Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is receiving an initial dose of vancomycin IV. The client begins experiencing dyspnea and swelling of the face. After discontinuing the vancomycin infusion, which of the following actions should the nurse take next?
A. Call the rapid response team.
The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.
B. Prepare the client for intubation.
Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.
C. Obtain an ABG level.
Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.
D. Administer diphenhydramine.
Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.
This question is an excerpt from Nurse Dive's nursing test bank - RN ati Concept-based assessment level proctored exam. Take the full exam now
Full Explanation
Choice A rationale:
The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.
Choice B rationale:
Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.
Choice C rationale:
Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.
Choice D rationale:
Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.
Similar Questions
A nurse is providing teaching to the parents of a child who has cerebral palsy and a new prescription for baclofen. The nurse should instruct the parents to monitor the child for which of the following adverse effects of the medication?
A. Rhinorrhea
Rhinorrhea is not a common adverse effect of baclofen.
B. Hirsutism
Hirsutism (excessive hair growth) is not a common adverse effect of baclofen.
C. Tachycardia
Tachycardia is not a common adverse effect of baclofen.
D. Constipation
Constipation is a common adverse effect of baclofen. Baclofen is a muscle relaxant that can affect the gastrointestinal system, leading to reduced bowel motility and constipation.
Full Explanation
Choice A rationale:
Rhinorrhea is not a common adverse effect of baclofen.
Choice B rationale:
Hirsutism (excessive hair growth) is not a common adverse effect of baclofen.
Choice C rationale:
Tachycardia is not a common adverse effect of baclofen.
Choice D rationale:
Constipation is a common adverse effect of baclofen. Baclofen is a muscle relaxant that can affect the gastrointestinal system, leading to reduced bowel motility and constipation.
A nurse on a mental health unit is admitting a client following a suicide attempt. Which of the following actions is the nurse's priority?
A. Establish a therapeutic relationship with the client.
Establishing a therapeutic relationship is important, but the immediate priority is to ensure the safety of the client by maintaining constant observation.
B. Instruct the client on stress management techniques.
Instructing the client on stress management techniques is important, but safety comes first.
C. Have the client sign a no-suicide contract.
Having the client sign a no-suicide contract may provide some reassurance, but it is not a substitute for constant observation.
D. Maintain constant observation of the client.
Maintaining constant observation of the client is the priority to prevent any further self-harm or suicide attempts.
Full Explanation
Choice A rationale:
Establishing a therapeutic relationship is important, but the immediate priority is to ensure the safety of the client by maintaining constant observation.
Choice B rationale:
Instructing the client on stress management techniques is important, but safety comes first.
Choice C rationale:
Having the client sign a no-suicide contract may provide some reassurance, but it is not a substitute for constant observation.
Choice D rationale:
Maintaining constant observation of the client is the priority to prevent any further self-harm or suicide attempts.
A nurse is teaching the partner of a client who has a new diagnosis of Alzheimer's disease about home care. Which of the following information should the nurse include in the teaching?
A. "Keep the television on at a low volume in the background."
Keeping the television on at a low volume in the background can provide sensory stimulation and a familiar environment for the client with Alzheimer's disease. It can also help decrease feelings of isolation and confusion.
B. "Decorate your partner's room with abstract paintings."
Abstract paintings may be confusing or agitating for a person with Alzheimer's disease. Familiar and recognizable decorations are more suitable.
C. "Reorient your partner daily to the day and time."
Reorienting the client daily to the day and time can be helpful, but it is not the priority teaching in this context.
D. "Use dim lighting in your home."
Using dim lighting is not recommended as it can contribute to confusion and disorientation in a person with Alzheimer's disease. Adequate lighting is important for safety and orientation.
Full Explanation
Choice A rationale:
Keeping the television on at a low volume in the background can provide sensory stimulation and a familiar environment for the client with Alzheimer's disease. It can also help decrease feelings of isolation and confusion.
Choice B rationale:
Abstract paintings may be confusing or agitating for a person with Alzheimer's disease. Familiar and recognizable decorations are more suitable.
Choice C rationale:
Reorienting the client daily to the day and time can be helpful, but it is not the priority teaching in this context.
Choice D rationale:
Using dim lighting is not recommended as it can contribute to confusion and disorientation in a person with Alzheimer's disease. Adequate lighting is important for safety and orientation.