Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is scheduled for diagnostic thoracentesis. Which of the following actions should the nurse take when assisting with this test?
A. Instruct the client to take deep breaths during the test.
Instructing the client to take deep breaths during the test is not appropriate for a thoracentesis. This procedure involves the insertion of a needle into the pleural space to drain fluid or air, and taking deep breaths could interfere with the accuracy and safety of the procedure.
B. Assist the client to a prone position prior to the test.
Assisting the client to a prone position prior to the test is also incorrect. During a thoracentesis, the client is usually seated upright or in a slightly forward-leaning position to allow better access to the pleural space and improve breathing.
C. Inform the client that the new onset of a cough is expected following the test.
Informing the client that the new onset of a cough is expected following the test is not accurate. While a cough can be a possible side effect, it is not a common or expected outcome of a thoracentesis.
D. Apply pressure to the client's puncture site after the test is complete.
Applying pressure to the client's puncture site after the test is complete is the correct action. This helps to prevent bleeding and reduce the risk of pneumothorax (collapsed lung) by promoting clot formation at the site of the needle insertion.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN VATI Adult Medical Surgical S 2019 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Instructing the client to take deep breaths during the test is not appropriate for a thoracentesis. This procedure involves the insertion of a needle into the pleural space to drain fluid or air, and taking deep breaths could interfere with the accuracy and safety of the procedure.
Choice B rationale:
Assisting the client to a prone position prior to the test is also incorrect. During a thoracentesis, the client is usually seated upright or in a slightly forward-leaning position to allow better access to the pleural space and improve breathing.
Choice C rationale:
Informing the client that the new onset of a cough is expected following the test is not accurate. While a cough can be a possible side effect, it is not a common or expected outcome of a thoracentesis.
Choice D rationale:
Applying pressure to the client's puncture site after the test is complete is the correct action. This helps to prevent bleeding and reduce the risk of pneumothorax (collapsed lung) by promoting clot formation at the site of the needle insertion.
Similar Questions
A nurse is reviewing the medical record of a client who has developed a UTI. Which of the following findings should the nurse expect?
A. Hemoptysis.
Hemoptysis, which is the coughing up of blood, is not typically associated with a urinary tract infection (UTI). It is more commonly related to respiratory or pulmonary issues.
B. Hematuria.
Hematuria, the presence of blood in the urine, is a common finding in a UTI. Inflammation and infection in the urinary tract can lead to the presence of blood cells in the urine.
C. Hyperglycemia.
Hyperglycemia, an elevated blood glucose level, is not directly related to a UTI. It may be seen in individuals with diabetes, but it is not a typical finding in a UTI.
D. Hypocalcemia.
Hypocalcemia, a low level of calcium in the blood, is not a characteristic finding in a UTI. UTIs primarily affect the urinary system and do not directly involve calcium metabolism.
Full Explanation
Choice A rationale:
Hemoptysis, which is the coughing up of blood, is not typically associated with a urinary tract infection (UTI). It is more commonly related to respiratory or pulmonary issues.
Choice B rationale:
Hematuria, the presence of blood in the urine, is a common finding in a UTI. Inflammation and infection in the urinary tract can lead to the presence of blood cells in the urine.
Choice C rationale:
Hyperglycemia, an elevated blood glucose level, is not directly related to a UTI. It may be seen in individuals with diabetes, but it is not a typical finding in a UTI.
Choice D rationale:
Hypocalcemia, a low level of calcium in the blood, is not a characteristic finding in a UTI. UTIs primarily affect the urinary system and do not directly involve calcium metabolism.
A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).
A. 0.4 mL.
0.4 mL is not the correct dose.
B. 0.5 mL.
Let's break down the calculation: Given: Patient weight: 154 lbs Enoxaparin dosage: 0.75 mg/kg Available enoxaparin: 60 mg/0.6 mL Step 1: Convert pounds to kilograms: 1 lb is approximately 0.4536 kg So, 154 lbs = 154 * 0.4536 kg/lb = 69.85 kg (approximately 70 kg) Step 2: Calculate the total dose of enoxaparin: Desired dose = 0.75 mg/kg * 70 kg = 52.5 mg Step 3: Determine the volume to administer: We have enoxaparin 60 mg/0.6 mL To find the volume for 52.5 mg: (52.5 mg / 60 mg) * 0.6 mL = 0.525 mL Rounded to the nearest tenth, this is 0.5 mL. Therefore, the nurse should administer 0.5 mL of enoxaparin
C. 0.8 mL.
0.8 mL is not the correct dose.
D. 1.0 mL.
1.0 mL is not the correct dose.
Full Explanation
Let's break down the calculation:
Given:
- Patient weight: 154 lbs
- Enoxaparin dosage: 0.75 mg/kg
- Available enoxaparin: 60 mg/0.6 mL
Step 1: Convert pounds to kilograms:
- 1 lb is approximately 0.4536 kg
- So, 154 lbs = 154 * 0.4536 kg/lb = 69.85 kg (approximately 70 kg)
Step 2: Calculate the total dose of enoxaparin:
- Desired dose = 0.75 mg/kg * 70 kg = 52.5 mg
Step 3: Determine the volume to administer:
- We have enoxaparin 60 mg/0.6 mL
- To find the volume for 52.5 mg:
- (52.5 mg / 60 mg) * 0.6 mL = 0.525 mL
- Rounded to the nearest tenth, this is 0.5 mL.
Therefore, the nurse should administer 0.5 mL of enoxaparin
A nurse is caring for a client who had abdominal surgery. The client tells the nurse that "something gave way.”. The nurse removes the dressing and sees the wound has eviscerated. Identify the correct sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.).
A. Place the client in a low Fowler's position with the knees bent.
Can help reduce tension on the abdominal incision, but it is not the priority when evisceration is present. The focus should be on immediate intervention and preparation for surgery.
B. Cover the client's wound with a sterile saline-soaked dressing.
Is essential to prevent further contamination and maintain moisture in the exposed tissue. This step helps protect the wound until the client can be taken to the operating room.
C. Notify the surgeon about the finding.
Is important, but it should not be done before taking more immediate action. Evisceration requires prompt intervention and transfer to surgery, and the surgeon will be involved once the client is ready for the operation.
D. Prepare the client for transfer to surgery.
Is the correct sequence of steps in this situation.Evisceration is a surgical emergency that requires immediate intervention to prevent complications and infection. The nurse should stabilize the wound with a sterile dressing and then prepare the client for surgery promptly.
Full Explanation
Choice A rationale:
Placing the client in a low Fowler's position with the knees bent (Choice A) can help reduce tension on the abdominal incision, but it is not the priority when evisceration is present. The focus should be on immediate intervention and preparation for surgery.
Choice B rationale:
Covering the client's wound with a sterile saline-soaked dressing (Choice B) is essential to prevent further contamination and maintain moisture in the exposed tissue. This step helps protect the wound until the client can be taken to the operating room.
Choice C rationale:
Notifying the surgeon about the finding (Choice C) is important, but it should not be done before taking more immediate action. Evisceration requires prompt intervention and transfer to surgery, and the surgeon will be involved once the client is ready for the operation.
Choice D rationale:
Preparing the client for transfer to surgery (Choice D) is the correct sequence of steps in this situation. Evisceration is a surgical emergency that requires immediate intervention to prevent complications and infection. The nurse should stabilize the wound with a sterile dressing and then prepare the client for surgery promptly.