Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?
A. Left lateral
B. Dorsal recumbent
C. Supine
D. Semi-Fowler's
This position allows for optimal drainage of secretions and reduces edema and tension on the suture line. It also facilitates breathing and prevents aspiration. Left lateral, dorsal recumbent and supine positions can increase the risk of airway obstruction, bleeding and infection.
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Full Explanation
The correct answer is D. Semi-Fowler's position. This position allows for optimal drainage of secretions and reduces edema and tension on the suture line. It also facilitates breathing and prevents aspiration. Left lateral, dorsal recumbent, and supine positions can increase the risk of airway obstruction, bleeding and infection.
Similar Questions
A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?
A. Position the client supine with legs elevated.
Positioning the client supine with legs elevated is not recommended for managing ascites. This position does not help in reducing fluid accumulation in the abdomen and may worsen respiratory issues.
B. Keep the client's daily protein intake below 0.8 g/kg.
Keeping the client’s daily protein intake below 0.8 g/kg is not typically recommended for clients with cirrhosis and ascites. Adequate protein intake is necessary to prevent muscle wasting and maintain nutritional status.
C. Restrict the client's sodium intake to 3 g per day.
Restricting the client’s sodium intake to 2 g not 3g per day is a common intervention for managing ascites, but it is usually more restrictive, often around 2 g per day, to effectively reduce fluid retention.
D. Measure the client's abdominal girth daily.
Measuring the client’s abdominal girth daily is essential for monitoring the progression of ascites. It helps in assessing the effectiveness of treatment and detecting any worsening of the condition.
Full Explanation
The correct answer is choice d. Measure the client’s abdominal girth daily.
Choice A rationale:
Positioning the client supine with legs elevated is not recommended for managing ascites. This position does not help in reducing fluid accumulation in the abdomen and may worsen respiratory issues.
Choice B rationale:
Keeping the client’s daily protein intake below 0.8 g/kg is not typically recommended for clients with cirrhosis and ascites. Adequate protein intake is necessary to prevent muscle wasting and maintain nutritional status.
Choice C rationale:
Restricting the client’s sodium intake to 2 g not 3g per day is a common intervention for managing ascites, but it is usually more restrictive, often around 2 g per day, to effectively reduce fluid retention.
Choice D rationale:
Measuring the client’s abdominal girth daily is essential for monitoring the progression of ascites. It helps in assessing the effectiveness of treatment and detecting any worsening of the condition.
A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?
A. Fruity breath odor
This is caused by the presence of acetone, a byproduct of fat metabolism, in the breath. Diabetic ketoacidosis is a condition where the body cannot use glucose as a fuel source due to insulin deficiency or resistance, and resorts to breaking down fat for energy, resulting in ketone production and acidosis. Clammy skin, bounding pulse and elevated blood pressure are signs of hyperglycemic hyperosmolar state (HHS), another complication of diabetes that is characterized by severe dehydration and hyperglycemia without significant ketosis or acidosis.
B. Clammy skin
C. Bounding pulse
D. Elevated blood pressure
Full Explanation
The correct answer is A. Fruity breath odor. This is caused by the presence of acetone, a byproduct of fat metabolism, in the breath. Diabetic ketoacidosis is a condition where the body cannot use glucose as a fuel source due to insulin deficiency or resistance, and resorts to breaking down fat for energy, resulting in ketone production and acidosis. Clammy skin, bounding pulse and elevated blood pressure are signs of a hyperglycemic hyperosmolar state (HHS), another complication of diabetes that is characterized by severe dehydration and hyperglycemia without significant ketosis or acidosis.
A nurse is gathering data from a client who has severe anxiety. Which of the following findings should the nurse identify as an indication that the client is experiencing a crisis?
A. Client reports a decreased appetite
B. Client isolates themselves from their family and friends
Rationale: A crisis is a situation that overwhelms a person's usual coping mechanisms and causes psychological distress. A client who isolates themselves from their family and friends is showing a sign of impaired social functioning, which indicates a crisis. The other options are not specific to a crisis and could be manifestations of anxiety or depression.
C. Client expresses an inability to experience pleasure
D. Client reports intermittent depressed mood
Full Explanation
Answer: B. Client isolates themselves from their family and friends
Rationale: A crisis is a situation that overwhelms a person's usual coping mechanisms and causes psychological distress. A client who isolates themselves from their family and friends is showing a sign of impaired social functioning, which indicates a crisis. The other options are not specific to a crisis and could be manifestations of anxiety or depression.