Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Pneumococcal vaccine
A. Pneumococcal vaccine → Not having it increases risk, but the option itself (“Pneumococcal vaccine”) is misleading; risk comes from lack of vaccine, not its presence.
B. Level of consciousness
B. Level of consciousness → Client is lethargic and has difficulty answering questions, which can increase risk of aspiration and reduce effective airway clearance.
C. Influenza vaccine
C. Influenza vaccine → Similarly, not getting the vaccine is a risk, but the option is phrased as “Influenza vaccine,” which is protective, not a risk factor.
D. Health history
D. Health history → Lack of pneumococcal and influenza vaccinations increases susceptibility to respiratory infections.
E. Fluid intake
E. Fluid intake → Client reports reduced fluid intake, leading to thickened secretions, impaired mucociliary clearance, and higher risk of pneumonia.
F. Age
F. Age → Middle-aged and older adults are at higher risk for pneumonia due to decreased physiologic reserve.
G. Smoking history
G. Smoking history → Smoking history is incorrect. While a history of smoking, or exposure to second-hand smoke, increases a client’s risk of contracting community-acquired pneumonia, the client reports no smoking history.
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Full Explanation
A. Pneumococcal vaccine → Not having it increases risk, but the option itself (“Pneumococcal vaccine”) is misleading; risk comes from lack of vaccine, not its presence.
B. Level of consciousness → Client is lethargic and has difficulty answering questions, which can increase risk of aspiration and reduce effective airway clearance.
C. Influenza vaccine → Similarly, not getting the vaccine is a risk, but the option is phrased as “Influenza vaccine,” which is protective, not a risk factor.
D. Health history → Lack of pneumococcal and influenza vaccinations increases susceptibility to respiratory infections.
E. Fluid intake → Client reports reduced fluid intake, leading to thickened secretions, impaired mucociliary clearance, and higher risk of pneumonia.
F. Age → Middle-aged and older adults are at higher risk for pneumonia due to decreased physiologic reserve.
G. Smoking history → Smoking history is incorrect. While a history of smoking, or exposure to second-hand smoke, increases a client’s risk of contracting community-acquired pneumonia, the client reports no smoking history.
Similar Questions
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?
A. Prophylactic antibiotics
Prophylactic antibiotics are not routinely given solely because of hemophilia A. They may be indicated based on the client's overall health and the procedure.
B. Packed RBCs
Packed RBCs are not typically needed for wisdom teeth extractions in clients with hemophilia A, as these procedures do not usually cause significant blood loss.
C. Recombinant factor VIII
Recombinant factor VIII is the specific treatment for hemophilia A and is administered prior to procedures to prevent bleeding.
D. Fresh frozen plasma
Fresh frozen plasma contains clotting factors but is not the treatment of choice for hemophilia A. Recombinant factor VIII is preferred due to its specific action and lower risk of complications.
Full Explanation
A. Prophylactic antibiotics are not routinely given solely because of hemophilia A. They may be indicated based on the client's overall health and the procedure.
B. Packed RBCs are not typically needed for wisdom teeth extractions in clients with hemophilia A, as these procedures do not usually cause significant blood loss.
C. Recombinant factor VIII is the specific treatment for hemophilia A and is administered prior to procedures to prevent bleeding.
D. Fresh frozen plasma contains clotting factors but is not the treatment of choice for hemophilia A. Recombinant factor VIII is preferred due to its specific action and lower risk of complications.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
A. Positive Western blot test
A positive Western blot test confirms HIV infection but does not provide immediate information on the client's immune status.
B. Platelets 150,000/mm3
Platelets within the normal range are important but do not directly indicate the client's immune status or HIV progression.
C. CD4-T-cell count 180 cells/mm3
CD4-T-cell count is crucial for monitoring HIV progression and immune function. A low count indicates immunosuppression and increased risk of opportunistic infections.
D. WBC 5,000/mm3
WBC count is important but does not specifically indicate the client's HIV status or immune function related to HIV.
Full Explanation
A. A positive Western blot test confirms HIV infection but does not provide immediate information on the client's immune status.
B. Platelets within the normal range are important but do not directly indicate the client's immune status or HIV progression.
C. CD4-T-cell count is crucial for monitoring HIV progression and immune function. A low count indicates immunosuppression and increased risk of opportunistic infections.
D. WBC count is important but does not specifically indicate the client's HIV status or immune function related to HIV.
A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?
A. Elevated WBC
Elevated WBC is not typically associated with ITP, which primarily affects platelet counts.
B. Fever
Fever may indicate infection but is not specific to ITP.
C. Fatigue
Fatigue can occur in clients with ITP due to anemia or chronic illness but is not specific to the condition.
D. Ecchymosis
Ecchymosis (bruising) is a hallmark manifestation of ITP due to low platelet counts and increased bleeding tendencies.
Full Explanation
A. Elevated WBC is not typically associated with ITP, which primarily affects platelet counts.
B. Fever may indicate infection but is not specific to ITP.
C. Fatigue can occur in clients with ITP due to anemia or chronic illness but is not specific to the condition.
D. Ecchymosis (bruising) is a hallmark manifestation of ITP due to low platelet counts and increased bleeding tendencies.