Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is admitting a client to a medical-surgical unit.
When performing medication reconciliation for the client, which of the following actions should the nurse take?
A. A. Compare new prescriptions with the list of medications the client reports
The nurse should compare new prescriptions with the list of medications the client reports. This is part of the medication reconciliation process, which is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
B. B. Encourage the client to make his own list after he returns to his home
because the nurse should not encourage the client to make his own list after he returns to his home. The nurse should provide the client with an updated and accurate list of medications before discharge and instruct the client to keep it with him at all times.
C. Include any adverse effects of the medications the client might develop
wrong because the nurse should not include any adverse effects of the medications the client might develop. The nurse should include any known allergies or adverse reactions the client has experienced in the past, but not potential adverse effects that have not occurred.
D. Exclude nutritional supplements from the list of medications the client reports
wrong because the nurse should not exclude nutritional supplements from the list of medications the client reports. The nurse should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions in the medication reconciliation process.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is choice A. The nurse should compare new prescriptions with the list of medications the client reports. This is part of the medication reconciliation process, which is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
Choice B is wrong because the nurse should not encourage the client to make his own list after he returns to his home. The nurse should provide the client with an updated and accurate list of medications before discharge and instruct the client to keep it with him at all times.
Choice C is wrong because the nurse should not include any adverse effects of the medications the client might develop. The nurse should include any known allergies or adverse reactions the client has experienced in the past, but not potential adverse effects that have not occurred.
Choice D is wrong because the nurse should not exclude nutritional supplements from the list of medications the client reports. The nurse should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions in the medication reconciliation process.
Some of these products may interact with prescribed medications or affect laboratory results.
Similar Questions
A nurse is assisting with food selection for a client who follows kosher dietary traditions.
Which of the following food choices should the nurse include on the client’s food tray?
A. Ham sandwich with milk.
that choices A, B, and C are not appropriate for someone following kosher dietary traditions as they all contain meat products (ham, shrimp, bacon) combined with dairy (milk). Choice D is the only option that does not contain any meat products and is therefore the most appropriate choice for someone following kosher dietary traditions.
B. Shrimp salad and tomato soup with milk
that choices A, B, and C are not appropriate for someone following kosher dietary traditions as they all contain meat products (ham, shrimp, bacon) combined with dairy (milk). Choice D is the only option that does not contain any meat products and is therefore the most appropriate choice for someone following kosher dietary traditions.
C. Bacon and cheese quiche with milk
that choices A, B, and C are not appropriate for someone following kosher dietary traditions as they all contain meat products (ham, shrimp, bacon) combined with dairy (milk). Choice D is the only option that does not contain any meat products and is therefore the most appropriate choice for someone following kosher dietary traditions.
D. Scrambled eggs and toast with milk
For a client who follows kosher dietary traditions, it's essential to adhere to the rules and restrictions that pertain to kosher food preparation and consumption. Among the given options, the only one that aligns with kosher dietary guidelines is scrambled eggs and toast with milk.
Full Explanation
D) Scrambled eggs and toast with milk.
For a client who follows kosher dietary traditions, it's essential to adhere to the rules and restrictions that pertain to kosher food preparation and consumption. Among the given options, the only one that aligns with kosher dietary guidelines is scrambled eggs and toast with milk.
The other options (A, B, and C) contain non-kosher ingredients, such as ham, shrimp, and bacon, which are not considered kosher. Additionally, mixing meat and dairy products is generally not allowed in kosher dietary practices. So, options A, B, and C would not be appropriate for someone following kosher dietary traditions.
A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture.
Which of the following actions by the client indicates an understanding of the teaching?
A. Moving both crutches with the stronger leg forward first.
Moving both crutches with the stronger leg forward first is incorrect for a three-point gait.This describes a two-point gait,which is used when a client can bear weight on both legs.In a three-point gait,the client bears weight on the unaffected leg and the crutches,not the stronger leg. This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.
B. Supporting his body weight while leaning on the axillary crutch pads
Supporting his body weight while leaning on the axillary crutch pads is also incorrect.This can lead to nerve damage in the armpits and should be avoided. The weight should be distributed through the hands and wrists,not the armpits.
C. Stepping with his affected leg first when going up stairs
Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous.The client should lead with the stronger leg when going up stairs to maintain balance and control.
D. Positioning both hands on the grips with his elbows slightly flexed.
Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait.This allows for proper weight distribution,balance,and control of the crutches. It also helps to prevent fatigue and strain in the arms and shoulders. Key points to remember about the three-point gait: Weight is borne on the unaffected leg and the crutches,not the affected leg. The crutches and the unaffected leg move forward together,followed by the affected leg. The client should look ahead,not down at their feet. The client should take small,even steps. The client should rest as needed.
Full Explanation
The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.
Choice A rationale:
- Moving both crutches with the stronger leg forward first is incorrect for a three-point gait. This describes a two-point gait, which is used when a client can bear weight on both legs. In a three-point gait, the client bears weight on the unaffected leg and the crutches, not the stronger leg.
- This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.
Choice B rationale:
- Supporting his body weight while leaning on the axillary crutch pads is also incorrect. This can lead to nerve damage in the armpits and should be avoided.
- The weight should be distributed through the hands and wrists, not the armpits.
Choice C rationale:
- Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous. The client should lead with the stronger leg when going up stairs to maintain balance and control.
Choice D rationale:
- Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait. This allows for proper weight distribution, balance, and control of the crutches.
- It also helps to prevent fatigue and strain in the arms and shoulders.
Key points to remember about the three-point gait:
- Weight is borne on the unaffected leg and the crutches, not the affected leg.
- The crutches and the unaffected leg move forward together, followed by the affected leg.
- The client should look ahead, not down at their feet.
- The client should take small, even steps.
- The client should rest as needed.
A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg.
Which of the following interventions should the nurse delegate to an assistive personnel?
A. Observe the position of the suspended weight
Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.
B. Check the client’s pedal pulse on the right leg
Checking the client's pedal pulse on the right leg is essential for monitoring circulation in the affected limb. Any changes in pulse quality or absence of a pulse could indicate a serious complication, such as compartment syndrome. This assessment should be performed by the nurse to ensure accurate findings and timely intervention if needed.
C. Ask the client to describe her pain
Asking the client to describe her pain is part of the nursing assessment and should be done by the nurse. The nurse needs to assess the client's pain level, location, and characteristics to develop an appropriate pain management plan. Delegating this to assistive personnel could lead to inaccurate or incomplete information.
D. Remind the client to use the incentive spirometer
Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.
E. None
None
F. None
None
Full Explanation
The correct answer is D. Remind the client to use the incentive spirometer.
Choice A rationale:
Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.
Choice B rationale:
Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.
Choice C rationale:
Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.
Choice D rationale:
Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.