Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider?
A. Obtain capillary blood glucose level every 2 hr
Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.
B. Check the neurovascular status of the client's lower extremities every hour
Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.
C. Apply a cold pack to the client's ankle for 30 min every hour
Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.
D. Maintain the affected ankle elevated and immobilized
Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
- A. Incorrect. Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.
- B. Incorrect. Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.
- C. Correct. Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.
- D. Incorrect. Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.
Similar Questions
A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching?
A. "I will not allow anyone to smoke near my baby."
Avoiding exposure to tobacco smoke is one of the measures to prevent SIDS, as it can affect the respiratory function and arousal of the newborn.
B. "I will place bumper pads in my baby's crib."
Placing bumper pads in the baby's crib is not recommended, as they can pose a suffocation or strangulation hazard for the newborn.
C. "My baby's head should be placed on a pillow for sleeping."
Placing the baby's head on a pillow for sleeping is not advised, as it can increase the risk of suffocation or rebreathing of carbon dioxide for the newborn.
D. "My baby should sleep in a side-lying position."
Placing the baby in a side-lying position for sleeping is not suggested, as it can increase the likelihood of rolling over to a prone position, which is associated with a higher incidence of SIDS.
Full Explanation
"I will not allow anyone to smoke near my baby."
- A. Correct. Avoiding exposure to tobacco smoke is one of the measures to prevent SIDS, as it can affect the respiratory function and arousal of the newborn.
- B. Incorrect. Placing bumper pads in the baby's crib is not recommended, as they can pose a suffocation or strangulation hazard for the newborn.
- C. Incorrect. Placing the baby's head on a pillow for sleeping is not advised, as it can increase the risk of suffocation or rebreathing of carbon dioxide for the newborn.
- D. Incorrect. Placing the baby in a side-lying position for sleeping is not suggested, as it can increase the likelihood of rolling over to a prone position, which is associated with a higher incidence of SIDS.
A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?
A. "I can designate my partner as my health care surrogate."
Designating a health care surrogate is one of the components of an advance directive, which allows the client to appoint someone who can make medical decisions on their behalf if they are unable to do so themselves.
B. "I am only 40 years old, so I don't need to worry about this yet."
Age is not a factor that determines the need for an advance directive, as anyone can become incapacitated at any time due to illness or injury.
C. “I will need a lawyer's help to draw up the documents."
A lawyer's help is not necessary to draw up an advance directive, as there are standardized forms available that can be filled out by the client and witnessed by two adults.
D. “I understand that my family can alter my advance directives if I become incapacitated."
The family cannot alter or override the advance directives of the client unless they have been designated as their health care surrogate or have obtained a court order to do so.
Full Explanation
"I can designate my partner as my health care surrogate."
- A. Correct. Designating a health care surrogate is one of the components of an advance directive, which allows the client to appoint someone who can make medical decisions on their behalf if they are unable to do so themselves.
- B. Incorrect. Age is not a factor that determines the need for an advance directive, as anyone can become incapacitated at any time due to illness or injury.
- C. Incorrect. A lawyer's help is not necessary to draw up an advance directive, as there are standardized forms available that can be filled out by the client and witnessed by two adults. - D. Incorrect. The family cannot alter or override the advance directives of the client unless they have been designated as their health care surrogate or have obtained a court order to do so.
A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?
A. "I will administer aspirin to my child to treat pain or fever."
Aspirin can trigger asthma attacks in some children and should be avoided.
B. "I will record an average of three readings from my child's peak expiratory flow meter."
The peak expiratory flow meter should be used daily, not just when the child has symptoms, and the highest reading should be recorded, not the average.
C. I will place carpet in my child's bedroom to control allergens."
Carpet can harbor dust mites, mold, and other allergens that can worsen asthma. It is better to have hardwood or tile floors and washable rugs.
D. "I will make sure my child receives a yearly influenza immunization."
Influenza immunization can prevent serious complications from respiratory infections in children with asthma.
Full Explanation
A: Incorrect. Aspirin can trigger asthma attacks in some children and should be avoided.
B: Incorrect. The peak expiratory flow meter should be used daily, not just when the child has symptoms, and the highest reading should be recorded, not the average.
C: Incorrect. Carpet can harbor dust mites, mold, and other allergens that can worsen asthma. It is better to have hardwood or tile floors and washable rugs.
D: Correct. Influenza immunization can prevent serious complications from respiratory infections in children with asthma.