pressure, heart rate, and oxygen saturation of the client.
D. Ambulate the client 1 hr following the procedure.
Ambulating the client 1 hr following the procedure is not advisable, as it can cause bleeding, hematoma, or vascular injury. The client should remain on bed rest for 2 to 6 hours after the procedure, or as directed by the provider, and resume ambulation gradually and with assistance.
Full Explanation
Performing neurovascular checks with vital signs is an important action to take following a cardiac catheterization accessed through the femoral artery, as it can help monitor for complications such as bleeding, hematoma, infection, thrombosis, or embolism. The nurse should assess the color, temperature, sensation, movement, and pulses of the affected leg, as well as the blood pressure, heart rate, and oxygen saturation of the client.
Instructing the client to perform range-of-motion exercises to his lower extremities is not appropriate, as it can increase the risk of bleeding or dislodging the arterial sheath or closure device. The client should keep the affected leg straight and avoid bending or lifting it for several hours after the procedure, or as directed by the provider.
Restricting the client's fluid intake is not necessary, as fluid intake can help prevent dehydration and contrast- induced nephropathy following a cardiac catheterization. The client should be encouraged to drink fluids, unless contraindicated.
d Ambulating the client 1 hr following the procedure is not advisable, as it can cause bleeding, hematoma, or vascular injury. The client should remain on bed rest for 2 to 6 hours after the procedure, or as directed by the provider, and resume ambulation gradually and with assistance.