Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is undergoing a lumbar puncture.
Which of the following is the priority action for the nurse to take to maintain privacy for the client?
A. Pull the curtains around the client's bed.
Pulling the curtains around the client’s bed ensures privacy during the procedure.
B. Ask family members to leave the room.
Asking family members to leave the room might be necessary, but it’s not the priority action.
C. Use sterile drapes to cover the client.
Using sterile drapes to cover the client is important for maintaining sterility, not privacy.
D. Close the door to the client's room.
Closing the door to the client’s room can provide privacy, but pulling the curtains around the bed is a more immediate action.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Med Surg Custom Proctored Exam 2. Take the full exam now
Full Explanation
Choice A rationale:
Pulling the curtains around the client’s bed ensures privacy during the procedure.
Choice B rationale:
Asking family members to leave the room might be necessary, but it’s not the priority action.
Choice C rationale:
Using sterile drapes to cover the client is important for maintaining sterility, not privacy.
Choice D rationale:
Closing the door to the client’s room can provide privacy, but pulling the curtains around the bed is a more immediate action.
Similar Questions
A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast.
Which of the following actions is the nurse's priority?
A. Notify the nurse manager.
Notifying the nurse manager is important, but it’s not the priority action.
B. Monitor the client for hypoglycemia.
Monitoring the client for hypoglycemia is the priority because the nurse administered an excessive insulin dose.
C. Complete an incident report.
Completing an incident report is necessary, but it’s not the priority action.
D. Give the client 15 to 20 g of carbohydrate.
Giving the client 15 to 20 g of carbohydrate might be necessary if the client shows signs of hypoglycemia.
Full Explanation
Choice A rationale:
Notifying the nurse manager is important, but it’s not the priority action.
Choice B rationale:
Monitoring the client for hypoglycemia is the priority because the nurse administered an excessive insulin dose.
Choice C rationale:
Completing an incident report is necessary, but it’s not the priority action.
Choice D rationale:
Giving the client 15 to 20 g of carbohydrate might be necessary if the client shows signs of hypoglycemia.
A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes.
The nurse should expect the client to have which of the following manifestations associated with early menopause?.
A. Urinary retention.
Urinary retention is not typically associated with menopause.
B. Dryness with intercourse.
Dryness with intercourse is a common symptom of menopause due to decreased estrogen levels.
C. Elevation in body temperature above 37.8° C (100° F).
An elevation in body temperature above 37.8° C (100° F) is not typically associated with menopause.
D. Decreased blood pressure.
Decreased blood pressure is not typically associated with menopause.
Full Explanation
Choice A rationale:
Urinary retention is not typically associated with menopause.
Choice B rationale:
Dryness with intercourse is a common symptom of menopause due to decreased estrogen levels.
Choice C rationale:
An elevation in body temperature above 37.8° C (100° F) is not typically associated with menopause.
Choice D rationale:
Decreased blood pressure is not typically associated with menopause.
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
A. Apneustic respirations.
Apneustic respirations are characterized by prolonged inspiratory phase with shortened expiratory phase, not alternating periods of hyperventilation and apnea.
B. Stridor.
Stridor is a high-pitched, wheezing sound caused by disrupted airflow, not a pattern of breathing.
C. Kussmaul respirations.
Kussmaul respirations are deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis, not alternating periods of hyperventilation and apnea.
D. Cheyne-Stokes respirations.
Cheyne-Stokes respirations are characterized by alternating periods of hyperventilation and apnea.
Full Explanation
Choice A rationale:
Apneustic respirations are characterized by prolonged inspiratory phase with shortened expiratory phase, not alternating periods of hyperventilation and apnea.
Choice B rationale:
Stridor is a high-pitched, wheezing sound caused by disrupted airflow, not a pattern of breathing.
Choice C rationale:
Kussmaul respirations are deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis, not alternating periods of hyperventilation and apnea.
Choice D rationale:
Cheyne-Stokes respirations are characterized by alternating periods of hyperventilation and apnea.