Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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.
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. 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.
Similar Questions
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.
A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?
A. Place the client in high-Fowler's position.
The correct answer is choice A. Placing the client in high-Fowler's position will help to increase the client's oxygenation. This is a priority in the care of a client with pulmonary embolism and dyspnea. Choices B, C, and D are not correct because although obtaining vital signs, administering heparin, and encouraging cough and deep breathing are important interventions, improving oxygenation is the priority intervention.
B. Obtain the client's vital signs.
is not correct because although assessing vital signs is important, it is not the priority intervention.
C. Administer heparin to the client.
is not correct because although administering heparin is crucial for anticoagulation and dissolution of the clot, it is not the priority intervention.
D. Encourage the client to cough and deep breathe.
is not correct because although coughing and deep breathing can help to prevent respiratory complications, increasing oxygenation is the priority intervention.