Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has a heart rate of 56/min. Which of the following findings should the nurse expect?
A. Report of dizziness
A heart rate of 56/min is considered bradycardia, which is defined as a heart rate slower than 60 beats per minute 1. Bradycardia can prevent the brain and other organs from getting enough oxygen, possibly causing symptoms such as dizziness or light-headedness.
B. History of cigarete smoking
C. Hypoglycaemia
D. Temperature of 39°C (102°F)
This question is an excerpt from Nurse Dive's nursing test bank - NURS 100 fundamentals swami test 14.18.23 proctored exam. Take the full exam now
Full Explanation
A heart rate of 56/min is considered bradycardia, which is defined as a heart rate slower than 60 beats per minute 1. Bradycardia can prevent the brain and other organs from getting enough oxygen, possibly causing symptoms such as dizziness or light-headedness.
Similar Questions
A nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?
A. Place the client in a room with negative pressure airflow.
B. Clean hands with soap and water after caring for the client.
C. Apply a mask on the client when they are outside their room.
D. Wash hands for 10 seconds after caring for the client.
Full Explanation
Clostridium difficile (C. difficile) is a highly contagious bacteria that can cause diarrhea and colitis 1. To prevent the spread of infection, it is important for the nurse to practice good hand hygiene by washing their hands with soap and water after caring for the client.
A nurse is teaching a newly licensed nurse about measuring body temperature in clients. Which of the following clients should the nurse instruct to obtain an oral temperature?
A. A client who has haemorrhoids
A) A client who has hemorrhoids: Clients with hemorrhoids can safely have their body temperature measured orally, as hemorrhoids do not interfere with the oral route. This is an appropriate option for obtaining an accurate temperature reading.
B. A client who had recent oral surgery
B) A client who had recent oral surgery: Oral temperature measurement is contraindicated in clients with recent oral surgery, as it may cause discomfort, disrupt healing, or lead to inaccurate readings.
C. A client who has a coagulation disorder
C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.
D. A client who is drinking ice water
D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.
None
Full Explanation
Answer: A
Rationale:
A) A client who has hemorrhoids: An oral temperature is appropriate for this client as there are no contraindications for using the oral route. Hemorrhoids do not affect the accuracy or safety of oral temperature measurement.
B) A client who had recent oral surgery: Oral temperature measurement should be avoided for this client as it may cause discomfort or disrupt the healing process. Alternative routes, such as tympanic or axillary, are more appropriate.
C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.
D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.
A nurse is planning to perform perineal care for a female client. Which of the following actions should the nurse plan to take?
A. Allow the client’s perineum to air dry.
B. Start at the client’s rectum and clean to the client’s perineum.
C. Use the same section of washcloth for each area cleaned.
D. Use soap and water to clean the client’s perineum.
When performing perineal care for a female client, the nurse should use soap and water to clean the client’s perineum. This helps to remove any urine or fecal mater and prevent skin irritation or infection. The nurse should also use a clean section of the washcloth for each area cleaned and should clean from front to back to prevent the spread of bacteria from the rectal area to the urethra.
Full Explanation
When performing perineal care for a female client, the nurse should use soap and water to clean the client’s perineum. This helps to remove any urine or fecal mater and prevent skin irritation or infection. The nurse should also use a clean section of the washcloth for each area cleaned and should clean from front to back to prevent the spread of bacteria from the rectal area to the urethra.
