Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has dementia and is at risk for falls. Which of the following preventive measures should the nurse take?
A. Place the client’s bed in the low position.
This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.
B. Encourage the client to wear socks when ambulating.
Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.
C. Position the client’s bedside table at the foot of the bed.
Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.
D. Raise four side rails on the client’s bed.
Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.
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Full Explanation
This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.
Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.
Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.
Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.
Similar Questions
A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the following actions should the nurse take?
A. Delay the admission while the client fills out the facility’s advance directives form.
Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form. The client has the right to refuse or accept any treatment, including filling out an advance directives form. The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.
B. Confirm with the client’s family that the consent form has been signed.
Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed. The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options. The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate. The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.
C. Explain to the client that signing the facility’s consent form means they cannot refuse care.
Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care. Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery. The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.
D. Determine if the client has prepared their advance directives.
The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.
Full Explanation
The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.
Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.
The client has the right to refuse or accept any treatment, including filling out an advance directives form.
The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.
Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.
The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.
The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.
The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.
Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.
Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.
The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.
A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the following findings is outside of the expected reference range?
A. Respiratory rate 68/min.
This is outside of the expected reference range for a 2-week-old infant, which is 30 to 60 breaths per minute. A respiratory rate higher than 60 breaths per minute can indicate respiratory distress or infection.
B. BP 64/42 mm Hg.
Choice B is wrong because BP 64/42 mm Hg is within the normal range for a 2-week-old infant, which is 65 to 85/45 to 55 mm Hg.
C. Axillary temperature 36.6° C (97.9° F).
Choice C is wrong because Axillary temperature 36.6° C (97.9° F) is within the normal range for a 2-week-old infant, which is 36.5 to 37.5° C (97.7 to 99.5° F).
D. Apical heart rate 124/min.
Choice D is wrong because Apical heart rate 124/min is within the normal range for a 2-week-old infant, which is 110 to 160 beats per minute.
Full Explanation
This is outside of the expected reference range for a 2-week-old infant, which is 30 to 60 breaths per minute. A respiratory rate higher than 60 breaths per minute can indicate respiratory distress or infection.
Choice B is wrong because BP 64/42 mm Hg is within the normal range for a 2-week-old infant, which is 65 to 85/45 to 55 mm Hg.
Choice C is wrong because Axillary temperature 36.6° C (97.9° F) is within the normal range for a 2-week-old infant, which is 36.5 to 37.5° C (97.7 to 99.5° F).
Choice D is wrong because Apical heart rate 124/min is within the normal range for a 2-week-old infant, which is 110 to 160 beats per minute.
A nurse is collecting data from an adolescent client who takes digoxin.
The nurse should monitor the client for which of the following adverse effects?
A. Yellow Sclera.
Choice A is wrong because yellow sclera is not an adverse effect of digoxin. It can be a sign of jaundice or liver disease.
B. Blurred vision.
Blurred vision is a common adverse effect of digoxin that affects the eyes and the central nervous system. It can also cause yellow or green vision, halos around lights, and night blindness.
C. Frequent swallowing.
Choice C is wrong because frequent swallowing is not an adverse effect of digoxin. It can be a sign of dysphagia or throat irritation.
D. Bleeding gums.
Choice D is wrong because bleeding gums is not an adverse effect of digoxin. It can be a sign of gingivitis or coagulation disorder. Other adverse effects of digoxin include nausea, vomiting, diarrhea, lower stomach pain, dizziness, drowsiness, headache, weakness, confusion, depression, anxiety, hallucinations, expressed fear of impending death, rash, weight loss, loss of appetite, and various cardiac arrhythmias.
Full Explanation
Blurred vision is a common adverse effect of digoxin that affects the eyes and the central nervous system. It can also cause yellow or green vision, halos around lights, and night blindness.
Choice A is wrong because yellow sclera is not an adverse effect of digoxin. It can be a sign of jaundice or liver disease.
Choice C is wrong because frequent swallowing is not an adverse effect of digoxin.
It can be a sign of dysphagia or throat irritation.
Choice D is wrong because bleeding gums is not an adverse effect of digoxin. It can be a sign of gingivitis or coagulation disorder.
Other adverse effects of digoxin include nausea, vomiting, diarrhea, lower stomach pain, dizziness, drowsiness, headache, weakness, confusion, depression, anxiety, hallucinations, expressed fear of impending death, rash, weight loss, loss of appetite, and various cardiac arrhythmias.
Some of these effects can indicate digoxin toxicity and require immediate medical attention.
Normal ranges for serum digoxin levels are 0.5 to 2 ng/mL for adults and 0.8 to 2 ng/mL for children.
Serum digoxin levels should be monitored regularly to avoid overdose or underdose.