Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who develops a pulmonary embolism.
Which of the following interventions is the priority for the nurse to take?
A. Administer IV morphine.
Administer IV morphine. Administering IV morphine may be necessary for pain management in a client with a pulmonary embolism. However, pain relief should not take precedence over ensuring the patient's oxygenation and cardiovascular stability. Oxygen therapy is the top priority to address hypoxia and prevent further deterioration. Once oxygenation is secured, pain management can be considered.
B. Start an IV infusion of lactated Ringer's.
Start an IV infusion of lactated Ringer's. Initiating an IV infusion of lactated Ringer's solution may be important for maintaining hydration and electrolyte balance in a patient with a pulmonary embolism. However, this is not the top priority when a client is at risk of or experiencing a pulmonary embolism. Ensuring oxygenation and cardiovascular stability takes precedence. Once the patient is stable, intravenous fluids can be administered if needed.
C. Begin oxygen therapy.
D. Initiate cardiac monitoring.
Initiate cardiac monitoring. Initiating cardiac monitoring is important in assessing the patient's cardiac rhythm and identifying any dysrhythmias or changes that may occur due to the pulmonary embolism. While this is a vital step, it is not the highest priority when the client is in a state of hypoxia and respiratory distress. Oxygen therapy should be the first intervention to address the immediate threat to the patient's life.
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Full Explanation
Choice A rationale:
Administer IV morphine. Administering IV morphine may be necessary for pain management in a client with a pulmonary embolism. However, pain relief should not take precedence over ensuring the patient's oxygenation and cardiovascular stability. Oxygen therapy is the top priority to address hypoxia and prevent further deterioration. Once oxygenation is secured, pain management can be considered.
Choice B rationale:
Start an IV infusion of lactated Ringer's. Initiating an IV infusion of lactated Ringer's solution may be important for maintaining hydration and electrolyte balance in a patient with a pulmonary embolism. However, this is not the top priority when a client is at risk of or experiencing a pulmonary embolism. Ensuring oxygenation and cardiovascular stability takes precedence. Once the patient is stable, intravenous fluids can be administered if needed.
Choice D rationale:
Initiate cardiac monitoring. Initiating cardiac monitoring is important in assessing the patient's cardiac rhythm and identifying any dysrhythmias or changes that may occur due to the pulmonary embolism. While this is a vital step, it is not the highest priority when the client is in a state of hypoxia and respiratory distress. Oxygen therapy should be the first intervention to address the immediate threat to the patient's life.
Similar Questions
A nurse is collecting data from a client prior to administering atenolol.
For which of the following findings should the nurse withhold the medication?
A. Heart rate 50/min.
Atenolol is a beta-blocker that can significantly lower heart rate. A heart rate of 50/min is considered bradycardia (slow heart rate), and administering atenolol could further decrease the heart rate to a dangerously low level. Therefore, the nurse should withhold the medication in this case.
B. Respiratory rate 18/min.
A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not contraindicate the use of atenolol. Therefore, this finding would not require withholding the medication.
C. Oxygen saturation 95%.
An oxygen saturation of 95% is within the normal range (typically 95-100%) and does not contraindicate the use of atenolol. Thus, this finding would not necessitate withholding the medication.
D. Blood pressure 160/94 mm Hg.
While a blood pressure of 160/94 mm Hg indicates hypertension, atenolol is often prescribed to manage high blood pressure. Therefore, this finding would not require withholding the medication.
Full Explanation
The correct answer is choice A. Heart rate 50/min.
Choice A rationale:
Atenolol is a beta-blocker that can significantly lower heart rate. A heart rate of 50/min is considered bradycardia (slow heart rate), and administering atenolol could further decrease the heart rate to a dangerously low level. Therefore, the nurse should withhold the medication in this case.
Choice B rationale:
A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not contraindicate the use of atenolol. Therefore, this finding would not require withholding the medication.
Choice C rationale:
An oxygen saturation of 95% is within the normal range (typically 95-100%) and does not contraindicate the use of atenolol. Thus, this finding would not necessitate withholding the medication.
Choice D rationale:
While a blood pressure of 160/94 mm Hg indicates hypertension, atenolol is often prescribed to manage high blood pressure. Therefore, this finding would not require withholding the medication.
A nurse is caring for a client who is postoperative and has developed atelectasis.
Which of the following findings should the nurse expect?
A. Facial flushing.
Facial flushing. Facial flushing is not typically associated with atelectasis. Atelectasis is the collapse of a portion of the lung, which can lead to decreased oxygenation and respiratory distress but does not directly cause facial flushing. Flushing may be related to other factors such as fever or allergic reactions.
B. Dry cough.
Dry cough. A dry cough can be a common symptom of atelectasis. As the lung tissue collapses and airways become obstructed, it can lead to irritation and a dry, non-productive cough as the body attempts to clear the airway. So, a dry cough is an expected finding in a client with atelectasis.
C. Decreasing respiratory rate.
Decreasing respiratory rate. A decreasing respiratory rate is not typically associated with atelectasis. In fact, atelectasis often leads to an increased respiratory rate as the body tries to compensate for the reduced oxygen exchange. The patient may experience tachypnea (rapid breathing) as a result.
D. Increasing dyspnea.
Increasing dyspnea. Increasing dyspnea is a common and expected finding in a client with atelectasis. As lung tissue collapses and oxygen exchange is compromised, the patient will likely experience worsening shortness of breath. This is a concerning symptom and should be closely monitored, as it may indicate a need for intervention to improve lung expansion and oxygenation.
Full Explanation
Choice A rationale:
Facial flushing. Facial flushing is not typically associated with atelectasis. Atelectasis is the collapse of a portion of the lung, which can lead to decreased oxygenation and respiratory distress but does not directly cause facial flushing. Flushing may be related to other factors such as fever or allergic reactions.
Choice B rationale:
Dry cough. A dry cough can be a common symptom of atelectasis. As the lung tissue collapses and airways become obstructed, it can lead to irritation and a dry, non-productive cough as the body attempts to clear the airway. So, a dry cough is an expected finding in a client with atelectasis.
Choice C rationale:
Decreasing respiratory rate. A decreasing respiratory rate is not typically associated with atelectasis. In fact, atelectasis often leads to an increased respiratory rate as the body tries to compensate for the reduced oxygen exchange. The patient may experience tachypnea (rapid breathing) as a result.
Choice D rationale:
Increasing dyspnea. Increasing dyspnea is a common and expected finding in a client with atelectasis. As lung tissue collapses and oxygen exchange is compromised, the patient will likely experience worsening shortness of breath. This is a concerning symptom and should be closely monitored, as it may indicate a need for intervention to improve lung expansion and oxygenation.
A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.
The client states that his chest pain is relieved but now he has a headache.
Which of the following responses by the nurse is appropriate?
A. "A headache indicates tolerance to the medication.”.
Tolerance to nitroglycerin is not indicated by the presence of a headache. Nitroglycerin is a vasodilator used to relieve angina, and headaches can be a common side effect.
B. "It sounds as if you are allergic to this medication.”.
Allergic reactions to nitroglycerin are rare, and a headache is not a typical symptom of an allergy to this medication.
C. "A headache is a common adverse effect of this medication, but it will probably occur less often over time.”.
"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”. This is the correct response. Nitroglycerin commonly causes headaches due to its vasodilatory effects. Patients often experience this side effect initially, but it tends to improve or occur less frequently with continued use. The nurse should educate the client about this and reassure them that the headaches should diminish over time.
D. "Your headache is probably a result of anxiety about the chest pain.”.
Anxiety may exacerbate chest pain, but it is not the likely cause of the headache. It is important to address the headache as a potential side effect of the medication.
Full Explanation
Choice A rationale:
Tolerance to nitroglycerin is not indicated by the presence of a headache. Nitroglycerin is a vasodilator used to relieve angina, and headaches can be a common side effect.
Choice B rationale:
Allergic reactions to nitroglycerin are rare, and a headache is not a typical symptom of an allergy to this medication.
Choice C rationale:
"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”. This is the correct response. Nitroglycerin commonly causes headaches due to its vasodilatory effects. Patients often experience this side effect initially, but it tends to improve or occur less frequently with continued use. The nurse should educate the client about this and reassure them that the headaches should diminish over time.
Choice D rationale:
Anxiety may exacerbate chest pain, but it is not the likely cause of the headache. It is important to address the headache as a potential side effect of the medication.