Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting a postoperative client.
The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.
The client is now sleeping and is difficult to arouse.
Pupils are 3 mm, equal and reactive to light.
Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.
Which documentation in the client’s medical record requires further action by the nurse?
A. Pupils are 3 mm, equal and reactive to light
Pupils being 3 mm, equal and reactive to light is a normal finding and does not require further action.
B. Client is sleeping and is difficult to arouse
The client being difficult to arouse could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
C. Respirations are 10/min
Respirations being 10/min could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
D. Pulse oximetry is 87% on room air .
Pulse oximetry reading of 87% on room air is concerning. Normal pulse oximetry readings are typically between 95% and 100%. A reading of 87% indicates the client is not getting enough oxygen, which requires immediate action.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Lpn Med Surg Proctored Exam 1. Take the full exam now
Full Explanation
Choice A rationale
Pupils being 3 mm, equal and reactive to light is a normal finding and does not require further action.
Choice B rationale
The client being difficult to arouse could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice C rationale
Respirations being 10/min could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice D rationale
Pulse oximetry reading of 87% on room air is concerning. Normal pulse oximetry readings are typically between 95% and 100%. A reading of 87% indicates the client is not getting enough oxygen, which requires immediate action.
Similar Questions
A nurse is educating a patient newly diagnosed with iron deficiency anemia.
Which of the following would be a component of the education?
A. Avoid intramuscular injections
Avoiding intramuscular injections is not typically a component of patient education for iron deficiency anemia. Intramuscular injections do not have a direct impact on iron absorption or utilization.
B. Include orange juice when taking iron
Including orange juice when taking iron supplements is often recommended. The vitamin C in orange juice can enhance the absorption of iron, making it more available for the body to use. This is particularly important in iron deficiency anemia, where the body needs more iron to produce sufficient red blood cells.
C. Avoid green leafy vegetables
Avoiding green leafy vegetables is not usually advised for patients with iron deficiency anemia. In fact, green leafy vegetables are a good source of iron and are often recommended as part of a diet for someone with this condition.
D. Avoid live immunizations
Avoiding live immunizations is not typically a part of patient education for iron deficiency anemia. The condition does not affect the immune response to vaccines, nor do vaccines interfere with iron absorption or utilization.
Full Explanation
Choice A rationale
Avoiding intramuscular injections is not typically a component of patient education for iron deficiency anemia. Intramuscular injections do not have a direct impact on iron absorption or utilization.
Choice B rationale
Including orange juice when taking iron supplements is often recommended. The vitamin C in orange juice can enhance the absorption of iron, making it more available for the body to use. This is particularly important in iron deficiency anemia, where the body needs more iron to produce sufficient red blood cells.
Choice C rationale
Avoiding green leafy vegetables is not usually advised for patients with iron deficiency anemia. In fact, green leafy vegetables are a good source of iron and are often recommended as part of a diet for someone with this condition.
Choice D rationale
Avoiding live immunizations is not typically a part of patient education for iron deficiency anemia. The condition does not affect the immune response to vaccines, nor do vaccines interfere with iron absorption or utilization.
A nurse is caring for a client with an electrical burn.
The client states that since the wound on the skin is small, the burn must not be too bad.
Which of the following is the best response by the nurse?
A. Electrical burns usually cause much more skin damage than what can be seen on your skin.
While it’s true that electrical burns can cause more skin damage than what can be seen on the skin, this statement does not fully address the client’s misconception about the severity of their burn.
B. Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
This is the best response because it directly addresses the client’s misconception and provides accurate information. Electrical burns can indeed have small amounts of skin damage but cause more extensive damage beneath the skin. This is because the electrical current can pass through the body and damage internal tissues and organs, even if the visible wound on the skin is small.
C. Electrical burns commonly cause reddened/purplish skin without blistering.
While electrical burns can cause reddened or purplish skin, they do not typically cause blistering. Furthermore, this statement does not address the client’s misconception about the severity of their burn.
D. Electrical burns typically are minor.
This statement is incorrect. Electrical burns are not typically minor. They can cause serious internal injuries and complications, even if the visible wound on the skin is small.
Full Explanation
Choice A rationale
While it’s true that electrical burns can cause more skin damage than what can be seen on the skin, this statement does not fully address the client’s misconception about the severity of their burn.
Choice B rationale
This is the best response because it directly addresses the client’s misconception and provides accurate information. Electrical burns can indeed have small amounts of skin damage but cause more extensive damage beneath the skin. This is because the electrical current can pass through the body and damage internal tissues and organs, even if the visible wound on the skin is small.
Choice C rationale
While electrical burns can cause reddened or purplish skin, they do not typically cause blistering. Furthermore, this statement does not address the client’s misconception about the severity of their burn.
Choice D rationale
This statement is incorrect. Electrical burns are not typically minor. They can cause serious internal injuries and complications, even if the visible wound on the skin is small.
When caring for a patient with burns, which assessment data will alert the nurse to the possibility of a local infection of the burned area?
A. Reports pain at burn site
While pain at the burn site can be a symptom of many conditions, it is not a specific indicator of a local infection in the burned area.
B. Hands are edematous
Edematous hands can be a sign of many conditions, including burns, but they are not a specific indicator of a local infection in the burned area.
C. Burned area has a foul odor
A foul odor from the burned area is a strong indicator of a local infection. Bacteria and other microorganisms that cause infections can produce waste products that have a foul smell.
D. Temperature is 99.8 degrees Fahrenheit .
A temperature of 99.8 degrees Fahrenheit is within the normal body temperature range and is not a specific indicator of a local infection in the burned area.
Full Explanation
Choice A rationale
While pain at the burn site can be a symptom of many conditions, it is not a specific indicator of a local infection in the burned area.
Choice B rationale
Edematous hands can be a sign of many conditions, including burns, but they are not a specific indicator of a local infection in the burned area.
Choice C rationale
A foul odor from the burned area is a strong indicator of a local infection. Bacteria and other microorganisms that cause infections can produce waste products that have a foul smell.
Choice D rationale
A temperature of 99.8 degrees Fahrenheit is within the normal body temperature range and is not a specific indicator of a local infection in the burned area.