Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is receiving mechanical ventilation following a stroke.
Which of the following actions should the nurse take?
A. Cluster nursing care activities.
Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.
B. Hyperoxygenate the client before suctioning.
Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.
C. Keep the room well lit to orient the client.
Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.
D. Maintain the client's PaCO2 at 50 mm Hg.
Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.
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Full Explanation
Choice A rationale:
Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.
Choice B rationale:
Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.
Choice C rationale:
Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.
Choice D rationale:
Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.
Similar Questions
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?
A. Absent deep tendon reflexes
Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.
B. Fetal heart rate of 120/min
A fetal heart rate of 120/min is within a normal range and is not concerning.
C. Blood pressure 150/92 mm Hg
Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.
D. Facial flushing
Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.
Full Explanation
Choice A rationale:
Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.
Choice B rationale:
A fetal heart rate of 120/min is within a normal range and is not concerning.
Choice C rationale:
Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.
Choice D rationale:
Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.
A nurse is planning care for a client who has chronic pancreatitis. Which of the following interventions should the nurse include in the plan?
A. Initiate a high-protein diet for the client.
A high-protein diet might not be recommended for a client with chronic pancreatitis, as certain high-protein foods can exacerbate symptoms.
B. Encourage the client to eat high-fiber foods.
Encouraging the client to eat high-fiber foods can help manage symptoms of chronic pancreatitis, as well as promote regular bowel movements and prevent constipation.
C. Administer laxatives to the client PRN daily.
Administering laxatives daily is not typically part of the management plan for chronic pancreatitis and can lead to dependency.
D. Provide the client with six small meals per day.
Providing six small meals per day might be helpful, but the specific dietary content is important for managing chronic pancreatitis.
Full Explanation
Choice A rationale:
A high-protein diet might not be recommended for a client with chronic pancreatitis, as certain high-protein foods can exacerbate symptoms.
Choice B Rationale:
Encouraging the client to eat high-fiber foods can help manage symptoms of chronic pancreatitis, as well as promote regular bowel movements and prevent constipation.
Choice C rationale:
Administering laxatives daily is not typically part of the management plan for chronic pancreatitis and can lead to dependency.
Choice D rationale:
Providing six small meals per day might be helpful, but the specific dietary content is important for managing chronic pancreatitis.
A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following goals should the nurse include?
A. Client sleeps 6 hr each night.
During the manic phase of bipolar disorder, sleep disturbances are common. Setting a goal for the client to achieve an appropriate amount of sleep can help stabilize their mood and reduce the intensity of manic symptoms.
B. Client has a 0.9 kg (2 lb) weight loss from previous week.
A weight loss goal might be more appropriate during the depressive phase, as manic episodes are often associated with increased energy and decreased appetite.
C. Client has an increase in urine specific gravity
Increased urine specific gravity is not a specific goal for managing the manic phase of bipolar disorder.
D. Client gives personal gifts to other clients.
Giving personal gifts to other clients might be a manifestation of the client's manic behavior and is not a goal to strive for.
Full Explanation
Choice A rationale:
During the manic phase of bipolar disorder, sleep disturbances are common. Setting a goal for the client to achieve an appropriate amount of sleep can help stabilize their mood and reduce the intensity of manic symptoms.
Choice B rationale:
A weight loss goal might be more appropriate during the depressive phase, as manic episodes are often associated with increased energy and decreased appetite.
Choice C rationale:
Increased urine specific gravity is not a specific goal for managing the manic phase of bipolar disorder.
Choice D rationale:
Giving personal gifts to other clients might be a manifestation of the client's manic behavior and is not a goal to strive for.