Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia.
Which of the following assessment findings requires immediate intervention by the nurse?
A. The client's capillary refill in the left toe is 6 seconds.
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin. A normal capillary refill time is less than 2 seconds. A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
B. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
C. The client has an oral temperature of 38.3° C (100.9° F).
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
D. The client has 100 mL of blood in the closed-suction drain.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
Similar Questions
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate.
The client reports bladder spasms and the nurse observes decreased urinary output.
Which of the following actions should the nurse take?
A. Remove the indwelling urinary catheter.
Choice A is not the correct answer because removing the indwelling urinary catheter would not address the underlying issue of blood clots blocking the catheter.
B. Decrease traction on the catheter.
Choice B is not the correct answer because decreasing traction on the catheter would not address the underlying issue of blood clots blocking the catheter.
C. Administer ibuprofen 400 mg for pain relief.
Choice C is not the correct answer because while ibuprofen may provide some pain relief, it would not address the underlying issue of blood clots blocking the catheter.
D. Flush the catheter manually with 0.9% sodium chloride.
“Flush the catheter manually with 0.9% sodium chloride.” The client is receiving continuous bladder irrigation following a transurethral resection of the prostate and reports bladder spasms and decreased urinary output. These symptoms may indicate that the catheter is blocked with blood clots. Flushing the catheter manually with 0.9% sodium chloride can help to remove any blood clots and restore urinary output.
Full Explanation
“Flush the catheter manually with 0.9% sodium chloride.” The client is receiving continuous bladder irrigation following a transurethral resection of the prostate and reports bladder spasms and decreased urinary output.
These symptoms may indicate that the catheter is blocked with blood clots.
Flushing the catheter manually with 0.9% sodium chloride can help to remove any blood clots and restore urinary output.
Choice A is not the correct answer because removing the indwelling urinary catheter would not address the underlying issue of blood clots blocking the catheter.
Choice B is not the correct answer because decreasing traction on the catheter would not address the underlying issue of blood clots blocking the catheter.
Choice C is not the correct answer because while ibuprofen may provide some pain relief, it would not address the underlying issue of blood clots blocking the catheter.
A nurse is reviewing the medical record of a client who is scheduled for a CT scan with contrast media.
Which of the following medications should the nurse instruct the client to withhold for 48 hr following the procedure?
A. Clopidogrel.
Choice A, Clopidogrel, is not an answer because it is not mentioned in the search results as a medication that needs to be withheld after a CT scan with contrast media.
B. Furosemide.
Choice B, Furosemide, is not an answer because it is not mentioned in the search results as a medication that needs to be withheld after a CT scan with contrast media.
C. Metformin.
Metformin should be withheld for a minimum of 48 hours after the procedure. This is because metformin can increase the risk of contrast-induced acute kidney injury (CI-AKI) when undergoing contrast imaging.
D. Carvedilol.
Choice D, Carvedilol, is not an answer because it is not mentioned in the search results as a medication that needs to be withheld after a CT scan with contrast media.
Full Explanation
Metformin should be withheld for a minimum of 48 hours after the procedure.
This is because metformin can increase the risk of contrast-induced acute kidney injury (CI-AKI) when undergoing contrast imaging.
Choice A, Clopidogrel, is not an answer because it is not mentioned in the search results as a medication that needs to be withheld after a CT scan with contrast media.
Choice B, Furosemide, is not an answer because it is not mentioned in the search results as a medication that needs to be withheld after a CT scan with contrast media.
Choice D, Carvedilol, is not an answer because it is not mentioned in the search results as a medication that needs to be withheld after a CT scan with contrast media.
A nurse is planning care for a client who has full-thickness burns on the lower extremities.
Which of the following interventions should the nurse include?
A. Clean the equipment in the client's room once per week.
Choice A, cleaning the equipment in the client’s room once per week, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
B. Provide a diet of fresh fruits and vegetables for the client.
Choice B, providing a diet of fresh fruits and vegetables for the client, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
C. Limit visitation time for the client's children to 40 min per day.
Choice C, limiting visitation time for the client’s children to 40 min per day, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
D. Apply new gloves when alternating between wound care sites.
The nurse should apply new gloves when alternating between wound care sites. This is to prevent cross-contamination and infection.
Full Explanation
The nurse should apply new gloves when alternating between wound care sites.
This is to prevent cross-contamination and infection.
Choice A, cleaning the equipment in the client’s room once per week, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
Choice B, providing a diet of fresh fruits and vegetables for the client, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
Choice C, limiting visitation time for the client’s children to 40 min per day, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.