Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is suspected to have developed sensitivity to latex.
Which of the following interventions should the nurse plan to implement?
A. Use a disposable adhesive probe when measuring the client's SaO2
Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.
B. Wrap a blood pressure cuff in a stockinette for use in the client's room.
Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.
C. Document in the medical record that the client should not use silicone products.
Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.
D. Clean vial stoppers for 15 seconds before using them to withdraw-medications for the client.
Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.
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Full Explanation
Choice A rationale:
Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.
Choice B rationale:
Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.
Choice C rationale:
Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.
Choice D rationale:
Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.
Similar Questions
A nurse is teaching the parent of an infant about the varicella virus vaccine. Which of the following statements by the parent indicates an understanding of the teaching?
A. "My child should not receive the vaccine if she is allergic to eggs."
Allergic reactions to eggs are a concern with some vaccines, but the varicella vaccine is generally considered safe for children with egg allergies.
B. "There is a series of three doses of the vaccine that my child will receive."
The varicella vaccine is typically given in two doses, not three.
C. "My child should not take aspirin for 6 weeks following vaccination."
Children should avoid taking aspirin for about 6 weeks after receiving the varicella vaccine to reduce the risk of Reye's syndrome, a rare but serious condition associated with aspirin use during viral infections.
D. "The vaccine will be injected into the muscle of my child's upper arm."
The varicella vaccine is usually administered subcutaneously, not into the muscle.
Full Explanation
Choice A rationale:
Allergic reactions to eggs are a concern with some vaccines, but the varicella vaccine is generally considered safe for children with egg allergies.
Choice B rationale:
The varicella vaccine is typically given in two doses, not three. Choice C rationale:
Children should avoid taking aspirin for about 6 weeks after receiving the varicella vaccine to reduce the risk of Reye's syndrome, a rare but serious condition associated with aspirin use during viral infections.
Choice D rationale:
The varicella vaccine is usually administered subcutaneously, not into the muscle.
A nurse is creating a plan of care for an infant who has osteogenesis imperfecta. Which of the following interventions should the nurse include in the plan?
A. Use pillows to position the infant when changing a diaper.
Infants with osteogenesis imperfecta have fragile bones that can fracture easily. Using pillows or other soft support can help prevent accidental fractures during diaper changes.
B. Instruct the parents to withhold immunizations until 1 year of age.
Immunizations are important for all infants and should not be withheld, even in the presence of osteogenesis imperfecta.
C. Obtain the infant's blood pressure with an automatic cuff.
Blood pressure measurement is not a common concern in infants with osteogenesis imperfecta.
D. Avoid using splints to support the infant's limbs
Splints may be used to provide support for the infant's limbs to minimize the risk of fractures.
Full Explanation
Choice A rationale:
Infants with osteogenesis imperfecta have fragile bones that can fracture easily. Using pillows or other soft support can help prevent accidental fractures during diaper changes.
Choice B rationale:
Immunizations are important for all infants and should not be withheld, even in the presence of osteogenesis imperfecta.
Choice C rationale:
Blood pressure measurement is not a common concern in infants with osteogenesis imperfecta.
Choice D rationale:
Splints may be used to provide support for the infant's limbs to minimize the risk of fractures.
A nurse is caring for a client who is at 36 weeks of gestation and reports a headache.
Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Graphic Results Temperature 37° C (98.6° F) Heart rate 88/min Respiratory rate 18/min
Blood pressure 144/94 mm Hg
Upper abdominal pain rating 4/10 on a scale from 0 to 10
A. Perform a contraction stress test.
A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.
B. Prepare for delivery of the fetus.
The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.
C. Increase the client's dietary salt intake to 2 g/day.
Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.
D. Administer ferrous sulfate to the client.
Administering ferrous sulfate is unrelated to the client's symptoms and concerns.
E. Upper abdominal pain rating 4/10 on a scale from 0 to 10
Full Explanation
Choice A rationale:
A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.
Choice B rationale:
The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.
Choice C rationale:
Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.
Choice D rationale:
Administering ferrous sulfate is unrelated to the client's symptoms and concerns.