Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?
A. Check the client's gag reflex.
The nurse should assess the client's gag reflex before allowing oral intake to prevent aspiration. The client's throat may be numb after a bronchoscopy, which is a procedure that uses a thin tube with a camera and light to examine the lungs and airways . The other actions are important but not the priority.
B. Inform the client they might experience a low-grade fever.
C. Provide the client with sips of water.
D. Instruct the client to report bleeding.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN adult medical surgical 2019 with NGN - Proctored Exam 3. Take the full exam now
Full Explanation
The nurse should assess the client's gag reflex before allowing oral intake to prevent aspiration. The client's throat may be numb after a bronchoscopy, which is a procedure that uses a thin tube with a camera and light to examine the lungs and airways . The other actions are important but not the priority.
Similar Questions
A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?
A. "I will empty my bag when it is full."
The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation.
B. "I will take a laxative when I'm constipated."
The client should avoid laxatives, which can cause dehydration and electrolyte imbalance.
C. "I will expect my stools to be loose."
An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.
D. "I will eat a high-fiber diet."
The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.
Full Explanation
An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.
A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching?
A. "I should use canned instead of frozen vegetables."
B. "I can season my foods with lemon juice."
A 2-g sodium diet means limiting sodium intake to no more than 2000 mg per day. Sodium is found in salt and many processed foods, such as canned vegetables, soups, sauces, and baked goods. Sodium can cause fluid retention and worsen heart failure symptoms, such as shortness of breath, swelling, and fatigue. Therefore, the client should avoid adding salt or salt substitutes (such as baking soda) to their foods and choose fresh or frozen vegetables over canned ones. Lemon juice is a low-sodium alternative that can add flavor to foods without increasing sodium intake.
C. "I should use salt sparingly while cooking."
D. "I can use baking soda when I bake."
Full Explanation
A 2-g sodium diet means limiting sodium intake to no more than 2000 mg per day. Sodium is found in salt and many processed foods, such as canned vegetables, soups, sauces, and baked goods. Sodium can cause fluid retention and worsen heart failure symptoms, such as shortness of breath, swelling, and fatigue. Therefore, the client should avoid adding salt or salt substitutes (such as baking soda) to their foods and choose fresh or frozen vegetables over canned ones. Lemon juice is a low-sodium alternative that can add flavor to foods without increasing sodium intake.
A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permanent pacemaker?
A. Vasovagal bradycardia without syncope
Vasovagal bradycardia is a temporary drop in heart rate and blood pressure caused by a stimulus thattriggers the vagus nerve, such as pain, stress, or straining. It usually resolves on its own or with simple measures, such as lying down or elevating the legs.
B. Complete AV block with rates slower than 40/min
A complete AV block (also called third-degree AV block) is a type of heart block in which there is no electrical communication between the atria and ventricles. This means that the atria and ventriclesbeat independently of each other, resulting in a slow and irregular pulse. A complete AV block can cause symptoms such as dizziness, fainting, chest pain, shortness of breath, and heart failure. A permanent pacemaker is a device that sends electrical impulses to the heart to regulate its rhythm and prevent bradycardia (slow heart rate). A permanent pacemaker is indicated for clients with complete AV block and rates slower than 40/min or symptomatic bradycardia. The other options are not indications for a permanent pacemaker.
C. Sinus tachycardia with rates faster than 80/min
Sinus tachycardia is a normal increase in heart rate in response to physical or emotional stress, such as exercise, fever, or anxiety. It usually does not require treatment unless it is caused by an underlying condition or causes symptoms.
D. Asymptomatic second-degree AV block
Asymptomatic second-degree AV block is a type of heart block in which some of the electrical impulses from the atria are blocked from reaching the ventricles. It may not cause any symptoms or affect the overall heart rate. It may be benign or transient, or it may progress to a more serious type of heart block. It may require monitoring or medication, but not a permanent pacemaker unless it causes symptomatic bradycardia.
Full Explanation
A complete AV block (also called third-degree AV block) is a type of heart block in which there is no electrical communication between the atria and ventricles. This means that the atria and ventricles beat independently of each other, resulting in a slow and irregular pulse. A complete AV block can cause symptoms such as dizziness, fainting, chest pain, shortness of breath, and heart failure.
A permanent pacemaker is a device that sends electrical impulses to the heart to regulate its rhythm and prevent bradycardia (slow heart rate). A permanent pacemaker is indicated for clients with complete AV block and rates slower than 40/min or symptomatic bradycardia.
The other options are not indications for a permanent pacemaker. Vasovagal bradycardia is a temporary drop in heart rate and blood pressure caused by a stimulus that triggers the vagus nerve, such as pain, stress, or straining.
It usually resolves on its own or with simple measures, such as lying down or elevating the legs. Sinus tachycardia is a normal increase in heart rate in response to physical or emotional stress, such as exercise, fever, or anxiety. It usually does not require treatment unless it is caused by an underlying condition or causes symptoms.
Asymptomatic second-degree AV block is a type of heart block in which some of the electrical impulses from the atria are blocked from reaching the ventricles. It may not cause any symptoms or affect the overall heart rate. It may be benign or transient, or it may progress to a more serious type of heart block. It may require monitoring or medication, but not a permanent pacemaker unless it causes symptomatic bradycardia.