Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?
A. Lactated Ringer's
Lactated Ringer's is a balanced electrolyte solution, but it contains sodium in a similar concentration to normal serum levels. It is not appropriate for a client with hypernatremia, as it could further increase their sodium levels.
B. 0.45% sodium chloride
0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution with a lower concentration of sodium than normal serum levels. It can help to lower the sodium levels in a client with hypernatremia by diluting the excess sodium in the body.
C. Dextrose 5% in 0.9% sodium chloride
Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that contains both dextrose and sodium. It would not be appropriate for a client with hypernatremia, as it could exacerbate the condition.
D. Dextrose 10% in water
Dextrose 10% in water is a hypertonic solution with a high concentration of dextrose.It does not contain sodium, but it is still a hypertonic solution and not appropriate for a client with hypernatremia.
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Full Explanation
A. Lactated Ringer's is a balanced electrolyte solution, but it contains sodium in a similar concentration to normal serum levels. It is not appropriate for a client with hypernatremia, as it could further increase their sodium levels.
B. 0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution with a lower concentration of sodium than normal serum levels. It can help to lower the sodium levels in a client with hypernatremia by diluting the excess sodium in the body.
C. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that contains both dextrose and sodium. It would not be appropriate for a client with hypernatremia, as it could exacerbate the condition.
D. Dextrose 10% in water is a hypertonic solution with a high concentration of dextrose.
It does not contain sodium, but it is still a hypertonic solution and not appropriate for a client with hypernatremia.
Similar Questions
A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client.
Which of the following ethical principles did the nurse violate?
A. Beneficence
The nurse violated the ethical principle of Beneficence by not completing an incident report. Beneficence involves taking actions that promote the well-being and safety of the client. Failing to report an incorrect medication administration, even if no harm occurred, could potentially jeopardize the well-being of future clients.
B. Autonomy
Autonomy refers to the right of the client to make decisions about their own care and treatment. While it is an important ethical principle, it is not directly relevant to the nurse's failure to complete an incident report.
C. Veracity
Veracity involves truthfulness and honesty. While not completing an incident report may be seen as a lack of transparency, the primary ethical principle violated in this scenario is beneficence.
D. Confidentiality
Confidentiality pertains to protecting the privacy and confidentiality of client information. This principle is not directly related to the nurse's failure to complete an incident report.
Full Explanation
A. The nurse violated the ethical principle of Beneficence by not completing an incident report. Beneficence involves taking actions that promote the well-being and safety of the client. Failing to report an incorrect medication administration, even if no harm occurred, could potentially jeopardize the well-being of future clients.
B. Autonomy refers to the right of the client to make decisions about their own care and treatment. While it is an important ethical principle, it is not directly relevant to the nurse's failure to complete an incident report.
C. Veracity involves truthfulness and honesty. While not completing an incident report may be seen as a lack of transparency, the primary ethical principle violated in this scenario is beneficence.
D. Confidentiality pertains to protecting the privacy and confidentiality of client information. This principle is not directly related to the nurse's failure to complete an incident report.
A nurse is preparing to administer three liquid medications to a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?
A. Dilute each medication with 10 mL of tap water.
Diluting each medication with tap water is not a recommended practice. It's important to administer medications in their prescribed form to ensure the client receives the correct dose.
B. Pinch the tube prior to attaching the medication syringe.
Pinching the tube prior to attaching the medication syringe helps prevent the medication from being immediately pulled into the suction equipment. This allows the medication to stay in the stomach for absorption.
C. Reattach the suction directly after administering the medication.
Reattaching the suction directly after administering the medication wouldimmediately start suctioning again, which could pull the medication out of the stomach before it has a chance to be absorbed.
D. Mix the three medications together prior to administering.
Mixing the three medications together is not recommended, as some medications may interact with each other, potentially leading to undesirable effects. Each medication should be administered separately to ensure proper absorption and effectiveness.
Full Explanation
A. Diluting each medication with tap water is not a recommended practice. It's important to administer medications in their prescribed form to ensure the client receives the correct dose.
B. Pinching the tube prior to attaching the medication syringe helps prevent the medication from being immediately pulled into the suction equipment. This allows the medication to stay in the stomach for absorption.
C. Reattaching the suction directly after administering the medication would
immediately start suctioning again, which could pull the medication out of the stomach before it has a chance to be absorbed.
D. Mixing the three medications together is not recommended, as some medications may interact with each other, potentially leading to undesirable effects. Each medication should be administered separately to ensure proper absorption and effectiveness.
A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
A. Use a stiff toothbrush to clean the client's teeth.
Using a stiff toothbrush is not recommended for oral care, especially for clients who may have sensitive gums or mouth tissues. A soft-bristle toothbrush or disposable foam swabs are more appropriate for gentle oral care.
B. Turn the client on his side before starting oral care.
Turning the client on his side before starting oral care is a good practice to prevent aspiration and ensure proper positioning during the procedure. This allows any excess fluid or oral care products to drain out of the mouth.
C. Use the thumb and index finger to keep the client's mouth open.
Using the thumb and index finger to keep the client's mouth open can be uncomfortable and potentially harm the client's mouth. It's better to use a mouth prop or ask the client to open their mouth gently.
D. Apply petroleum jelly to the client's lips after oral care.
Applying petroleum jelly to the client's lips after oral care is a beneficial step to help moisturize and protect the lips, especially for clients who may be at risk for dryness or cracking.
Full Explanation
A - Using a stiff toothbrush is not appropriate for oral care in immobile clients, as it can irritate or damage the gums and oral tissues. A soft-bristled toothbrush is recommended to ensure gentle cleaning.
B - Turning the client on his side is the correct action to prevent aspiration. This position allows fluids and saliva to drain from the mouth, reducing the risk of aspiration, which is critical for immobile clients.
C - Using the thumb and index finger to keep the client’s mouth open can lead to accidental injury. Instead, a padded tongue blade should be used to maintain the client’s mouth open safely during oral care.
D - Applying petroleum jelly to the lips should be avoided, as it is oil-based and can increase the risk of aspiration if inhaled. A water-based lubricant or lip balm should be used instead.