Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?
A. Measure the circumference of the thigh.
Choice A reason: This is incorrect. Measuring the circumference of the thigh can help detect swelling or compartment syndrome, but it does not assess the neurovascular status of the lower leg. The nurse should measure the circumference of both thighs and compare them for any significant difference.
B. Instruct the client to wiggle his toes.
Choice B reason: This is the correct answer. Instructing the client to wiggle his toes can assess the motor function and sensation of the lower leg. The nurse should observe if the client can move his toes voluntarily and if he feels any pain, numbness, or tingling.
C. Palpate the femoral pulse.
Choice C reason: This is incorrect. Palpating the femoral pulse can assess the arterial blood supply to the lower leg, but it does not assess the venous return or the nerve function. The nurse should palpate both femoral pulses and compare them for any significant difference in strength or quality.
D. Monitor the client's calf for edema.
Choice D reason: This is incorrect. Monitoring the client's calf for edema can help detect venous congestion or deep vein thrombosis, but it does not assess the arterial blood supply or the nerve function. The nurse should inspect both calves and compare them for any significant difference in size, color, or temperature.
This question is an excerpt from Nurse Dive's nursing test bank - NY BSN Proctored Exam. Take the full exam now
Similar Questions
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?
A. Include foods high in starch and protein.
Choice A reason: This is incorrect. Foods high in starch and protein are not harmful for a client who has chronic cholecystitis, but they are not beneficial either. Starch and protein do not affect the production or secretion of bile, which is the main cause of biliary colic.
B. Avoid foods high in fat.
Choice B reason: This is the correct answer. Foods high in fat can trigger biliary colic by stimulating the gallbladder to contract and release bile. However, if the gallbladder is inflamed or has stones, this can cause pain and obstruction. Therefore, a client who has chronic cholecystitis should avoid foods high in fat, such as fried foods, faty meats, cheese, buter, cream, and pastries.
C. Avoid foods high in sodium.
Choice C reason: This is incorrect. Foods high in sodium are not related to biliary colic or chronic cholecystitis. Sodium can affect blood pressure and fluid balance, but it does not affect bile production or secretion.
D. Include foods high in fiber.
Choice D reason: This is incorrect. Foods high in fiber are beneficial for general health and digestion, but they do not prevent or treat biliary colic or chronic cholecystitis. Fiber can help prevent constipation and lower cholesterol levels, but it does not affect bile production or secretion.
A nurse is caring for a client who is 1 day postoperative following hip open reduction with internal fixation. The client is scheduled to begin physical therapy in 30 min. Which of the following actions should the nurse take?
A. Position the client's legs in an adducted position.
Choice A reason: This is incorrect. Positioning the client's legs in an adducted position means bringing them together or crossing them. This can cause dislocation of the hip joint or damage to the nerves and blood vessels. The nurse should position the client's legs in an abducted position, which means keeping them apart with a pillow or wedge between them.
B. Bathe and dress the client.
Choice B reason: This is incorrect. Bathing and dressing the client are not priority actions before physical therapy. The nurse should assist the client with hygiene and grooming as needed, but not at the expense of delaying or interfering with the therapy session. The nurse should also respect the client's preferences and level of independence.
C. Offer to administer analgesia.
Choice C reason: This is the correct answer. Offering to administer analgesia is a priority action before physical therapy. The nurse should assess the client's pain level and provide adequate pain relief as prescribed. This can help the client tolerate the therapy session and prevent complications such as muscle spasms, immobility, or infection.
D. Tell the client to bend forward at the waist when getting out of bed.
Choice D reason: This is incorrect. Telling the client to bend forward at the waist when getting out of bed can cause dislocation of the hip joint or damage to the nerves and blood vessels. The nurse should instruct the client to keep the operative leg straight and use a trapeze bar or assistance to get out of bed. The nurse should also avoid flexing the hip more than 90 degrees or rotating it inward or outward.
A charge nurse observes a nurse administer intermitent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?
A. The nurse irrigates the NG tube with tap water after feeding.
Choice A reason: This is incorrect. Irrigating the NG tube with tap water after feeding is an acceptable practice, unless the client is immunocompromised or has fluid restrictions. Tap water can help flush out any residual formula and prevent clogging of the tube.
B. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
Choice B reason: This is incorrect. Initiating the feeding after aspirating 50 mL of gastric residual is an acceptable practice, unless the facility has a different protocol. Gastric residual volume (GRV) is the amount of fluid left in the stomach before feeding. A GRV of less than 250 mL indicates that the stomach is emptying properly and that the client can tolerate the feeding.
C. The nurse administers the feeding through a syringe barrel by gravity.
Choice C reason: This is incorrect. Administering the feeding through a syringe barrel by gravity is an acceptable practice, unless the client has a history of aspiration or intolerance to bolus feedings. Gravity feedings are faster and easier than pump feedings, but they require careful monitoring of the flow rate and the client's response.
D. The nurse allows the client to rest in a supine position during feeding.
Choice D reason: This is the correct answer. Allowing the client to rest in a supine position during feeding is a dangerous practice that can cause aspiration, pneumonia, or death. The nurse should elevate the head of the bed at least 30 degrees during and for at least one hour after feeding. This can help prevent regurgitation and aspiration of the formula into the lungs.