Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is receiving a continuous enteral tube feeding and develops diarrhea. Which of the following actions should the nurse take?
A. Administer the client's formula at room temperature.
Administer the client's formula at room temperature. The nurse should administer the formula at room temperature to reduce gastrointestinal motility and prevent diarrhea.
B. Provide the client with low-calorie formula.
C. Increase the rate of the client's feeding.
D. Switch the client to a formula containing less protein
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is A. Administer the client's formula at room temperature. The nurse should administer the formula at room temperature to reduce gastrointestinal motility and prevent diarrhea.
Similar Questions
A nurse is preparing to provide tracheostomy care for a client.
Which of the following actions should the nurse plan to take?
A. Cleanse the inner cannula with isopropyl alcohol
Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.
B. Prepare sterile supplies after removing the inner cannula.
Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.
C. Clean the stoma using an inward to outward circular motion
Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.
D. Ensure at least three finger widths of space under tracheostomy ties.
Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.
Full Explanation
The correct answer is choice C. Clean the stoma using an inward to outward circular motion.
Choice A rationale:
Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.
Choice B rationale:
Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.
Choice C rationale:
Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.
Choice D rationale:
Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.
A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client.Which of the following adverse effects should the nurse include in the teaching?
A. Decreased blood pressure
Cigarette smoking typically causes an increase in blood pressure due to the nicotine’s stimulating effects on the cardiovascular system, not a decrease.
B. Bradycardia
Smoking is more likely to cause tachycardia (increased heart rate) rather than bradycardia (decreased heart rate) because nicotine stimulates the release of adrenaline.
C. Somnolence
Somnolence (drowsiness) is not a common adverse effect of cigarette smoking. Smoking usually has a stimulating effect due to nicotine.
D. Decreased hemoglobin
Decreased hemoglobin can occur as a result of smoking because it can lead to chronic obstructive pulmonary disease (COPD) and other respiratory issues, which can impair oxygen transport in the blood. Additionally, smoking can cause carbon monoxide to bind with hemoglobin, reducing its oxygen-carrying capacity.
Full Explanation
The correct answer is choice D. Decreased hemoglobin.
Choice A rationale:
Cigarette smoking typically causes an increase in blood pressure due to the nicotine’s stimulating effects on the cardiovascular system, not a decrease.
Choice B rationale:
Smoking is more likely to cause tachycardia (increased heart rate) rather than bradycardia (decreased heart rate) because nicotine stimulates the release of adrenaline.
Choice C rationale:
Somnolence (drowsiness) is not a common adverse effect of cigarette smoking. Smoking usually has a stimulating effect due to nicotine.
Choice D rationale:
Decreased hemoglobin can occur as a result of smoking because it can lead to chronic obstructive pulmonary disease (COPD) and other respiratory issues, which can impair oxygen transport in the blood. Additionally, smoking can cause carbon monoxide to bind with hemoglobin, reducing its oxygen-carrying capacity.
A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of the following statements by the partner indicates an understanding of the teaching?
A. "Playing music will increase my husband's alertness."
B. "I will discontinue music therapy when my husband is no longer responsive."
C. "My husband won't need medication for breakthrough pain while using music therapy.
D. "Music will distract my husband's awareness of the pain."
Music therapy can help reduce pain perception by providing a pleasant distraction and stimulating endorphin release.
Full Explanation
The correct answer is D. Music will distract my husband's awareness of the pain. Music therapy can help reduce pain perception by providing a pleasant distraction and
stimulating endorphin release.