Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
A. Perform passive range of motion on each extremity.
B. Record the client's intake and output.
C. Suction saliva from the client's mouth.
The highest priority nursing intervention for a client who is unconscious following a stroke is to suction saliva from the client's mouth. This can help prevent aspiration and maintain a patent airway, which is essential for the client's survival. Performing passive range of motion on each extremity, recording the client's intake and output, and monitoring the client's electrolyte levels are also important nursing interventions for this client. However, these interventions are not as high of a priority as maintaining a patent airway.
D. Monitor the client's electrolyte levels.
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Full Explanation
The highest priority nursing intervention for a client who is unconscious following a stroke is to suction saliva from the client's mouth. This can help prevent aspiration and maintain a patent airway, which is essential for the client's survival.
Performing passive range of motion on each extremity, recording the client's intake and output, and monitoring the client's electrolyte levels are also important nursing interventions for this client. However, these interventions are not as high of a priority as maintaining a patent airway.
Similar Questions
A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?
A. "Russell's traction uses a sling under the knee to treat a fracture of the femur."
The nurse should tell the newly licensed nurse that Russell's traction uses a sling under the knee to treat a fracture of the femur. Russell's traction is a type of skin traction that is used to immobilize and align a fractured femur. It involves placing a sling under the knee and applying weights to the affected leg to provide continuous traction. Russell's traction does not use a cervical halter, skeletal pins, or a pelvic girdle belt. A cervical halter is used to treat neck injuries. Skeletal pins are used in skeletal traction to stabilize fractures. A pelvic girdle belt is used to treat lower back pain.
B. "Russell's traction uses a cervical halter to decrease cervical muscle spasms."
C. "Russell's traction uses skeletal pins to stabilize the fracture."
D. "Russell's traction uses a pelvic girdle belt to decrease lower back pain."
Full Explanation
The nurse should tell the newly licensed nurse that Russell's traction uses a sling under the knee to treat a fracture of the femur. Russell's traction is a type of skin traction that is used to immobilize and align a fractured femur. It involves placing a sling under the knee and applying weights to the affected leg to provide continuous traction.
Russell's traction does not use a cervical halter, skeletal pins, or a pelvic girdle belt. A cervical halter is used to treat neck injuries. Skeletal pins are used in skeletal traction to stabilize fractures. A pelvic girdle belt is used to treat lower back pain.
A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?
A. Sudden sleepiness
The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury. Headache, diplopia, and slight ataxia are also important findings that the nurse should report to the provider. However, these findings are not as urgent as sudden sleepiness. Headache can be a common symptom following a head injury. Diplopia is double vision and can indicate cranial nerve damage. Slight ataxia is unsteadiness or lack of coordination and can indicate neurological damage.
B. Headache
C. Diplopia
D. Slight ataxia
Full Explanation
The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury.
Headache, diplopia, and slight ataxia are also important findings that the nurse should report to the provider. However, these findings are not as urgent as sudden sleepiness. Headache can be a common symptom following a head injury. Diplopia is double vision and can indicate cranial nerve damage. Slight ataxia is unsteadiness or lack of coordination and can indicate neurological damage.
A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?
A. The client requires total nursing care.
A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.
B. The client is in a deep coma.
A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.
C. The client is alert and oriented.
A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.
D. The client has a stable neurological status.
A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.
Full Explanation
a. A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.
b. A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.
c. A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.
d. A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.