Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
A. Relieve the client's pain.
Relieve the client's pain: While pain management is important for client comfort and recovery, it is not the priority immediately following intermaxillary fixation. Pain relief can be addressed once the more urgent concerns, such as preventing aspiration, are addressed.
B. Promote oral hygiene
Promote oral hygiene: Promoting oral hygiene is essential for preventing complications such as infection, but it is not the priority immediately after surgery and intermaxillary fixation. The client's airway and respiratory status should be the primary focus at this time.
C. Ensure adequate nutrition
Ensure adequate nutrition: Ensuring adequate nutrition is important for the client's overall recovery, but it is not the immediate priority after surgery and intermaxillary fixation. The priority is to prevent complications such as aspiration and maintain the client's airway.
D. Prevent aspiration
Prevent aspiration: This is the priority action for the nurse. Intermaxillary fixation restricts the client's ability to open their mouth, increasing the risk of aspiration if vomiting occurs. The nurse should ensure that the client's airway is clear and that measures are in place to prevent aspiration, such as positioning the client appropriately and monitoring for signs of respiratory distress.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nursing 4650 Comprehensive Proctored Exam. Take the full exam now
Full Explanation
A. Relieve the client's pain: While pain management is important for client comfort and recovery, it is not the priority immediately following intermaxillary fixation. Pain relief can be addressed once the more urgent concerns, such as preventing aspiration, are addressed.
B. Promote oral hygiene: Promoting oral hygiene is essential for preventing complications such as infection, but it is not the priority immediately after surgery and intermaxillary fixation. The client's airway and respiratory status should be the primary focus at this time.
C. Ensure adequate nutrition: Ensuring adequate nutrition is important for the client's overall recovery, but it is not the immediate priority after surgery and intermaxillary fixation. The priority is to prevent complications such as aspiration and maintain the client's airway.
D. Prevent aspiration: This is the priority action for the nurse. Intermaxillary fixation restricts the client's ability to open their mouth, increasing the risk of aspiration if vomiting occurs. The nurse should ensure that the client's airway is clear and that measures are in place to prevent aspiration, such as positioning the client appropriately and monitoring for signs of respiratory distress.
Similar Questions
When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?
A. The AP's ability to complete the task without assistance
The AP's ability to complete the task without assistance: While it's important for the AP to be able to complete the task independently, this is not the only consideration when delegating tasks. The nurse should also consider whether the AP has the necessary knowledge and skill to perform the task safely and effectively.
B. The AP's rapport with clients
The AP's rapport with clients: Although the AP's rapport with clients is valuable in providing care, it is not directly related to the ability to perform a delegated task. The nurse should prioritize delegation based on the AP's competency and skill level rather than their interpersonal skills.
C. The AP’s ability to prioritize
The AP’s ability to prioritize: While the AP's ability to prioritize tasks is important in providing efficient care, it is not specifically related to the nurse's consideration when delegating tasks. Delegation decisions should primarily be based on the AP's knowledge and skill to perform the task safely and effectively.
D. The AP has the knowledge and skill to perform the task
The AP has the knowledge and skill to perform the task: This is the most appropriate consideration when delegating tasks. Ensuring that the AP has the necessary knowledge and skill to perform the delegated task safely and effectively is essential for patient safety and quality care. The nurse should assess the AP's competency and provide appropriate supervision and guidance as needed.
Full Explanation
A. The AP's ability to complete the task without assistance: While it's important for the AP to be able to complete the task independently, this is not the only consideration when delegating tasks. The nurse should also consider whether the AP has the necessary knowledge and skill to perform the task safely and effectively.
B. The AP's rapport with clients: Although the AP's rapport with clients is valuable in providing care, it is not directly related to the ability to perform a delegated task. The nurse should prioritize delegation based on the AP's competency and skill level rather than their interpersonal skills.
C. The AP’s ability to prioritize: While the AP's ability to prioritize tasks is important in providing efficient care, it is not specifically related to the nurse's consideration when delegating tasks. Delegation decisions should primarily be based on the AP's knowledge and skill to perform the task safely and effectively.
D. The AP has the knowledge and skill to perform the task: This is the most appropriate consideration when delegating tasks. Ensuring that the AP has the necessary knowledge and skill to perform the delegated task safely and effectively is essential for patient safety and quality care. The nurse should assess the AP's competency and provide appropriate supervision and guidance as needed.
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?
A. Lubricate the suction catheter tip with sterile saline
A) Lubricate the suction catheter tip with sterile saline: Lubricating the suction catheter tip is not recommended, as it can introduce additional fluids into the airway and may contribute to complications or further secretions.
B. Suction two to three times with a 50-second pause between passes
B) Suction two to three times with a 50-second pause between passes: While it is appropriate to limit suctioning passes to minimize trauma, the pause should generally be 30 seconds to allow for reoxygenation. A 50-second pause could result in hypoxia.
C. Hyperventilate the client on 100% oxygen prior to suctioning
C) Hyperventilate the client on 100% oxygen prior to suctioning: This action is crucial as it helps to preoxygenate the client, minimizing the risk of hypoxia during the suctioning procedure. Hyperventilation with 100% oxygen helps maintain adequate oxygen levels, especially when the airway may be compromised.
D. Perform chest physiotherapy prior to suctioning
D) Perform chest physiotherapy prior to suctioning: While chest physiotherapy can help mobilize secretions, it is typically done as a separate intervention and not immediately before suctioning. The priority during suctioning is to clear secretions efficiently and safely, and chest physiotherapy may not be necessary right before this procedure.
E. None
None
F. None
None
Full Explanation
Correct Answer: B. Position the sterile drape leaving the perineum exposed.
Rationales
A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.
B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.
C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.
D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.
A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? (Select all that apply)
A. Rotavirus (RV)
Rotavirus (RV): Rotavirus vaccine is routinely recommended for infants to protect against rotavirus infection, which can cause severe diarrhea and dehydration in young children. It is typically administered orally in multiple doses starting at around 2 months of age.
B. Human papillomavirus (HPV)
Human papillomavirus (HPV): The HPV vaccine is not routinely administered to infants at 1 year of age. It is typically recommended for preteens and adolescents to protect against HPV-related cancers and genital warts.
C. Measles, mumps rubella (MMR)
Measles, mumps rubella (MMR): The MMR vaccine is routinely given to infants around 1 year of age to protect against measles, mumps, and rubella (German measles). It is typically administered as a single injection.
D. Varicella (VAR)
Varicella (VAR): The varicella vaccine is routinely recommended for infants to protect against chickenpox (varicella) infection. It is typically administered as a single injection around 1 year of age.
E. Diphtheria, tetanus and acellular pertussis (DTaP)
Diphtheria, tetanus and acellular pertussis (DTaP): The DTaP vaccine is routinely given to infants to protect against diphtheria, tetanus, and pertussis (whooping cough). It is typically administered as a series of injections starting at around 2 months of age.
Full Explanation
A. Rotavirus (RV): Rotavirus vaccine is routinely recommended for infants to protect against rotavirus infection, which can cause severe diarrhea and dehydration in young children. It is typically administered orally in multiple doses starting at around 2 months of age.
B. Human papillomavirus (HPV): The HPV vaccine is not routinely administered to infants at 1 year of age. It is typically recommended for preteens and adolescents to protect against HPV-related cancers and genital warts.
C. Measles, mumps rubella (MMR): The MMR vaccine is routinely given to infants around 1 year of age to protect against measles, mumps, and rubella (German measles). It is typically administered as a single injection.
D. Varicella (VAR): The varicella vaccine is routinely recommended for infants to protect against chickenpox (varicella) infection. It is typically administered as a single injection around 1 year of age.
E. Diphtheria, tetanus and acellular pertussis (DTaP): The DTaP vaccine is routinely given to infants to protect against diphtheria, tetanus, and pertussis (whooping cough). It is typically administered as a series of injections starting at around 2 months of age.