Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.
A. Weight
Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
B. Neuro status
Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
C. Auditory hallucinations
Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
D. Speech
Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
E. Restlessness
Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is B, C, and E.
- A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
- B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
- C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
- D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
- E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.
Similar Questions
A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG) and a prescription for neostigmine. Which of the following information should the nurse include about the action of the medication?
A. Improves muscle strength.
Neostigmine is a medication used in the treatment of myasthenia gravis (MG). It belongs to a class of drugs called cholinesterase inhibitors. Neostigmine works by inhibiting the breakdown of acetylcholine, a neurotransmiter involved in muscle contraction. In MG, there is a decrease in the amount of acetylcholine available at the neuromuscular junction, leading to muscle weakness and fatigue. By inhibiting the breakdown of acetylcholine, neostigmine helps to increase the concentration of acetylcholine at the neuromuscular junction. This, in turn, improves muscle strength and can alleviate the symptoms of weakness and fatigue associated with MG.
B. Destroys the antibodies that cause MG
Destroying the antibodies that cause MG, is not accurate. Myasthenia gravis is an autoimmune disorder characterized by the presence of antibodies that interfere with neuromuscular transmission. Neostigmine does not directly target or eliminate these antibodies.
C. Enhances immune system function
Enhancing immune system function, is not accurate either. Neostigmine primarily acts on the neuromuscular junction to improve muscle strength and does not have a direct effect on immune system function.
D. Prevents excessive coughing
Preventing excessive coughing, is not the primary action of neostigmine. While increased muscle strength may indirectly improve respiratory function and reduce coughing in individuals with myasthenia gravis, it is not the primary indication or action of neostigmine.
Full Explanation
a. Improves muscle strength.
Explanation:
Neostigmine is a medication used in the treatment of myasthenia gravis (MG). It belongs to a class of drugs called cholinesterase inhibitors. Neostigmine works by inhibiting the breakdown of acetylcholine, a neurotransmiter involved in muscle contraction. In MG, there is a decrease in the amount of acetylcholine available at the neuromuscular junction, leading to muscle weakness and fatigue.
By inhibiting the breakdown of acetylcholine, neostigmine helps to increase the concentration of acetylcholine at the neuromuscular junction. This, in turn, improves muscle strength and can alleviate the symptoms of weakness and fatigue associated with MG.
Option b, destroying the antibodies that cause MG, is not accurate. Myasthenia gravis is an autoimmune disorder characterized by the presence of antibodies that interfere with neuromuscular transmission.
Neostigmine does not directly target or eliminate these antibodies.
Option c, enhancing immune system function, is not accurate either. Neostigmine primarily acts on the neuromuscular junction to improve muscle strength and does not have a direct effect on immune system function.
Option d, preventing excessive coughing, is not the primary action of neostigmine. While increased muscle strength may indirectly improve respiratory function and reduce coughing in individuals with myasthenia gravis, it is not the primary indication or action of neostigmine.
Therefore, the most accurate information to include in teaching about neostigmine for a client with myasthenia gravis is that it improves muscle strength.
A nurse is caring for a client who is 1 hr postpartum.
Nurses' Notes 1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous IV infusion.
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.
Select the actions the nurse should take.
A. Firmly massage the uterine fundus
This is a correct action. Firmly massaging the uterine fundus can help contract the uterus and reduce bleeding by expelling clots and compressing blood vessels.
B. Provide emotional support
This is a correct action. Providing emotional support can help calm the client and reduce anxiety, which can worsen bleeding by increasing heart rate and blood pressure.
C. Administer oxygen
This is a correct action. Administering oxygen can help improve tissue perfusion and oxygenation, which can prevent hypoxia and shock due to blood loss.
D. Weigh the perineal pads
This is a correct action. Weighing the perineal pads can help estimate the amount of blood loss and monitor the effectiveness of interventions to control bleeding.
E. Insert indwelling urinary catheter
This is a correct action. Inserting an indwelling urinary catheter can help empty the bladder and prevent it from displacing or compressing the uterus, which can interfere with uterine contraction and increase bleeding.
Full Explanation
A. Firmly massaging the uterine fundus helps promote uterine contraction and reduce postpartum hemorrhage.
B. Providing emotional support helps address the client’s anxiety and distress.
C. Administering oxygen supports tissue perfusion, especially as the client is showing signs of hypovolemic shock.
D. Weighing perineal pads helps quantify blood loss and assess the severity of hemorrhage.
E. Inserting an indwelling urinary catheter ensures accurate output measurement and prevents bladder distension, which can interfere with uterine contraction.
A nurse is caring for a client who is postoperative following an appendectomy.
Vital Signs 1800:
Temperature 98.4° F (36.8° C) Heart rate 104/min
Respiratory rate 22/min
Blood pressure 142/80 mm Hg O2 saturation 97% on room air 1800:
Client alert and oriented x 4
Skin warm and dry
Lungs clear on auscultation
Bowel sounds hypoactive in all four quadrants Urine clear yellow
Incisional dressing clean and dry
Client reports pain as 6 on a scale of 0 to 10
1815:
Morphine administered as prescribed
2000:
Temperature 98.4° F (36.8° C) Heart rate 110/min Respiratory rate 24/min
Blood pressure 158/88 mm Hg O2 saturation 93% on room air.
Which of the following 4 client findings should the nurse report to the provider?
A. Bowel sounds
Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
B. Oxygen saturation
Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
C. Nausea
Nausea is a common feature of appendicitis and should go away with appendectomy. This finding should, therefore, be reported to the healthcare provider.
D. Vomiting
Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
E. Pain level
Pain level is 6 on a scale of 0 to 10. The client received morphine as prescribed at 1815, and the pain level is still significant. This is a finding that needs to be reported to the provider
F. Heart rate
Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
G. Incision characteristics
Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
H. Lungs sounds
Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.
Full Explanation
- A. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
- B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
- C. Nausea is a common feature of appendicitis and should go away with appendectomy. This finding should, therefore, be reported to the healthcare provider.
- D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
- E. Pain level is 6 on a scale of 0 to 10. The client received morphine as prescribed at 1815, and the pain level is still significant. This is a finding that needs to be reported to the provider
- F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
- G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
- H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.