Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with the care of a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?
A. Respiratory rate 28/min
Respiratory rate 28/min is not a sign of effective oxygen therapy, as it indicates tachypnea, which is a rapid breathing rate. Tachypnea can be caused by hypoxia, anxiety, fever, or pain.
B. Pink mucous membranes
Pink mucous membranes are a sign of effective oxygen therapy, as they indicate adequate oxygenation of the tissues. Pink mucous membranes are a normal finding, while pale, cyanotic, or jaundiced mucous membranes can indicate hypoxia or other problems.
C. Heart rate 110/min
Heart rate 110/min is not a sign of effective oxygen therapy, as it indicates tachycardia, which is a rapid heart rate. Tachycardia can be caused by hypoxia, stress, dehydration, or infection.
D. Restlessness
Restlessness is not a sign of effective oxygen therapy, as it indicates agitation, anxiety, or discomfort. Restlessness can be caused by hypoxia, pain, or medication side effects.
This question is an excerpt from Nurse Dive's nursing test bank - NS117 T Winter 2023 Monroe college NY PN Fundamental of nursing proctored exam 2. Take the full exam now
Full Explanation
Choice A reason: Respiratory rate 28/min is not a sign of effective oxygen therapy, as it indicates tachypnea, which is a rapid breathing rate. Tachypnea can be caused by hypoxia, anxiety, fever, or pain.
Choice B reason: Pink mucous membranes are a sign of effective oxygen therapy, as they indicate adequate oxygenation of the tissues. Pink mucous membranes are a normal finding, while pale, cyanotic, or jaundiced mucous membranes can indicate hypoxia or other problems.
Choice C reason: Heart rate 110/min is not a sign of effective oxygen therapy, as it indicates tachycardia, which is a rapid heart rate. Tachycardia can be caused by hypoxia, stress, dehydration, or infection.
Choice D reason: Restlessness is not a sign of effective oxygen therapy, as it indicates agitation, anxiety, or discomfort. Restlessness can be caused by hypoxia, pain, or medication side effects.
Similar Questions
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?
A. Collect urine from the catheter's port.
Collecting urine from the catheter's port is not a correct action for the nurse to take, as it can introduce contamination and infection into the urinary tract. The nurse should insert a new, sterile catheter into the bladder and collect the urine directly from the catheter.
B. Use a sterile specimen container.
Using a sterile specimen container is a correct action for the nurse to take, as it ensures that the urine sample is not contaminated by any bacteria or other substances. The nurse should label the container with the client's name, date, and time of collection and send it to the laboratory as soon as possible.
C. Use sterile water to inflate the balloon.
Using sterile water to inflate the balloon is not a relevant action for the nurse to take, as it applies to an indwelling catheter, not a straight catheter. A straight catheter does not have a balloon and is removed after the urine is drained.
D. Instruct the client to clean from front to back with an antiseptic solution.
Instructing the client to clean from front to back with an antiseptic solution is a good action for the nurse to take, as it helps to prevent the introduction of bacteria from the anal area into the urethra. However, it is not the best answer, as it is a general hygiene measure, not a specific action for obtaining a urine specimen.
Full Explanation
Choice A reason: Collecting urine from the catheter's port is not a correct action for the nurse to take, as it can introduce contamination and infection into the urinary tract. The nurse should insert a new, sterile catheter into the bladder and collect the urine directly from the catheter.
Choice B reason: Using a sterile specimen container is a correct action for the nurse to take, as it ensures that the urine sample is not contaminated by any bacteria or other substances. The nurse should label the container with the client's name, date, and time of collection and send it to the laboratory as soon as possible.
Choice C reason: Using sterile water to inflate the balloon is not a relevant action for the nurse to take, as it applies to an indwelling catheter, not a straight catheter. A straight catheter does not have a balloon and is removed after the urine is drained.
Choice D reason: Instructing the client to clean from front to back with an antiseptic solution is a good action for the nurse to take, as it helps to prevent the introduction of bacteria from the anal area into the urethra. However, it is not the best answer, as it is a general hygiene measure, not a specific action for obtaining a urine specimen.
A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program. Which of the following findings indicates to the nurse the need to catheterize the client?
A. Reflex incontinence
Reflex incontinence is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs when the bladder is overfilled and the sphincter relaxes. Reflex incontinence can be managed by following a regular catheterization schedule, not by waiting for symptoms.
B. Urge incontinence
Urge incontinence is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs when the bladder contracts involuntarily and the sphincter cannot prevent leakage. Urge incontinence can be managed by using anticholinergic medications, bladder training, or pelvic floor exercises, not by catheterization.
C. Nocturnal enuresis
Nocturnal enuresis is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs during sleep. Nocturnal enuresis can be managed by limiting fluid intake before bedtime, using an alarm device, or taking desmopressin, not by catheterization.
D. Suprapubic discomfort
Suprapubic discomfort is a sign of the need to catheterize the client, as it indicates bladder distension and possible urinary retention. Suprapubic discomfort can be relieved by draining the urine from the bladder using a catheter.
Full Explanation
Choice A reason: Reflex incontinence is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs when the bladder is overfilled and the sphincter relaxes. Reflex incontinence can be managed by following a regular catheterization schedule, not by waiting for symptoms.
Choice B reason: Urge incontinence is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs when the bladder contracts involuntarily and the sphincter cannot prevent leakage. Urge incontinence can be managed by using anticholinergic medications, bladder training, or pelvic floor exercises, not by catheterization.
Choice C reason: Nocturnal enuresis is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs during sleep. Nocturnal enuresis can be managed by limiting fluid intake before bedtime, using an alarm device, or taking desmopressin, not by catheterization.
Choice D reason: Suprapubic discomfort is a sign of the need to catheterize the client, as it indicates bladder distension and possible urinary retention. Suprapubic discomfort can be relieved by draining the urine from the bladder using a catheter.
A nurse is reinforcing discharge teaching with the parents of an infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?
A. The pulse oximeter might not be accurate during times of excessive movement.
The pulse oximeter might not be accurate during times of excessive movement is a correct statement, as movement can interfere with the detection of the pulse and the oxygen saturation. The parents should try to keep the infant still and calm while using the pulse oximeter.
B. We will notify the doctor if the pulse oximeter consistently reads 100%.
We will notify the doctor if the pulse oximeter consistently reads 100% is an incorrect statement, as it indicates a misunderstanding of the normal range of oxygen saturation. The parents should not be alarmed if the pulse oximeter reads 100%, as it means that the infant's blood is fully saturated with oxygen. The normal range of oxygen saturation for infants is 95% to 100%.
C. The probe of the pulse oximeter can be applied to a finger or a toe.
The probe of the pulse oximeter can be applied to a finger or a toe is a correct statement, as these are suitable sites for measuring the oxygen saturation in infants. The parents should make sure that the probe fits snugly and securely on the infant's finger or toe.
D. We will rotate the probe of the pulse oximeter every 24 hours.
We will rotate the probe of the pulse oximeter every 24 hours is a correct statement, as it helps to prevent skin irritation, pressure ulcers, or infection from prolonged contact with the probe. The parents should also check the infant's skin regularly for any signs of redness, swelling, or pain.
Full Explanation
Choice A reason: The pulse oximeter might not be accurate during times of excessive movement is a correct statement, as movement can interfere with the detection of the pulse and the oxygen saturation. The parents should try to keep the infant still and calm while using the pulse oximeter.
Choice B reason: We will notify the doctor if the pulse oximeter consistently reads 100% is an incorrect statement, as it indicates a misunderstanding of the normal range of oxygen saturation. The parents should not be alarmed if the pulse oximeter reads 100%, as it means that the infant's blood is fully saturated with oxygen. The normal range of oxygen saturation for infants is 95% to 100%.
Choice C reason: The probe of the pulse oximeter can be applied to a finger or a toe is a correct statement, as these are suitable sites for measuring the oxygen saturation in infants. The parents should make sure that the probe fits snugly and securely on the infant's finger or toe.
Choice D reason: We will rotate the probe of the pulse oximeter every 24 hours is a correct statement, as it helps to prevent skin irritation, pressure ulcers, or infection from prolonged contact with the probe. The parents should also check the infant's skin regularly for any signs of redness, swelling, or pain.