Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr.
Which of the following interventions should the nurse anticipate?
A. Administer a fluid bolus
The client has signs of dehydration and oliguria, which are low urine output and dark yellow urine. A fluid bolus can help restore the fluid balance and improve the renal perfusion. The normal urine output for an adult is 0.5-1.5 mL/kg/hr, and the client’s urine output is only 25 mL/hr, which is below the minimum acceptable level. Dark yellow urine can indicate a high concentration of waste products and a low intake of fluids. Administering a fluid bolus is appropriate when a client’s urine output is low, which in this case is less than the minimum expected output of 30 mL/hr.
B. Initiate continuous bladder irrigation
is wrong because continuous bladder irrigation is used to prevent or treat blood clots in the bladder after surgery or injury, not to increase urine output
C. Obtain a urine specimen for culture and sensitivity
wrong because a urine specimen for culture and sensitivity is used to diagnose a urinary tract infection, which is not the most likely cause of the client’s low urine output. The client does not have other symptoms of infection, such as fever, pain, or cloudy urine
D. Clamp the catheter tubing for 30 min
because clamping the catheter tubing for 30 min can cause urinary retention, bladder distension, and increased risk of infection. It can also interfere with the accurate measurement of urine output.
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, administer a fluid bolus.
Choice A rationale:
Administering a fluid bolus is appropriate when a client’s urine output is low, which in this case is less than the minimum expected output of 30 mL/hr. The dark yellow color of the urine also suggests dehydration or concentrated urine, which can be addressed with increased fluid intake.
Choice B rationale:
Initiating continuous bladder irrigation is typically done to clear the urinary tract of blood clots or debris following urologic surgery, not for low urine output or dark urine. Therefore, this intervention is not indicated based on the given scenario.
Choice C rationale:
Obtaining a urine specimen for culture and sensitivity is an action taken when there is a suspicion of a urinary tract infection. The scenario does not provide evidence of infection, such as fever or cloudy urine with a strong odor, so this would not be the first intervention to anticipate.
Choice D rationale:
Clamping the catheter tubing is done in preparation for catheter removal or to assess if the client can void without the catheter. It is not an appropriate intervention for low urine output or dark urine and could potentially cause bladder distention or discomfort.
Similar Questions
A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse manager include?
A. Document the client’s condition every 15 min
Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:
B. Request a PRN restraint prescription for clients who are aggressive
Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.
C. Attach the restraint to the bed’s side rails
Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.
D. Remove the client’s restraint every
Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.
Full Explanation
When updating protocols for the use of belt restraints, the nurse manager should include the following guideline:
A) Document the client’s condition every 15 min
Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:
B) Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.
C) Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.
D) Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.
A nurse is assessing a child who has bacterial pneumonia.
Which of the following manifestations should the nurse expect?
A. Drooling
drooling, is wrong because it is not a typical symptom of bacterial pneumonia. Drooling can be caused by other conditions, such as sore throat, dental problems, or neurological disorders.
B. Tinnitus
, tinnitus, is wrong because it is not a symptom of bacterial pneumonia either. Tinnitus is a ringing or buzzing sound in the ears that can be caused by exposure to loud noise, ear infections, or other ear problems.
C. Malaise
Malaise is a general feeling of discomfort, weakness, or illness that can be a sign of infection. According to the health search result from Focus Medica , bacterial pneumonia is an infection of the air sacs in one or both lungs that causes symptoms such as cough with phlegm, fever, chills, and difficulty breathing. Malaise is one of the symptoms that may follow these signs of infection.
D. Rhinorrhea
rhinorrhea, is wrong because it is not specific to bacterial pneumonia. Rhinorrhea is a runny nose that can be caused by many factors, such as allergies, colds, or sinus infections.
Full Explanation
The correct answer is choice C, malaise.
Malaise is a general feeling of discomfort, weakness, or illness that can be a sign of infection. According to the health search result from Focus Medica , bacterial pneumonia is an infection of the air sacs in one or both lungs that causes symptoms such as cough with phlegm, fever, chills, and difficulty breathing.
Malaise is one of the symptoms that may follow these signs of infection.
Choice A, drooling, is wrong because it is not a typical symptom of bacterial pneumonia.
Drooling can be caused by other conditions, such as sore throat, dental problems, or neurological disorders.
Choice B, tinnitus, is wrong because it is not a symptom of bacterial pneumonia either.
Tinnitus is a ringing or buzzing sound in the ears that can be caused by exposure to loud noise, ear infections, or other ear problems.
Choice D, rhinorrhea, is wrong because it is not specific to bacterial pneumonia.
Rhinorrhea is a runny nose that can be caused by many factors, such as allergies, colds, or sinus infections.
Rhinorrhea can sometimes occur with viral pneumonia, but not usually with bacterial pneumonia.
Question 26.
A nurse is caring for a 2-year-old toddler.
Which of the following food choices should the nurse recommend to promote independence in eating?
A. Popcorn
wrong because popcorn is a choking hazard for toddlers. It is hard, crunchy, and can get stuck in the airway. The NHS advises not to give whole nuts and peanuts to children under 5 years old.
B. Grapes
wrong because grapes are also a choking hazard for toddlers. They are round, slippery, and can block the airway. The NHS recommends cutting grapes into quarters before giving them to young children.
C. C. Banana slices
Banana slices are soft, easy to chew, and can be picked up by the toddler’s fingers, which promotes independence in eating. According to the CDC, foods that toddlers should avoid include: Added sugars and no-calorie sweeteners, such as sugar-sweetened and diet drinks High-salt foods, such as canned foods, processed meats, frozen dinners, fast food, and junk food Unpasteurized juice, milk, yogurt, or cheese Foods that may cause choking, such as hard or crunchy foods, sticky foods, stringy cheese, and foods that are not cut up into small pieces
D. D. Hot dog
is wrong because hot dogs are high in salt and can cause choking if not cut up into small pieces. The Extension warns against giving hot dogs to young toddlers.
Full Explanation
Banana slices are soft, easy to chew, and can be picked up by the toddler’s fingers, which promotes independence in eating. According to the CDC, foods that toddlers should avoid include:
- Added sugars and no-calorie sweeteners, such as sugar-sweetened and diet drinks
- High-salt foods, such as canned foods, processed meats, frozen dinners, fast food, and junk food
- Unpasteurized juice, milk, yogurt, or cheese
- Foods that may cause choking, such as hard or crunchy foods, sticky foods, stringy cheese, and foods that are not cut up into small pieces
Choice A is wrong because popcorn is a choking hazard for toddlers.
It is hard, crunchy, and can get stuck in the airway. The NHS advises not to give whole nuts and peanuts to children under 5 years old.
Choice B is wrong because grapes are also a choking hazard for toddlers.
They are round, slippery, and can block the airway. The NHS recommends cutting grapes into quarters before giving them to young children.
Choice D is wrong because hot dogs are high in salt and can cause choking if not cut up into small pieces. The Extension warns against giving hot dogs to young toddlers.