Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client with a major burn injury.
Which of the following findings should the nurse prioritize?
A. The client is producing black colored sputum.
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
B. The client has large blistered areas over his chest.
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
C. The client has edema at the burn site.
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
D. The client has decreased sensation over the burn areas.
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.
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Full Explanation
Choice A rationale
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
Choice B rationale
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
Choice C rationale
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
Choice D rationale
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.
Similar Questions
The nurse is caring for an 85-year-old patient with septic shock.
What should the nurse consider when repositioning this patient?
A. Place the patient in the Trendelenburg position.
The Trendelenburg position, which involves laying the patient flat on their back with their legs elevated higher than their head, is not recommended for patients with septic shock. This position can increase intracranial pressure and does not improve circulation or oxygenation.
B. Change the patient’s position slowly.
Changing the patient’s position slowly is important in managing an elderly patient with septic shock. Rapid changes in position can cause a drop in blood pressure (orthostatic hypotension), which can lead to falls or decreased perfusion to vital organs.
C. Reduce the oxygen flow.
Reducing the oxygen flow is not recommended for patients with septic shock. These patients often have difficulty with oxygenation and may require supplemental oxygen to maintain adequate oxygen levels.
D. Increase the IV fluid flow.
Increasing the IV fluid flow is part of the initial management of septic shock to restore perfusion, but it should be done based on careful assessment and monitoring of the patient’s response to fluids. Overzealous fluid resuscitation can lead to fluid overload and complications such as pulmonary edema.
Full Explanation
Choice A rationale
The Trendelenburg position, which involves laying the patient flat on their back with their legs elevated higher than their head, is not recommended for patients with septic shock. This position can increase intracranial pressure and does not improve circulation or oxygenation.
Choice B rationale
Changing the patient’s position slowly is important in managing an elderly patient with septic shock. Rapid changes in position can cause a drop in blood pressure (orthostatic hypotension), which can lead to falls or decreased perfusion to vital organs.
Choice C rationale
Reducing the oxygen flow is not recommended for patients with septic shock. These patients often have difficulty with oxygenation and may require supplemental oxygen to maintain adequate oxygen levels.
Choice D rationale
Increasing the IV fluid flow is part of the initial management of septic shock to restore perfusion, but it should be done based on careful assessment and monitoring of the patient’s response to fluids. Overzealous fluid resuscitation can lead to fluid overload and complications such as pulmonary edema.
Which laboratory finding is commonly associated with acute pancreatitis?
A. Decreased serum IgA.
Serum IgA levels are not typically associated with acute pancreatitis. IgA is an antibody that plays a crucial role in the immune function of mucous membranes. Changes in serum IgA levels can occur in various conditions, but they are not a characteristic finding in acute pancreatitis.
B. Decreased serum bilirubin.
Decreased serum bilirubin is not commonly associated with acute pancreatitis. While jaundice (indicated by increased bilirubin levels) can occur in some cases of acute pancreatitis due to blockage of the bile duct, decreased bilirubin levels are not a typical finding.
C. Elevated serum albumin.
Elevated serum albumin is not typically associated with acute pancreatitis. In fact, levels of albumin, a protein made by the liver, can sometimes decrease in acute pancreatitis due to inflammation and leakage of protein into the abdomen.
D. Elevated serum amylase.
Elevated serum amylase is commonly associated with acute pancreatitis. Amylase is an enzyme that helps digest carbohydrates. It’s produced in the pancreas and the glands that make saliva. When the pancreas is inflamed, levels of amylase in the blood often rise.
Full Explanation
Choice A rationale
Serum IgA levels are not typically associated with acute pancreatitis. IgA is an antibody that plays a crucial role in the immune function of mucous membranes. Changes in serum IgA levels can occur in various conditions, but they are not a characteristic finding in acute pancreatitis.
Choice B rationale
Decreased serum bilirubin is not commonly associated with acute pancreatitis. While jaundice (indicated by increased bilirubin levels) can occur in some cases of acute pancreatitis due to blockage of the bile duct, decreased bilirubin levels are not a typical finding.
Choice C rationale
Elevated serum albumin is not typically associated with acute pancreatitis. In fact, levels of albumin, a protein made by the liver, can sometimes decrease in acute pancreatitis due to inflammation and leakage of protein into the abdomen.
Choice D rationale
Elevated serum amylase is commonly associated with acute pancreatitis. Amylase is an enzyme that helps digest carbohydrates. It’s produced in the pancreas and the glands that make saliva. When the pancreas is inflamed, levels of amylase in the blood often rise.
A client with a terminal illness asks the nurse, “If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?” Which of the following statements should the nurse provide to explain a DNR prescription?
A. “A DNR prescription means you will only receive pain medication for your treatments.”.
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
B. “A DNR prescription will limit your current treatment regimen.”.
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
C. “A DNR prescription will allow you to continue with your current treatment regimen.”.
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
D. “A DNR prescription will limit your ability to receive invasive procedures.”. .
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.
Full Explanation
Choice A rationale
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
Choice B rationale
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
Choice C rationale
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
Choice D rationale
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.