Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?
A. A client who is being discharged to a long-term care facility
A client being discharged to a long-term care facility may need comprehensive discharge planning, which involves familiarity with long-term care requirements, but this is not typically within the primary expertise of a PACU nurse.
B. A client who is postoperative following a lobectomy and has a chest tube
A client who is postoperative following a lobectomy and has a chest tube falls within the PACU nurse's area of expertise. PACU nurses are experienced in monitoring and managing postoperative clients, including those with chest tubes, as these clients require close monitoring for complications such as respiratory distress or chest tube malfunction.
C. A client who needs teaching about insulin self-administration
Teaching about insulin self-administration is important, but this task is more suited to nurses experienced in chronic care management, such as those from medical-surgical or endocrinology units.
D. A client who needs teaching prior to initiating cardiac rehabilitation activities
Teaching prior to initiating cardiac rehabilitation requires specialized knowledge in cardiac care, which may not be the primary focus of a PACU nurse's practice.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg pharm comprehensive proctored exam. Take the full exam now
Full Explanation
A. A client being discharged to a long-term care facility may need comprehensive discharge planning, which involves familiarity with long-term care requirements, but this is not typically within the primary expertise of a PACU nurse.
B. A client who is postoperative following a lobectomy and has a chest tube falls within the PACU nurse's area of expertise. PACU nurses are experienced in monitoring and managing postoperative clients, including those with chest tubes, as these clients require close monitoring for complications such as respiratory distress or chest tube malfunction.
C. Teaching about insulin self-administration is important, but this task is more suited to nurses experienced in chronic care management, such as those from medical-surgical or endocrinology units.
D. Teaching prior to initiating cardiac rehabilitation requires specialized knowledge in cardiac care, which may not be the primary focus of a PACU nurse's practice.
Similar Questions
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
A. Magnesium
Magnesium is used for torsades de pointes and hypomagnesemia.
B. Atropine
Atropine is the first-line treatment for symptomatic bradycardia as it increases heart rate by blocking the vagus nerve's effect on the heart.
C. Sodium bicarbonate
Sodium bicarbonate is used to correct metabolic acidosis, not bradycardia.
D. Epinephrine
Epinephrine is used in cardiac arrest for asystole, pulseless electrical activity, and severe bradycardia when atropine is ineffective.
Full Explanation
A. Magnesium is used for torsades de pointes and hypomagnesemia.
B. Atropine is the first-line treatment for symptomatic bradycardia as it increases heart rate by blocking the vagus nerve's effect on the heart.
C. Sodium bicarbonate is used to correct metabolic acidosis, not bradycardia.
D. Epinephrine is used in cardiac arrest for asystole, pulseless electrical activity, and severe bradycardia when atropine is ineffective.
A nurse is preparing to administer clindamycin 900 mg by intermittent IV bolus over 30 min. Available is clindamycin 900 mg in 100 mL dextrose 5% (DW). The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the infusion rate in mL/hr for administering clindamycin 900 mg in 100 mL dextrose 5% over 30 minutes, you would use the formula: (Total Volume in mL / Time in hours) = Rate in mL/hr. Since the medication needs to be administered over 30 minutes, you convert 30 minutes into hours, which is 0.5 hours. Using the formula, you get (100 mL / 0.5 hours) = 200 mL/hr. Therefore, the nurse should set the IV pump to deliver 200 mL/hr.
A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?
A. Auscultates bowel sounds for 3 to 5 min
Auscultating bowel sounds for 3 to 5 minutes is appropriate if sounds are not initially heard.
B. Clamps the NG tube during auscultation
Clamping the NG tube prevents false bowel sounds from the tube.
C. Performs auscultation between meals
Performing auscultation between meals ensures accurate assessment of bowel sounds.
D. Palpates the abdomen prior to performing auscultation.
Palpating the abdomen prior to auscultation can alter bowel sounds, making it important to auscultate before palpation.
Full Explanation
Rationale:
A. Auscultating bowel sounds for 3 to 5 minutes is appropriate if sounds are not initially heard.
B. Clamping the NG tube prevents false bowel sounds from the tube.
C. Performing auscultation between meals ensures accurate assessment of bowel sounds.
D. Palpating the abdomen prior to auscultation can alter bowel sounds, making it important to auscultate before palpation.