Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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.
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
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.
Similar Questions
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.
A nurse is collecting data from a client about her current pain status. Which of the following questions should the nurse ask to determine the quality of the client's pain?
A. "Could you rate your pain on a scale from 0 to 10?"
Asking a patient to rate their pain on a scale from 0 to 10 is a common method to assess the intensity of pain, not the quality. Zero indicates no pain, and ten represents the most severe pain imaginable. This scale is quantitative and helps in tracking the effectiveness of pain management over time.
B. "Is your pain the same as it has been?"
Inquiring if the pain is the same as it has been is a question that assesses the consistency or changes in the patient’s pain over time. It does not provide information about the quality of the pain but rather its course or any variations in the experience of pain.
C. "Do you have any pain this morning?"
Asking whether the patient has any pain this morning is a question that determines the presence or absence of pain at a particular time. It does not elicit details about the nature or characteristics of the pain, which are essential to understanding its quality.
D. "What does your pain feel like?"
Asking “What does your pain feel like?” is a qualitative question that aims to describe the characteristics of the pain, such as aching, stabbing, or burning. This information is crucial for diagnosing the cause of pain and tailoring appropriate treatment strategies. It directly addresses the quality of the pain, which is the focus of the nurse’s inquiry.
Full Explanation
The correct answer is: D.
Choice A reason: Asking a patient to rate their pain on a scale from 0 to 10 is a common method to assess the intensity of pain, not the quality. Zero indicates no pain, and ten represents the most severe pain imaginable. This scale is quantitative and helps in tracking the effectiveness of pain management over time.
Choice B reason: Inquiring if the pain is the same as it has been is a question that assesses the consistency or changes in the patient’s pain over time. It does not provide information about the quality of the pain but rather its course or any variations in the experience of pain.
Choice C reason: Asking whether the patient has any pain this morning is a question that determines the presence or absence of pain at a particular time. It does not elicit details about the nature or characteristics of the pain, which are essential to understanding its quality.
Choice D reason: Asking “What does your pain feel like?” is a qualitative question that aims to describe the characteristics of the pain, such as aching, stabbing, or burning. This information is crucial for diagnosing the cause of pain and tailoring appropriate treatment strategies. It directly addresses the quality of the pain, which is the focus of the nurse’s inquiry.
A nurse is reviewing laboratory values of a client who has severe dyspnea. Which of the following laboratory values indicates heart failure?
A. Brain natriuretic peptide 275 pg/mL
The correct answer is choice A. Brain natriuretic peptide (BNP) value of 275 pg/mL indicates heart failure in a client with severe dyspnea. BNP is a hormone secreted by the heart in response to pressure changes and fluid overload. High levels of BNP in the blood are indicative of heart failure. Choices B, C, and D are not correct because calcium, sodium, and potassium levels are not specific to heart failure and their changes may not necessarily indicate heart failure. Reason why each of the other choices are not answers:
B. Calcium 9.0 mg/dL
is not correct because Calcium levels are not specific to heart failure and their changes may not necessarily indicate heart failure. Calcium levels could be affected by other conditions like hypoparathyroidism, vitamin D deficiency, or renal disease.
C. Sodium 140 mEq/L
is not correct because Sodium levels are not specific to heart failure and their changes may not necessarily indicate heart failure. Sodium levels could be affected by other conditions like dehydration, hyperaldosteronism, or inappropriate antidiuretic hormone (ADH) secretion.
D. Potassium 4.0 mEq/L
is not correct because Potassium levels are not specific to heart failure and their changes may not necessarily indicate heart failure. Potassium levels could be affected by other conditions like renal failure, Addison's disease, or the use of diuretics.