Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client in the medical-surgical unit.
Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client?
Select all that apply.
A. Review the need for the indwelling urinary catheter daily.
Review the need for the indwelling urinary catheter daily. This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).
B. Place the drainage bag on the bed when transporting the client.
Place the drainage bag on the bed when transporting the client. This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent backflow of urine and contamination of the catheter.
C. Use soap and water to provide perineal care.
Use soap and water to provide perineal care. This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.
D. Encourage the client to drink 3000 mL of fluid daily.
Encourage the client to drink 3000 mL of fluid daily. This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.
E. Change the indwelling urinary catheter tubing every 3 days.
Change the indwelling urinary catheter tubing every 3 days. This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.
F. Empty the drainage bag when it is half-full.
Empty the drainage bag when it is half-full. This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
A: Review the need for the indwelling urinary catheter daily.
This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).
B: Place the drainage bag on the bed when transporting the client.
This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent the backflow of urine and contamination of the catheter.
C: Use soap and water to provide perineal care.
This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.
D: Encourage the client to drink 3000 mL of fluid daily.
This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.
E: Change the indwelling urinary catheter tubing every 3 days.
This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.
F: Empty the drainage bag when it is half full.
This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.
Similar Questions
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible.
Which of the following is an appropriate action by the nurse?
A. Suggest rinsing his mouth with an alcohol-based mouth wash.
because rinsing the mouth with an alcohol-based mouth wash can irritate the oral tissues and worsen xerostomia. Alcohol can also dehydrate the mouth and reduce saliva production.
B. Instruct the client on the use of esophageal speech.
because esophageal speech is a method of voice restoration after laryngectomy, not a treatment for xerostomia. Esophageal speech involves swallowing air into the esophagus and releasing it to create sound. It has nothing to do with saliva flow or dry mouth.
C. Offer the client saltine crackers between meals.
because saltine crackers are dry and hard to swallow without adequate saliva. They can also scratch the oral mucosa and cause pain or bleeding. Offering the client saltine crackers between meals can aggravate xerostomia and increase the risk of choking.
D. Provide humidification of the room air.
Provide humidification of the room air. This is because humidification can help moisten the oral mucosa and reduce the discomfort of xerostomia. Xerostomia is a condition of dry mouth caused by reduced or absent saliva flow, which can occur after radiation therapy to the head and neck area.
Full Explanation
Provide humidification of the room air. This is because humidification can help moisten the oral mucosa and reduce the discomfort of xerostomia. Xerostomia is a condition of dry mouth caused by reduced or absent saliva flow, which can occur after radiation therapy to the head and neck area.
Choice A is wrong because rinsing the mouth with an alcohol-based mouth wash can irritate the oral tissues and worsen xerostomia. Alcohol can also dehydrate the mouth and reduce saliva production.
Choice B is wrong because esophageal speech is a method of voice restoration after laryngectomy, not a treatment for xerostomia.
Esophageal speech involves swallowing air into the esophagus and releasing it to create sound.
It has nothing to do with saliva flow or dry mouth.
Choice C is wrong because saltine crackers are dry and hard to swallow without adequate saliva.
They can also scratch the oral mucosa and cause pain or bleeding. Offering the client saltine crackers between meals can aggravate xerostomia and increase the risk of choking.
Normal ranges for saliva flow vary depending on the method of measurement, but generally, a stimulated saliva flow rate of less than 0.7 mL/min or an unstimulated saliva flow rate of less than 0.1 mL/min is considered indicative of xerostomia.
A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback.
Which of the following actions should the nurse take?
A. Infuse the medication over 10 min.
Infusing penicillin G over 10 minutes is not recommended as it may cause adverse reactions. The infusion rate should be based on the specific guidelines for the medication and patient condition.
B. Instruct the client to notify the provider if diarrhea develops.
Diarrhea can be a sign of a serious side effect called Clostridium difficile-associated diarrhea, which can occur with antibiotic use. It is important for the client to notify the provider if this symptom develops.
C. Refrigerate the medication after reconstitution.
Penicillin G should be stored according to the manufacturer’s instructions, which typically do not include refrigeration after reconstitution. Incorrect storage can affect the medication’s efficacy.
D. Check the client for a sulfa allergy.
Checking for a sulfa allergy is not relevant for penicillin G administration. Sulfa allergies are related to sulfonamide antibiotics, not penicillins.
Full Explanation
The correct answer is choice b. Instruct the client to notify the provider if diarrhea develops.
Choice A rationale:
Infusing penicillin G over 10 minutes is not recommended as it may cause adverse reactions. The infusion rate should be based on the specific guidelines for the medication and patient condition.
Choice B rationale:
Diarrhea can be a sign of a serious side effect called Clostridium difficile-associated diarrhea, which can occur with antibiotic use. It is important for the client to notify the provider if this symptom develops.
Choice C rationale:
Penicillin G should be stored according to the manufacturer’s instructions, which typically do not include refrigeration after reconstitution. Incorrect storage can affect the medication’s efficacy.
Choice D rationale:
Checking for a sulfa allergy is not relevant for penicillin G administration. Sulfa allergies are related to sulfonamide antibiotics, not penicillins.
A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?
A. Contact the adolescent’s parent for assistance.
wrong because contacting the adolescent’s parent for assistance might violate the client’s confidentiality and autonomy, especially if the parent is not aware of or supportive of the pregnancy. The nurse should respect the client’s right to privacy and self-determination, unless there is a risk of harm to the client or the fetus.
B. Assist the adolescent in applying for Medicaid.
This action demonstrates the nurse’s role as an advocate and a resource person for the client, who might be eligible for financial assistance and health care coverage during her pregnancy and postpartum period. Medicaid is a federal and state program that provides health insurance for low-income individuals and families.
C. Refer the adolescent to a local mental health clinic.
is wrong because referring the adolescent to a local mental health clinic might imply that the client has a mental disorder or needs psychological counseling, which could be stigmatizing and discouraging. The nurse should assess the client’s emotional state and coping skills, and provide supportive and nonjudgmental care. The nurse can also offer referrals to other community resources, such as prenatal education, parenting classes, or social services, that might benefit the client.
D. Advise the adolescent to place the newborn for adoption.
is wrong because advising the adolescent to place the newborn for
Full Explanation
The correct answer is B.
Assist the adolescent in applying for Medicaid.
This action demonstrates the nurse’s role as an advocate and a resource person for the client, who might be eligible for financial assistance and health care coverage during her pregnancy and postpartum period. Medicaid is a federal and state program that provides health insurance for low-income individuals and families.
Choice A is wrong because contacting the adolescent’s parent for assistance might violate the client’s confidentiality and autonomy, especially if the parent is not aware of or supportive of the pregnancy. The nurse should respect the client’s right to privacy and self-determination, unless there is a risk of harm to the client or the fetus.
Choice C is wrong because referring the adolescent to a local mental health clinic might imply that the client has a mental disorder or needs psychological counseling, which could be stigmatizing and discouraging.
The nurse should assess the client’s emotional state and coping skills, and provide supportive and nonjudgmental care. The nurse can also offer referrals to other community resources, such as prenatal education, parenting classes, or social services, that might benefit the client.
Choice D is wrong because advising the adolescent to place the newborn for adoption might interfere with the client’s decision-making process and personal values.
The nurse should not impose his or her own opinions or beliefs on the client, but rather explore the client’s feelings and preferences about her pregnancy options. The nurse should provide factual information and education about adoption, abortion, or parenting, and help the client weigh the benefits and risks of each option.