Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a compound fracture of the femur.
Which of the following findings should the nurse report to the provider as a manifestation of a fat embolism?
A. Report of pain as 6 on a scale of 0 to 10.
Choice A is wrong because a report of pain as 6 on a scale of 0 to 10 is not specific to a fat embolism. Pain is a common symptom of many conditions and injuries.
B. Pulses 2+ distal to the client’s fracture.
Choice B is wrong because pulses 2+ distal to the client’s fracture are normal and indicate adequate blood flow to the extremity.
C. Petechiae over the client’s chest.
This is a manifestation of a fat embolism, which is a condition where particles of fat get into the bloodstream and block blood flow. A fat embolism can occur after trauma or surgery to the legs, when fat from the bone marrow escapes into the bloodstream.
D. Bruising around the fracture site.
Choice D is wrong because bruising around the fracture site is an expected finding after a compound fracture and does not indicate a fat embolism. Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg and for heart rate are 60 to 100 beats per minute.
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Full Explanation
This is a manifestation of a fat embolism, which is a condition where particles of fat get into the bloodstream and block blood flow. A fat embolism can occur after trauma or surgery to the legs, when fat from the bone marrow escapes into the bloodstream.
Choice A is wrong because a report of pain as 6 on a scale of 0 to 10 is not specific to a fat embolism.
Pain is a common symptom of many conditions and injuries.
Choice B is wrong because pulses 2+ distal to the client’s fracture are normal and indicate adequate blood flow to the extremity.
Choice D is wrong because bruising around the fracture site is an expected finding after a compound fracture and does not indicate a fat embolism.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg and for heart rate are 60 to 100 beats per minute.
Petechiae are small red or purple spots on the skin caused by bleeding under the skin.
They can range in size from pinpoint to several millimeters. Fat embolism syndrome (FES) is a serious complication of a fat embolism that affects the lungs, skin or brain and can be fatal. FES usually occurs 12 to 72 hours after trauma.
Similar Questions
A nurse is contributing to the plan of care for a newly-admitted client who has schizophrenia and a history of aggressive behavior.
Which of the following interventions should the nurse include in the initial plan?
A. Warn the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination.
Choice A is wrong because warning the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination is punitive and threatening. This can increase the client’s anxiety, paranoia, and hostility, and may worsen the psychotic symptoms. Seclusion should only be used as a last resort when the client poses a serious danger to self or others, and not as a punishment or coercion.
B. Keep the facility’s security personnel constantly visible to the client throughout treatment.
Choice B is wrong because keeping the facility’s security personnel constantly visible to the client throughout treatment is intimidating and stigmatizing. This can also increase the client’s fear, distrust, and resentment, and may trigger aggressive behavior. Security personnel should only be involved when there is an imminent risk of violence, and not as a routine measure.
C. Collaborate with the client to develop a daily physical exercise routine.
Collaborate with the client to develop a daily physical exercise routine. This intervention can help reduce aggression and impulsivity in schizophrenia by providing an outlet for frustration, enhancing self-esteem, and improving mood. Physical exercise can also improve physical health and reduce the risk of metabolic syndrome associated with antipsychotic medications.
D. Agree that the hallucinations are real if the client exhibits aggressive behavior toward other clients.
Choice D is wrong because agreeing that the hallucinations are real if the client exhibits aggressive behavior toward other clients is reinforcing the delusional belief and rewarding the aggression. This can also confuse the client and undermine the therapeutic relationship. The nurse should acknowledge the client’s experience of hallucinations, but not endorse them as reality. The nurse should also set clear limits on aggressive behavior and use de-escalation techniques to calm the client.
Full Explanation
Collaborate with the client to develop a daily physical exercise routine. This intervention can help reduce aggression and impulsivity in schizophrenia by providing an outlet for frustration, enhancing self-esteem, and improving mood. Physical exercise can also improve physical health and reduce the risk of metabolic syndrome associated with antipsychotic medications.
Choice A is wrong because warning the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination is punitive and threatening. This can increase the client’s anxiety, paranoia, and hostility, and may worsen the psychotic symptoms. Seclusion should only be used as a last resort when the client poses a serious danger to self or others, and not as a punishment or coercion.
Choice B is wrong because keeping the facility’s security personnel constantly visible to the client throughout treatment is intimidating and stigmatizing. This can also increase the client’s fear, distrust, and resentment, and may trigger aggressive behavior. Security personnel should only be involved when there is an imminent risk of violence, and not as a routine measure.
Choice D is wrong because agreeing that the hallucinations are real if the client exhibits aggressive behavior toward other clients is reinforcing the delusional belief and rewarding the aggression. This can also confuse the client and undermine the therapeutic relationship.
The nurse should acknowledge the client’s experience of hallucinations, but not endorse them as reality. The nurse should also set clear limits on aggressive behavior and use de-escalation techniques to calm the client.
A nurse is reviewing the laboratory values for an adolescent who is scheduled for a surgical procedure.
For which of the following laboratory values should the nurse notify the provider?
A. Platelet count 120,000/mm².
The nurse should notify the provider because this value is lower than the normal range of 150,000 to 450,000 platelets per microliter of blood. A low platelet count can indicate a risk of bleeding or a condition such as thrombocytopenia or disseminated intravascular coagulation (DIC).
B. WBC count 9,800/mm³.
Choice B is wrong because WBC count 9,800/mm³ is within the normal range of 4,500 to 11,000 cells per microliter of blood.
C. Hgb 13 mg/dL.
Choice C is wrong because Hgb 13 mg/dL is within the normal range of 12 to 16 mg/dL for females and 14 to 18 mg/dL for males.
D. Hct 42%.
Choice D is wrong because Hct 42% is within the normal range of 37% to 47% for females and 42% to 52% for males.
Full Explanation
The nurse should notify the provider because this value is lower than the normal range of 150,000 to 450,000 platelets per microliter of blood. A low platelet count can indicate a risk of bleeding or a condition such as thrombocytopenia or disseminated intravascular coagulation (DIC).
Choice B is wrong because WBC count 9,800/mm³ is within the normal range of 4,500 to 11,000 cells per microliter of blood.
Choice C is wrong because Hgb 13 mg/dL is within the normal range of 12 to 16 mg/dL for females and 14 to 18 mg/dL for males.
Choice D is wrong because Hct 42% is within the normal range of 37% to 47% for females and 42% to 52% for males.
A nurse is reinforcing teaching with a newly licensed nurse about incident reports.
The nurse should identify that which of the following situations requires the completion of an incident report?
A. Nitroglycerin transdermal was applied to a client’s chest.
Choice A is wrong because nitroglycerin transdermal is a medication used to prevent angina (chest pain) and can be applied to a client’s chest as prescribed.
B. Cefotaxime was administered to a client after obtaining blood cultures.
Choice B is wrong because cefotaxime is an antibiotic that can be administered to a client after obtaining blood cultures to treat an infection.
C. Digoxin was administered to a client who has a heart rate of 64/min.
Choice C is wrong because digoxin is a medication used to treat heart failure and atrial fibrillation and can be administered to a client who has a heart rate of 64/min, which is within the normal range of 60 to 100 beats per minute.
D. Insulin lispro was administered to a client immediately before bed.
Insulin lispro was administered to a client immediately before bed. This is a situation that requires the completion of an incident report because insulin lispro is a rapid-acting insulin that should be given within 15 minutes before or after a meal. Giving it immediately before bed can cause hypoglycemia (low blood sugar) during the night, which can be dangerous for the client.
Full Explanation
Insulin lispro was administered to a client immediately before bed. This is a situation that requires the completion of an incident report because insulin lispro is a rapid-acting insulin that should be given within 15 minutes before or after a meal. Giving it immediately before bed can cause hypoglycemia (low blood sugar) during the night, which can be dangerous for the client.
Choice A is wrong because nitroglycerin transdermal is a medication used to prevent angina (chest pain) and can be applied to a client’s chest as prescribed.
Choice B is wrong because cefotaxime is an antibiotic that can be administered to a client after obtaining blood cultures to treat an infection.
Choice C is wrong because digoxin is a medication used to treat heart failure and atrial fibrillation and can be administered to a client who has a heart rate of 64/min, which is within the normal range of 60 to 100 beats per minute.