Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?
A. The client is consuming 25% of their meals.
Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.
B. The client coughs frequently while eating.
Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.
C. The client's blood pressure is 142/94 mm Hg.
The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.
D. The client leans to the left side while sitting.
Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.
This question is an excerpt from Nurse Dive's nursing test bank - RN FUNDAMENTALS 2023 PROCTORED EXAM. Take the full exam now
Full Explanation
A. The client is consuming 25% of their meals.
Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.
B. The client coughs frequently while eating.
Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.
C. The client's blood pressure is 142/94 mm Hg.
The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.
D. The client leans to the left side while sitting.
Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.
Similar Questions
A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?
A. I will walk three times per week."
"I will walk three times per week." Weight-bearing exercises like walking help strengthen bones and reduce the risk of osteoporosis. Regular physical activity is a key component in maintaining bone health.
B. "I will take 250 milligrams of calcium once per day."
"I will take 250 milligrams of calcium once per day."This amount of calcium is insufficient. The recommended daily intake for older adults is typically around 1,000 to 1,200 milligrams of calcium per day, divided into doses for better absorption.
C. I will decrease my intake of dairy products."
"I will decrease my intake of dairy products."Dairy products are rich sources of calcium and are beneficial for bone health. Decreasing their intake would not be advisable for reducing the risk of osteoporosis.
D. I will avoid exposure to the sun.
"I will avoid exposure to the sun."Sun exposure helps the body produce vitamin D, which is essential for calcium absorption and bone health. Avoiding sun exposure could lead to a deficiency in vitamin D, increasing the risk of osteoporosis.
Full Explanation
A. "I will walk three times per week."
Weight-bearing exercises like walking help strengthen bones and reduce the risk of osteoporosis. Regular physical activity is a key component in maintaining bone health.
B. "I will take 250 milligrams of calcium once per day."
This amount of calcium is insufficient. The recommended daily intake for older adults is typically around 1,000 to 1,200 milligrams of calcium per day, divided into doses for better absorption.
C. "I will decrease my intake of dairy products."
Dairy products are rich sources of calcium and are beneficial for bone health. Decreasing their intake would not be advisable for reducing the risk of osteoporosis.
D. "I will avoid exposure to the sun."
Sun exposure helps the body produce vitamin D, which is essential for calcium absorption and bone health. Avoiding sun exposure could lead to a deficiency in vitamin D, increasing the risk of osteoporosis.
A nurse is preparing to administer several medications via an NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?
A. Combine the medications with the formula in the feeding bag.
Combining medications with the formula in the feeding bag:This is not recommended because it may lead to interactions between the medications and the enteral feeding formula. Medications may also adhere to the tubing or interfere with the absorption of nutrients from the feeding formula.
B. Dilute each crushed medication with warm water.
Diluting each crushed medication with warm water:While diluting medications may be necessary for some drugs, it is not a general rule for all medications. Additionally, dilution with warm water may not be appropriate for all drugs, and the amount of water needed may vary. It's safer to use a standardized method, such as flushing the tube with sterile water.
C. Mix the medications together in a single syringe.
Mixing the medications together in a single syringe:This is generally not recommended because different medications may have incompatible properties or form precipitates when mixed together. Mixing medications in a single syringe can compromise the effectiveness of each medication and may lead to unpredictable reactions.
D. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration.
Flush the NG tube with 5 mL of sterile water for irrigation prior to administration:Flushing the tube with sterile water helps ensure that the tube is clear of any residual formula, preventing potential interactions between the medication and the enteral feeding. It also helps clear the tube, reducing the risk of clogs or blockages. Using sterile water helps maintain aseptic technique.
Full Explanation
A. Combining medications with the formula in the feeding bag:
This is not recommended because it may lead to interactions between the medications and the enteral feeding formula. Medications may also adhere to the tubing or interfere with the absorption of nutrients from the feeding formula.
B. Diluting each crushed medication with warm water:
While diluting medications may be necessary for some drugs, it is not a general rule for all medications. Additionally, dilution with warm water may not be appropriate for all drugs, and the amount of water needed may vary. It's safer to use a standardized method, such as flushing the tube with sterile water.
C. Mixing the medications together in a single syringe:
This is generally not recommended because different medications may have incompatible properties or form precipitates when mixed together. Mixing medications in a single syringe can compromise the effectiveness of each medication and may lead to unpredictable reactions.
D. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration:
Flushing the tube with sterile water helps ensure that the tube is clear of any residual formula, preventing potential interactions between the medication and the enteral feeding. It also helps clear the tube, reducing the risk of clogs or blockages. Using sterile water helps maintain aseptic technique.
A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?
A. Yogurt with fruit
Yogurt with fruit:While yogurt with fruit is a soft and easily digestible option, it is not representative of a progression from a clear liquid diet to a full liquid diet. Yogurt is typically included in a full liquid diet, but the addition of fruit may introduce solid particles. The transition from clear to full liquids usually involves avoiding solid or textured foods.
B. Pudding
Pudding:Pudding is a suitable choice that aligns with the progression from a clear liquid diet to a full liquid diet. Pudding is a smooth and creamy food, making it appropriate for someone transitioning from clear liquids. It provides a source of calories and is easy to swallow, meeting the criteria for a full liquid diet.
C. Cooked vegetables
Cooked vegetables:Cooked vegetables are not part of a full liquid diet. While they are a healthy food choice, they are too textured for someone transitioning from a clear liquid diet. Full liquid diets focus on foods that are liquid at room temperature or become liquid when they reach body temperature.
D. Bananas
Bananas:Bananas are a soft and easily digestible fruit, but they are not typically included in a full liquid diet. The texture of bananas may be too thick for someone progressing from a clear liquid diet, and they are not considered a liquid or a food that becomes liquid at room temperature.
Full Explanation
A. Yogurt with fruit:
While yogurt with fruit is a soft and easily digestible option, it is not representative of a progression from a clear liquid diet to a full liquid diet. Yogurt is typically included in a full liquid diet, but the addition of fruit may introduce solid particles. The transition from clear to full liquids usually involves avoiding solid or textured foods.
B. Pudding:
Pudding is a suitable choice that aligns with the progression from a clear liquid diet to a full liquid diet. Pudding is a smooth and creamy food, making it appropriate for someone transitioning from clear liquids. It provides a source of calories and is easy to swallow, meeting the criteria for a full liquid diet.
C. Cooked vegetables:
Cooked vegetables are not part of a full liquid diet. While they are a healthy food choice, they are too textured for someone transitioning from a clear liquid diet. Full liquid diets focus on foods that are liquid at room temperature or become liquid when they reach body temperature.
D. Bananas:
Bananas are a soft and easily digestible fruit, but they are not typically included in a full liquid diet. The texture of bananas may be too thick for someone progressing from a clear liquid diet, and they are not considered a liquid or a food that becomes liquid at room temperature.