Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has partial-thickness burns on 50% of his body and is receiving total parenteral nutrition. The nurse should actively monitor the client for which of the following?
A. Decreased calcium levels.
B. Increased serum glucose levels.
Increased serum glucose levels. Total parenteral nutrition (TPN) can cause hyperglycemia as it provides a concentrated source of glucose to the bloodstream. Monitoring serum glucose levels is important to detect and intervene early if trends of hyperglycemia occur. Decreased calcium levels may indicate an electrolyte imbalance, not a result of TPN. Absent bowel sounds and intermittent abdominal pain may indicate a gastrointestinal problem
C. Absent bowel sounds.
D. Intermittent abdominal pain.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Similar Questions
A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?
A. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke."
B. "I can decrease my risk for a stroke by losing excess weight."
. "I can decrease my risk for a stroke by losing excess weight." Losing excess weight is an important lifestyle modification that can help reduce the risk of stroke in people with diabetes mellitus. Glucocorticoids are not generally used as a preventative measure for stroke. HbA1c levels that are 6 percent or less indicate good glucose control and are not necessarily associated with an increased risk of stroke. Having a total cholesterol level below 200 mg/dL does not increase the risk for stroke; in fact, it may help reduce the risk. Choice A: Glucocorticoids are not generally used as a preventative measure for stroke. Choice C: HbA1c levels that are 6 percent or less indicate good glucose control and are not necessarily associated with an increased risk of stroke. Choice D: Having a total cholesterol level below 200 mg/dL does not increase the risk for stroke.
C. "My risk for a stroke increases if my HbA1c level is 6 percent or less."
D. "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke."
A nurse is caring for a client who is 4 hr postoperative following an abdominal surgery and notes that the client's abdominal incision is open and the internal organs are protruding. After contacting the rapid response team, which of the following actions should the nurse take next?
A. Obtain a set of vital signs.
Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.
B. Flex the client's knees and hips.
Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.
C. Apply a moist saline dressing to the area.
Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.
D. Elevate the head of the client's bed 20°.
Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.
Full Explanation
The correct answer is c. Apply a moist saline dressing to the area.
Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.
Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.
Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.
Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.
A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforcing teaching about the use of an automatic epinephrine injector, which of the following actions is the priority?
A. Review the signs of anaphylaxis with the client.
Reviewing the signs of anaphylaxis with the client is important, but it’s not the priority. The client must first know what to do in case of an emergency.
B. Instruct the client to store the injector at room temperature.
Instructing the client to store the injector at room temperature is a part of the storage instructions, but it’s not the immediate action to take during an anaphylactic reaction.
C. Inform the client to seek medical attention following administration of the injection.
This is the priority because anaphylaxis is a potentially life-threatening condition and even after administering epinephrine, it’s crucial to seek immediate medical attention.
D. Have the client perform a return demonstration of the equipment.
Having the client perform a return demonstration of the equipment is a good teaching method, but it’s not the immediate action to take when an anaphylactic reaction occurs.
Full Explanation
The correct answer is c. Inform the client to seek medical attention following administration of the injection.
Choice A reason: Reviewing the signs of anaphylaxis with the client is important, but it’s not the priority. The client must first know what to do in case of an emergency.
Choice B reason: Instructing the client to store the injector at room temperature is a part of the storage instructions, but it’s not the immediate action to take during an anaphylactic reaction.
Choice C reason: This is the priority because anaphylaxis is a potentially life-threatening condition and even after administering epinephrine, it’s crucial to seek immediate medical attention.
Choice D reason: Having the client perform a return demonstration of the equipment is a good teaching method, but it’s not the immediate action to take when an anaphylactic reaction occurs.