Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following is the priority action the nurse should take?
A. Maintain the patency of the client's airway.
"I will keep my walker at the end of my bed." This statement indicates that the client understands the importance of having the walker within reach. Placing the walker at the end of the bed ensures that the client can use it immediately upon getting up, providing support and stability, thus reducing the risk of falls.
B. Identify the poison the client ingested.
"I will keep the fluorescent ceiling light on in my room at night." While having adequate lighting is important, using a fluorescent ceiling light throughout the night might disrupt the client's sleep. Additionally, a nightlight or a bedside lamp with a low-wattage bulb can provide sufficient illumination without disturbing sleep.
C. Measure the client's blood pressure.
"I will place an area rug at the entry of my bathroom." This statement indicates a lack of understanding. Area rugs can be tripping hazards, especially in areas prone to moisture like bathrooms. It is advisable to remove rugs and ensure non-slip flooring to prevent slips and falls.
D. Position the client on her side.
"I will place a bath seat in my shower to use when I bathe." While using a bath seat is a good safety measure, it does not address the client's risk of falling outside the shower area. Installing grab bars and non-slip mats in the bathroom, along with removing potential hazards, would be more comprehensive in ensuring the client's safety. .
This question is an excerpt from Nurse Dive's nursing test bank - Nursing Fundamentals Exam 3. Take the full exam now
Full Explanation
Choice A rationale:
"I will keep my walker at the end of my bed." This statement indicates that the client understands the importance of having the walker within reach. Placing the walker at the end of the bed ensures that the client can use it immediately upon getting up, providing support and stability, thus reducing the risk of falls.
Choice B rationale:
"I will keep the fluorescent ceiling light on in my room at night." While having adequate lighting is important, using a fluorescent ceiling light throughout the night might disrupt the client's sleep. Additionally, a nightlight or a bedside lamp with a low-wattage bulb can provide sufficient illumination without disturbing sleep.
Choice C rationale:
"I will place an area rug at the entry of my bathroom." This statement indicates a lack of understanding. Area rugs can be tripping hazards, especially in areas prone to moisture like bathrooms. It is advisable to remove rugs and ensure non-slip flooring to prevent slips and falls.
Choice D rationale:
"I will place a bath seat in my shower to use when I bathe." While using a bath seat is a good safety measure, it does not address the client's risk of falling outside the shower area. Installing grab bars and non-slip mats in the bathroom, along with removing potential hazards, would be more comprehensive in ensuring the client's safety. .
Similar Questions
A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.
Which of the following information should the nurse include? (Select all that apply.)
A. Family members who smoke must be at least 10 ft from the client when oxygen is in use.
Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.
B. Nail polish remover or hair spray should not be used near a client who is receiving oxygen.
Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.
C. A "No Smoking" sign should be placed on the front door.
Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.
D. Cotton bedding and clothing should be replaced with items made from wool.
Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.
E. A fire extinguisher should be readily available in the home.
Full Explanation
Choice A rationale:
Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.
Choice B rationale:
Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.
Choice C rationale:
Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.
Choice D rationale:
Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.
A nurse is caring for a client who is sitting in a chair and asks to return to bed.
Which of the following actions is the nurse's priority?
A. Obtain a walker for the client to use to transfer back to bed.
While obtaining a walker might be helpful, it's not the first step. The nurse needs to assess the client's ability to assist with the transfer before deciding on the most appropriate aid.
B. Call for additional staff to assist with the transfer.
Calling for additional staff may be necessary, but this should come after assessing the client's ability to help with the transfer.
C. Use a transfer belt and assist the client back into bed.
Using a transfer belt is a good practice for safe transfers, but again, the nurse must first determine if the client can assist. This ensures the appropriate use of resources and techniques.
D. Determine the client's ability to help with the transfer.
Assessing the client's ability to help with the transfer is the first step. This assessment will guide the nurse in choosing the safest and most appropriate method for transferring the client, considering their capabilities and safety.
Full Explanation
The correct answer is D. Determine the client's ability to help with the transfer.
Choice A rationale:
While obtaining a walker might be helpful, it's not the first step. The nurse needs to assess the client's ability to assist with the transfer before deciding on the most appropriate aid.
Choice B rationale:
Calling for additional staff may be necessary, but this should come after assessing the client's ability to help with the transfer.
Choice C rationale:
Using a transfer belt is a good practice for safe transfers, but again, the nurse must first determine if the client can assist. This ensures the appropriate use of resources and techniques.
Choice D rationale:
Assessing the client's ability to help with the transfer is the first step. This assessment will guide the nurse in choosing the safest and most appropriate method for transferring the client, considering their capabilities and safety.
A nurse is preparing to conduct a fall risk screening on a client.
Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)
A. Fall history.
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
B. Medical diagnosis.
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
C. Use of assistive devices.
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
D. Mental status.
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.
E. Do-not-resuscitate status.
Full Explanation
Choice A rationale:
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
Choice B rationale:
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
Choice C rationale:
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
Choice D rationale:
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.