Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist.
Which of the following information should the nurse plan to include?
A. Family medical history
Family medical history may be important for overall client care, but isnot directly relevant to a referral for a physical therapist.
B. Medications taken prior to admission
Medications taken prior to admission may be relevant if they affect the client's physical abilities or pain level, but again, physical assessment findings are more directly related to the referral for a physical therapist.
C. Physical assessment findings
Are important to include in a referral for a physical therapist because they provide information about the client's current physical condition, including range of motion, strength, and any areas of pain or discomfort. This information is essential for the physical therapist to develop an appropriate treatment plan for the client.
D. Medical health insurance claims
Medical health insurance claims may be important for overall client care, but isnot directly relevant to a referral for a physical therapist.
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Full Explanation
c. Physical assessment findings
Physical assessment findings are important to include in a referral for a physical therapist because they provide information about the client's current physical condition, including range of motion, strength, and any areas of pain or discomfort.
This information is essential for the physical therapist to develop an appropriate treatment plan for the client. Family medical history and medical health insurance claims may be important for overall client care, but are not directly relevant to a referral for a physical therapist.
Medications taken prior to admission may be relevant if they affect the client's physical abilities or pain level, but again, physical assessment findings are more directly related to the referral for a physical therapist.
Similar Questions
A nurse is preparing to provide tracheostomy care for a client.
Which of the following actions should the nurse plan to take?
A. Clean the stoma using an inward to outward circular motion.
When providing tracheostomy care, the nurse should clean the stoma using an inward to outward circular motion to remove any secretions or debris. It is important to avoid using excessive force or pressure, which can cause trauma to the stoma.
B. Cleanse the inner cannula with isopropyl alcohol.
Cleansing the inner cannula with isopropyl alcohol may be appropriate for some clients, but it is important to follow the healthcare provider's orders regarding inner cannula care.
C. Ensure at least three finger widths of space under tracheostomy ties.
When securing the tracheostomy ties, the nurse should ensure that there is enough space for two fingers, not three.
D. Prepare sterile supplies after removing the inner cannula.
The nurse should prepare sterile supplies before removing the inner cannula to ensure that they are readily available and reduce the risk of infection.
Full Explanation
a. Clean the stoma using an inward to outward circular motion.
When providing tracheostomy care, the nurse should clean the stoma using an inward to outward circular motion to remove any secretions or debris. It is important to avoid using excessive force or pressure, which can cause trauma to the stoma. Cleansing the inner cannula with isopropyl alcohol may be appropriate for some clients, but it is important to follow the healthcare provider's orders regarding inner cannula care.
When securing the tracheostomy ties, the nurse should ensure that there is enough space for two fingers, not three. Finally, the nurse should prepare sterile supplies before removing the inner cannula to ensure that they are readily available and reduce the risk of infection.
A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
A. Ecchymosis on the inner left thigh
May be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.
B. One fingerbreadth of space between the cast and the skin
Is a normal finding and indicates that the cast is not too tight.
C. Diminished pulses on the affected extremity
This finding may indicate compromised circulation, which is a serious complication that requires immediate intervention.
D. Client report of muscle spasms of the left leg
Is a common complaint in clients with casts and may be addressed with medication or other interventions, but it is not as urgent as diminished pulses.
Full Explanation
c. Diminished pulses on the affected extremity. This finding may indicate compromised circulation, which is
a serious complication that requires immediate intervention.
Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.
Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.
Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may
be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the affected extremity.
A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor?
A. Triiodothyronine
Is a thyroid hormone and is not directly related to warfarin therapy.
B. Blood urea nitrogen
Is a measure of kidney function and is also not directly related to warfarin therapy.
C. Arterial blood gases
Is a measure of oxygen and carbon dioxide levels in the blood and is not related to warfarin therapy.
D. Prothrombin time
Warfarin is an anticoagulant medication that works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver. Therefore, it is important to monitor the client's clotting ability to ensure that the medication is working properly and not causing any adverse effects. The laboratory test that is used to monitor warfarin therapy is the prothrombin time (PT), which measures the time it takes for the blood to clot. The nurse should monitor the client's PT regularly and adjust the dosage of warfarin as necessary to maintain the therapeutic range.
Full Explanation
Prothrombin time.
Explanation:
When a client is prescribed warfarin, monitoring the prothrombin time (PT) and the International Normalized Ratio (INR) is crucial. Warfarin is an anticoagulant medication that affects the clotting ability of the blood by inhibiting vitamin K-dependent clotting factors. Monitoring the prothrombin time and INR helps determine the client's blood's ability to clot and the appropriate dosage of warfarin to maintain the desired therapeutic range.
Option a (Triiodothyronine) is a thyroid hormone and is not directly related to warfarin therapy.
Option b (Blood urea nitrogen) is a measure of kidney function and is also not directly related to warfarin therapy.
Option c (Arterial blood gases) is a measure of oxygen and carbon dioxide levels in the blood and is not related to warfarin therapy.
