Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections?
A. Empty the urine drainage bag every 12 hours.
Empty the urine drainage bag every 12 hours: While it's essential to empty the urine drainage bag regularly to prevent it from becoming too full, emptying it every 12 hours alone is not sufficient to prevent urinary tract infections (UTIs).
B. Drain the urine from the tubing before ambulation.
Drain the urine from the tubing before ambulation: Correct. Before the client ambulates or moves, the nurse should ensure that the urinary catheter's tubing is emptied. This prevents urine from flowing back into the bladder, reducing the risk of UTIs.
C. Use a clean technique for urine specimen collection.
Use clean technique for urine specimen collection: While using clean technique during urine specimen collection is important for preventing contamination, it is not the primary action needed to prevent UTIs in a client with an indwelling urinary catheter.
D. Hang the urine drainage bag at the level of the bladder.
Hang the urine drainage bag at the level of the bladder: While proper positioning of the drainage bag is essential for optimal urine flow and to prevent backflow, it alone is not sufficient to prevent UTIs.
This question is an excerpt from Nurse Dive's nursing test bank - LPN ATI fundamental proctored exam. Take the full exam now
Full Explanation
A. Empty the urine drainage bag every 12 hours: While it's essential to empty the urine drainage bag regularly to prevent it from becoming too full, emptying it every 12 hours alone is not sufficient to prevent urinary tract infections (UTIs).
B. Drain the urine from the tubing before ambulation: Correct. Before the client ambulates or moves, the nurse should ensure that the urinary catheter's tubing is emptied. This prevents urine from flowing back into the bladder, reducing the risk of UTIs.
C. Use clean technique for urine specimen collection: While using clean technique during urine specimen collection is important for preventing contamination, it is not the primary action needed to prevent UTIs in a client with an indwelling urinary catheter.
D. Hang the urine drainage bag at the level of the bladder: While proper positioning of the drainage bag is essential for optimal urine flow and to prevent backflow, it alone is not sufficient to prevent UTIs.
Similar Questions
A nurse is taking notes of client information on a piece of paper while receiving a report.
Which of the following actions should the nurse take to dispose of the paper?
A. Obscure the client's name with a marker prior to disposal.
Obscure the client's name with a marker prior to disposal: While obscuring the client's name is better than not doing anything, it does not fully protect their confidential information. The paper could still be read by someone with access to it.
B. Place the paper in a trash can at the nurses' station.
Place the paper in a trash can at the nurses' station: This action does not ensure the proper disposal of confidential information. It could be accessible to unauthorized individuals and breach the client's privacy.
C. Shred the paper in a secure container.
Shred the paper in a secure container: Correct. Shredding confidential information is the best way to ensure that it cannot be accessed or read by unauthorized individuals.
D. Secure the paper in the nurse's personal locker.
Secure the paper in the nurse's personal locker: While securing the paper in a personal locker is better than leaving it exposed, it is not the most secure method of disposal for confidentialinformation.
Full Explanation
A. Obscure the client's name with a marker prior to disposal: While obscuring the client's name is better than not doing anything, it does not fully protect their confidential information. The paper could still be read by someone with access to it.
B. Place the paper in a trash can at the nurses' station: This action does not ensure the proper disposal of confidential information. It could be accessible to unauthorized individuals and breach the client's privacy.
C. Shred the paper in a secure container: Correct. Shredding confidential information is the best way to ensure that it cannot be accessed or read by unauthorized individuals.
D. Secure the paper in the nurse's personal locker: While securing the paper in a personal locker is better than leaving it exposed, it is not the most secure method of disposal for confidential
information.
A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body?
A. Remove dentures.
Removing dentures is a step often performed during post-mortem care but may not necessarily need to be completed before family viewing, especially if the dentures are normally worn by the deceased.
B. Apply a shroud around the body with a visible identification tag.
Applying a shroud with a visible identification tag is an important step for dignified covering and identification but might be more appropriate after the family has viewed the body.
C. Clean soiled areas of the body.
This is the most appropriate action to ensure the body appears as dignified and comfortable as possible for family viewing. It involves cleaning any visible soiled areas to provide a respectful presentation to the family.
D. Place the client's head in a dependent position.
Placing the client's head in a dependent position is not typically necessary or recommended in this context. The goal is to ensure the body appears as natural and dignified as possible.
Full Explanation
A. Remove dentures:
- Removing dentures is a step often performed during post-mortem care but may not necessarily need to be completed before family viewing, especially if the dentures are normally worn by the deceased.
B. Apply a shroud around the body with a visible identification tag:
- Applying a shroud with a visible identification tag is an important step for dignified covering and identification but might be more appropriate after the family has viewed the body.
C. Clean soiled areas of the body:
- This is the most appropriate action to ensure the body appears as dignified and comfortable as possible for family viewing. It involves cleaning any visible soiled areas to provide a respectful presentation to the family.
D. Place the client's head in a dependent position:
- Placing the client's head in a dependent position is not typically necessary or recommended in this context. The goal is to ensure the body appears as natural and dignified as possible.
A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?
A. Bone pain
Bone pain: Bone pain is not a characteristic finding of hypomagnesemia. Hypomagnesemia is an electrolyte imbalance, and bone pain is not a typical symptom associated with it.
B. Drowsiness
Drowsiness: Drowsiness may occur in hypomagnesemia, but it is not a specific or characteristic sign of this condition. Other electrolyte imbalances and medical conditions can also cause drowsiness.
C. Bowel hypomotility
Bowel hypomotility: Hypomagnesemia can cause bowel hypomotility (decreased bowel movements), but it is not the most specific finding associated with this condition.
D. Positive Chvostek's sign
Positive Chvostek's sign: Correct. Hypomagnesemia can lead to neuromuscular irritability, and a positive Chvostek's sign is a clinical manifestation of this condition. A positive Chvostek's sign is elicited by tapping the facial nerve (at the level of the zygomatic arch) and observing the atwitching of the facial muscles, which indicates increased neuromuscular excitability.
Full Explanation
A. Bone pain: Bone pain is not a characteristic finding of hypomagnesemia. Hypomagnesemia is an electrolyte imbalance, and bone pain is not a typical symptom associated with it.
B. Drowsiness: Drowsiness may occur in hypomagnesemia, but it is not a specific or characteristic sign of this condition. Other electrolyte imbalances and medical conditions can also cause drowsiness.
C. Bowel hypomotility: Hypomagnesemia can cause bowel hypomotility (decreased bowel movements), but it is not the most specific finding associated with this condition.
D. Positive Chvostek's sign: Correct. Hypomagnesemia can lead to neuromuscular irritability, and a positive Chvostek's sign is a clinical manifestation of this condition. A positive Chvostek's sign is elicited by tapping the facial nerve (at the level of the zygomatic arch) and observing a
twitching of the facial muscles, which indicates increased neuromuscular excitability.
