Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has just undergone a total laryngectomy.
Which of the following findings is the nurse's priority for immediate intervention?
A. Fever.
Choice A is wrong because while a fever may indicate an infection, it is not the priority for immediate intervention.
B. Blood-tinged secretions.
Choice B is wrong because while blood-tinged secretions may indicate bleeding, it is not the priority for immediate intervention.
C. Tachypnea.
The nurse’s priority for immediate intervention is tachypnea, which is rapid breathing. Tachypnea can be a sign of respiratory distress and requires immediate intervention.
D. IV infiltration.
Choice D is wrong because while IV infiltration may cause discomfort and require attention, it is not the priority for immediate intervention.
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 nurse’s priority for immediate intervention is tachypnea, which is rapid breathing.
Tachypnea can be a sign of respiratory distress and requires immediate intervention.
Choice A is wrong because while a fever may indicate an infection, it is not the priority for immediate intervention.
Choice B is wrong because while blood-tinged secretions may indicate bleeding, it is not the priority for immediate intervention.
Choice D is wrong because while IV infiltration may cause discomfort and require attention, it is not the priority for immediate intervention.
Similar Questions
A nurse is preparing to administer 2 units of packed RBCs to a client.
Which of the following actions should the nurse take?
A. Transfuse each unit of blood over 5 hr.
Transfusing each unit of blood over 5 hours (choice A) is not recommended as it may increase the risk of bacterial growth. Packed RBCs should be transfused over 2 to 3 hours.
B. Change the IV tubing after each unit of blood is transfused.
Changing the IV tubing after each unit of blood is transfused (choice B) is not necessary.
C. Prime the tubing with 0.9% sodium chloride.
When administering packed RBCs, the tubing should be primed with 0.9% sodium chloride.
D. Administer the blood through a 22-gauge intravenous catheter.
Administering the blood through a 22-gauge intravenous catheter (choice D) may not be appropriate as a larger gauge catheter is typically used for blood transfusions.
Full Explanation
When administering packed RBCs, the tubing should be primed with 0.9% sodium chloride.
Transfusing each unit of blood over 5 hours (choice A) is not recommended as it may increase the risk of bacterial growth.
Packed RBCs should be transfused over 2 to 3 hours.
Changing the IV tubing after each unit of blood is transfused (choice B) is not necessary.
Administering the blood through a 22-gauge intravenous catheter (choice D) may not be appropriate as a larger gauge catheter is typically used for blood transfusions.
A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10.
Which of the following interventions should the nurse take?
A. Place pillows under the client's knee.
Applying an ice pack can help reduce pain and swelling after total knee arthroplasty. Placing pillows under the client’s knee (choice A) is not recommended as it can hinder circulation and delay healing.
B. Perform range-of-motion exercises on the client's knee.
Performing range-of-motion exercises to the client’s knee (choice B) may be part of the rehabilitation process but should be done under the guidance of a physical therapist and may not be appropriate for immediate pain relief.
C. Apply an ice pack to the client's knee.
Applying an ice pack can help reduce pain and swelling after total knee arthroplasty.
D. Gently massage the area around the client's incision.
Gently massaging the area around the client’s incision (choice D) may not be appropriate as it can cause discomfort and disrupt the healing process.
Full Explanation
Applying an ice pack can help reduce pain and swelling after total knee arthroplasty.
Placing pillows under the client’s knee (choice A) is not recommended as it can hinder circulation and delay healing.
Performing range-of-motion exercises to the client’s knee (choice B) may be part of the rehabilitation process but should be done under the guidance of a physical therapist and may not be appropriate for immediate pain relief.
Gently massaging the area around the client’s incision (choice D) may not be appropriate as it can cause discomfort and disrupt the healing process.
A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake.
Which of the following choices should the nurse recommend as containing the least potassium?
A. 1/2 cup nonfat yogurt.
Nonfat yogurt (choice A) contains moderate amounts of potassium and may not be the best choice for someone who needs to limit their potassium intake.
B. 1 medium baked potato with skin.
A medium baked potato with skin (choice B) is high in potassium and should be limited to a
C. 2 tbsp peanut butter.
Peanut butter (choice C) also contains moderate amounts of potassium and may not be the best choice for someone who needs to limit their potassium intake.
D. 1 cup white rice.
White rice is a low-potassium food that can be recommended for a client who has chronic kidney disease and must limit potassium intake.
Full Explanation
White rice is a low-potassium food that can be recommended for a client who has chronic kidney disease and must limit potassium intake.
Nonfat yogurt (choice A) contains moderate amounts of potassium and may not be the best choice for someone who needs to limit their potassium intake.
A medium baked potato with skin (choice B) is high in potassium and should be limited to a low-potassium diet.
Peanut butter (choice C) also contains moderate amounts of potassium and may not be the best choice for someone who needs to limit their potassium intake.