Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has an implanted venous access port.
Which of the following should the nurse use to access the port?
A. butterfly needle
a butterfly needle is a small, winged needle that is used for peripheral venous access, not for accessing a port. A butterfly needle can damage the port’s septum and cause leakage or infection.
B. An angiocatheter
because an angiocatheter is a thin, plastic tube that is inserted into a vein using a needle. It is used for short-term IV therapy, not for accessing a port. An angiocatheter can also damage the port’s septum and cause complications.
C. A 25-gauge needle
wrong because a 25-gauge needle is too small to access a port. A 25-gauge needle is typically used for subcutaneous injections, not for intravenous injections. A 25-gauge needle can also clog the port or cause hemolysis (breakdown of red blood cells).
D. A noncoring needle
a noncoring needle. A noncoring needle is a special type of needle that has a beveled tip and a side hole. It is designed to prevent damage to the port’s septum, which is the soft silicone top that serves as the vein access point. A noncoring needle also reduces the risk of infection and clotting.
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
The correct answer is choice D, a noncoring needle.
A noncoring needle is a special type of needle that has a beveled tip and a side hole. It is designed to prevent damage to the port’s septum, which is the soft silicone top that serves as the vein access point.
A noncoring needle also reduces the risk of infection and clotting.
Choice A is wrong because a butterfly needle is a small, winged needle that is used for peripheral venous access, not for accessing a port. A butterfly needle can damage the port’s septum and cause leakage or infection.
Choice B is wrong because an angiocatheter is a thin, plastic tube that is inserted into a vein using a needle.
It is used for short-term IV therapy, not for accessing a port. An angiocatheter can also damage the port’s septum and cause complications.
Choice C is wrong because a 25-gauge needle is too small to access a port.
A 25-gauge needle is typically used for subcutaneous injections, not for intravenous injections. A 25-gauge needle can also clog the port or cause hemolysis (breakdown of red blood cells).
Normal ranges for ports vary depending on the type and size of the port, but generally they have a reservoir diameter of 1.5 to 2.5 cm, a catheter length of 40 to 60 cm, and a catheter diameter of 0.8 to 1.2 mm. Ports are usually flushed with saline or heparin solution every 4 to 6 weeks when not in use to prevent clotting.
Similar Questions
A nurse is admitting a client to a medical-surgical unit.
When performing medication reconciliation for the client, which of the following actions should the nurse take?
A. A. Compare new prescriptions with the list of medications the client reports
The nurse should compare new prescriptions with the list of medications the client reports. This is part of the medication reconciliation process, which is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
B. B. Encourage the client to make his own list after he returns to his home
because the nurse should not encourage the client to make his own list after he returns to his home. The nurse should provide the client with an updated and accurate list of medications before discharge and instruct the client to keep it with him at all times.
C. Include any adverse effects of the medications the client might develop
wrong because the nurse should not include any adverse effects of the medications the client might develop. The nurse should include any known allergies or adverse reactions the client has experienced in the past, but not potential adverse effects that have not occurred.
D. Exclude nutritional supplements from the list of medications the client reports
wrong because the nurse should not exclude nutritional supplements from the list of medications the client reports. The nurse should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions in the medication reconciliation process.
Full Explanation
The correct answer is choice A. The nurse should compare new prescriptions with the list of medications the client reports. This is part of the medication reconciliation process, which is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
Choice B is wrong because the nurse should not encourage the client to make his own list after he returns to his home. The nurse should provide the client with an updated and accurate list of medications before discharge and instruct the client to keep it with him at all times.
Choice C is wrong because the nurse should not include any adverse effects of the medications the client might develop. The nurse should include any known allergies or adverse reactions the client has experienced in the past, but not potential adverse effects that have not occurred.
Choice D is wrong because the nurse should not exclude nutritional supplements from the list of medications the client reports. The nurse should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions in the medication reconciliation process.
Some of these products may interact with prescribed medications or affect laboratory results.
A nurse is assisting with food selection for a client who follows kosher dietary traditions.
Which of the following food choices should the nurse include on the client’s food tray?
A. Ham sandwich with milk.
that choices A, B, and C are not appropriate for someone following kosher dietary traditions as they all contain meat products (ham, shrimp, bacon) combined with dairy (milk). Choice D is the only option that does not contain any meat products and is therefore the most appropriate choice for someone following kosher dietary traditions.
B. Shrimp salad and tomato soup with milk
that choices A, B, and C are not appropriate for someone following kosher dietary traditions as they all contain meat products (ham, shrimp, bacon) combined with dairy (milk). Choice D is the only option that does not contain any meat products and is therefore the most appropriate choice for someone following kosher dietary traditions.
C. Bacon and cheese quiche with milk
that choices A, B, and C are not appropriate for someone following kosher dietary traditions as they all contain meat products (ham, shrimp, bacon) combined with dairy (milk). Choice D is the only option that does not contain any meat products and is therefore the most appropriate choice for someone following kosher dietary traditions.
D. Scrambled eggs and toast with milk
For a client who follows kosher dietary traditions, it's essential to adhere to the rules and restrictions that pertain to kosher food preparation and consumption. Among the given options, the only one that aligns with kosher dietary guidelines is scrambled eggs and toast with milk.
Full Explanation
D) Scrambled eggs and toast with milk.
For a client who follows kosher dietary traditions, it's essential to adhere to the rules and restrictions that pertain to kosher food preparation and consumption. Among the given options, the only one that aligns with kosher dietary guidelines is scrambled eggs and toast with milk.
The other options (A, B, and C) contain non-kosher ingredients, such as ham, shrimp, and bacon, which are not considered kosher. Additionally, mixing meat and dairy products is generally not allowed in kosher dietary practices. So, options A, B, and C would not be appropriate for someone following kosher dietary traditions.
A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture.
Which of the following actions by the client indicates an understanding of the teaching?
A. Moving both crutches with the stronger leg forward first.
Moving both crutches with the stronger leg forward first is incorrect for a three-point gait.This describes a two-point gait,which is used when a client can bear weight on both legs.In a three-point gait,the client bears weight on the unaffected leg and the crutches,not the stronger leg. This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.
B. Supporting his body weight while leaning on the axillary crutch pads
Supporting his body weight while leaning on the axillary crutch pads is also incorrect.This can lead to nerve damage in the armpits and should be avoided. The weight should be distributed through the hands and wrists,not the armpits.
C. Stepping with his affected leg first when going up stairs
Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous.The client should lead with the stronger leg when going up stairs to maintain balance and control.
D. Positioning both hands on the grips with his elbows slightly flexed.
Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait.This allows for proper weight distribution,balance,and control of the crutches. It also helps to prevent fatigue and strain in the arms and shoulders. Key points to remember about the three-point gait: Weight is borne on the unaffected leg and the crutches,not the affected leg. The crutches and the unaffected leg move forward together,followed by the affected leg. The client should look ahead,not down at their feet. The client should take small,even steps. The client should rest as needed.
Full Explanation
The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.
Choice A rationale:
- Moving both crutches with the stronger leg forward first is incorrect for a three-point gait. This describes a two-point gait, which is used when a client can bear weight on both legs. In a three-point gait, the client bears weight on the unaffected leg and the crutches, not the stronger leg.
- This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.
Choice B rationale:
- Supporting his body weight while leaning on the axillary crutch pads is also incorrect. This can lead to nerve damage in the armpits and should be avoided.
- The weight should be distributed through the hands and wrists, not the armpits.
Choice C rationale:
- Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous. The client should lead with the stronger leg when going up stairs to maintain balance and control.
Choice D rationale:
- Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait. This allows for proper weight distribution, balance, and control of the crutches.
- It also helps to prevent fatigue and strain in the arms and shoulders.
Key points to remember about the three-point gait:
- Weight is borne on the unaffected leg and the crutches, not the affected leg.
- The crutches and the unaffected leg move forward together, followed by the affected leg.
- The client should look ahead, not down at their feet.
- The client should take small, even steps.
- The client should rest as needed.