Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is attending to a client who has suffered a basal skull fracture.
During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.
What should be the nurse’s immediate action?
A. Inform the charge nurse.
Informing the charge nurse is an important step, but it is not the immediate action. The nurse should first assess the situation before escalating it.
B. Apply a dressing under the client’s nose.
Applying a dressing under the client’s nose might help manage the drainage, but it does not address the underlying issue. The drainage could be cerebrospinal fluid (CSF), which is a serious condition that needs immediate attention.
C. Check the client’s temperature.
Checking the client’s temperature is a general assessment and does not directly relate to the symptom of clear nasal drainage.
D. Test the drainage for glucose.
Testing the drainage for glucose is the correct action. Clear nasal drainage after a basal skull fracture could be a sign of a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help confirm if it’s CSF34.
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
Informing the charge nurse is an important step, but it is not the immediate action. The nurse should first assess the situation before escalating it.
Choice B rationale
Applying a dressing under the client’s nose might help manage the drainage, but it does not address the underlying issue. The drainage could be cerebrospinal fluid (CSF), which is a serious condition that needs immediate attention.
Choice C rationale
Checking the client’s temperature is a general assessment and does not directly relate to the symptom of clear nasal drainage.
Choice D rationale
Testing the drainage for glucose is the correct action. Clear nasal drainage after a basal skull fracture could be a sign of a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help confirm if it’s CSF34.
Similar Questions
A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement.
Which symptom should the nurse address first?
A. Fatigue
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
B. Pain
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
C. Fever
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
D. Stridor
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.
Full Explanation
Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.
A nurse is attending to a client experiencing hypovolemic shock.
What findings should the nurse anticipate?
A. Hypertension
Hypertension is not typically associated with hypovolemic shock. In fact, hypotension, or low blood pressure, is more common.
B. Purpura
Purpura, or blood spots, are not typically associated with hypovolemic shock.
C. Bradypnea
Bradypnea, or slow breathing, is not typically associated with hypovolemic shock. Rapid, shallow breathing is more common.
D. Oliguria
Oliguria, or decreased urine output, is a common finding in hypovolemic shock. It occurs due to decreased blood flow to the kidneys.
Full Explanation
Choice A rationale
Hypertension is not typically associated with hypovolemic shock. In fact, hypotension, or low blood pressure, is more common.
Choice B rationale
Purpura, or blood spots, are not typically associated with hypovolemic shock.
Choice C rationale
Bradypnea, or slow breathing, is not typically associated with hypovolemic shock. Rapid, shallow breathing is more common.
Choice D rationale
Oliguria, or decreased urine output, is a common finding in hypovolemic shock. It occurs due to decreased blood flow to the kidneys.
A patient with acute pancreatitis is in severe pain.
Which position should the nurse suggest the patient to assume?
A. Semi-Fowler’s position
The Semi-Fowler’s position, while commonly used for patients with respiratory issues, is not the most effective position for relieving pain in acute pancreatitis.
B. Prone, with a pillow under the abdomen
Lying prone with a pillow under the abdomen is not typically recommended for acute pancreatitis pain relief.
C. Supine, with legs elevated and head on a small pillow
Lying supine with legs elevated and head on a small pillow is not typically recommended for acute pancreatitis pain relief.
D. Sitting in a chair, leaning forward with a pillow for back support
Sitting in a chair, leaning forward with a pillow for back support, is often recommended for pain relief in acute pancreatitis. This position can help decrease the pressure on the abdomen and relieve pain.
Full Explanation
Choice A rationale
The Semi-Fowler’s position, while commonly used for patients with respiratory issues, is not the most effective position for relieving pain in acute pancreatitis.
Choice B rationale
Lying prone with a pillow under the abdomen is not typically recommended for acute pancreatitis pain relief.
Choice C rationale
Lying supine with legs elevated and head on a small pillow is not typically recommended for acute pancreatitis pain relief.
Choice D rationale
Sitting in a chair, leaning forward with a pillow for back support, is often recommended for pain relief in acute pancreatitis. This position can help decrease the pressure on the abdomen and relieve pain.