Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?
A. Apply a vest restraint on the client.
Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.
B. Place the client in bed with the two side rails raised.
Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.
C. Place a seat alarm in the client's chair.
Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.
D. Administer lorazepam the client.
Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted
This question is an excerpt from Nurse Dive's nursing test bank - ATI Paediatrics Proctored Exam 1. Take the full exam now
Full Explanation
Choice A Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.
Choice B Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.
Choice C Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.
Choice D Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted
Similar Questions
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?
A. Lentils
Rationale: Lentils have one of the highest fiber contents per cup compared to the other options listed, making them a good choice to help alleviate constipation.
B. Asparagus
Rationale: Asparagus is a source of fiber but typically has lower fiber content per cup compared to lentils.
C. Oatmeal
Rationale: Oatmeal is known for its fiber content, but its fiber content per cup is typically lower than that of lentils.
D. Cabbage
Rationale: Cabbage is a source of fiber, but its fiber content per cup is usually lower than that of lentils.
Full Explanation
Choice A Rationale: Lentils have one of the highest fiber contents per cup compared to the other options listed, making them a good choice to help alleviate constipation.
Choice B Rationale: Asparagus is a source of fiber but typically has lower fiber content per cup compared to lentils.
Choice C Rationale: Oatmeal is known for its fiber content, but its fiber content per cup is typically lower than that of lentils.
Choice D Rationale: Cabbage is a source of fiber, but its fiber content per cup is usually lower than that of lentils.
When addressing the needs of a client with a newly diagnosed spinal cord injury, the nurse understands that which of the following are true about nutritional needs?
A. The client will be NPO until fitted for a halo vest
Rationale: Keeping the client NPO until fitted for a halo vest is not a standard practice, and nutritional support should be initiated as soon as possible.
B. A high calorie, high protein diet will be started within 3 days
Rationale: A high-calorie, high-protein diet is typically started within 3 days of a spinal cord injury to support healing and prevent muscle wasting.
C. High fiber and decreased protein is needed immediately after injury
Rationale: High fiber and decreased protein are not the immediate dietary needs after a spinal cord injury. High protein intake is important for tissue repair.
D. Low fiber and no protein is needed 2 days after the injury
Rationale: Low fiber and no protein would not be recommended 2 days after a spinal cord injury, as protein intake is crucial for healing and recovery.
Full Explanation
Choice A Rationale: Keeping the client NPO until fitted for a halo vest is not a standard practice, and nutritional support should be initiated as soon as possible.
Choice B Rationale: A high-calorie, high-protein diet is typically started within 3 days of a spinal cord injury to support healing and prevent muscle wasting.
Choice C Rationale: High fiber and decreased protein are not the immediate dietary needs after a spinal cord injury. High protein intake is important for tissue repair.
Choice D Rationale: Low fiber and no protein would not be recommended 2 days after a spinal cord injury, as protein intake is crucial for healing and recovery.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
A. "You should keep the diaphragm in place for at least 4 hours after intercourse."
Rationale: Keeping the diaphragm in place for at least 4 hours after intercourse is a recommendation, but it does not address the specific concern of the client wanting to continue using her diaphragm postpartum.
B. "You should have your provider refit you for a new diaphragm."
Rationale: Having the client's provider refit her for a new diaphragm is the appropriate instruction after childbirth. The size and shape of the cervix can change postpartum, affecting the fit of the diaphragm.
C. "You should use an oil-based vaginal lubricant when inserting your diaphragm."
Rationale: Using an oil-based vaginal lubricant can damage the diaphragm and is not recommended.
D. "You should store your diaphragm in sterile water after each use."
Rationale: Storing the diaphragm in sterile water after each use is not a standard practice. Proper cleaning and storage in a dry, cool place are recommended.
Full Explanation
Choice A Rationale: Keeping the diaphragm in place for at least 4 hours after intercourse is a recommendation, but it does not address the specific concern of the client wanting to continue using her diaphragm postpartum.
Choice B Rationale: Having the client's provider refit her for a new diaphragm is the appropriate instruction after childbirth. The size and shape of the cervix can change postpartum, affecting the fit of the diaphragm.
Choice C Rationale: Using an oil-based vaginal lubricant can damage the diaphragm and is not recommended.
Choice D Rationale: Storing the diaphragm in sterile water after each use is not a standard practice. Proper cleaning and storage in a dry, cool place are recommended.