Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who was admitted following an ischemic stroke. Which of the following actions should the nurse take? (Select all that apply.)
A. Provide rest breaks between nursing care activities.
Rest breaks help prevent excessive fatigue, which is important for the client's overall well-being during recovery from a stroke.
B. Notify the provider of a systolic BP higher than 180 mm Hg.
Elevated blood pressure can worsen the effects of a stroke. A systolic blood pressure higher than 180 mm Hg should be reported to the provider for prompt intervention.
C. Administer aspirin 650 mg every 6 hr for a headache.
Administering aspirin for a headache without a medical order and assessment is not advisable.
D. Keep the client's head in a midline neutral position.
Maintaining the client's head in a midline neutral position promotes proper alignment and blood flow to the brain.
E. Monitor the client's vital signs every 4 hr
Monitoring vital signs every 4 hours is important, but addressing elevated blood pressure takes priority.
This question is an excerpt from Nurse Dive's nursing test bank - RN ati Concept-based assessment level proctored exam. Take the full exam now
Full Explanation
A. Providing rest breaks between nursing care activities is essential to prevent fatigue and allow for recovery, as stroke patients often have reduced endurance and energy.
B. Notifying the provider of a systolic blood pressure higher than 180 mm Hg is crucial because hypertension can exacerbate brain injury following a stroke and increase the risk of hemorrhagic transformation.
C. Administering aspirin 650 mg every 6 hours for a headache is not recommended without a physician's order, especially post-stroke, as it can increase the risk of bleeding.
D. Keeping the client's head in a midline neutral position helps to promote venous drainage and decrease intracranial pressure, which is beneficial in the management of a stroke patient.
E. Monitoring the client's vital signs every 4 hours is important for detecting any changes in the patient's condition that may indicate complications or the need for medical intervention.
Similar Questions
A nurse is providing discharge teaching to the mother of a newborn who is breastfeeding.
Which of the following statements should the nurse make?
A. "Newborns typically lose about 15 percent of their body weight following birth."
B. "You should keep your baby on a strict feeding schedule."
C. "You should consume an extra 650 calories a day while breastfeeding."
D. "Offer your baby a pacifier before sleep when he is 1 month old.".
E. "Offer your baby a pacifier before sleep when he is 1 month old.".
Full Explanation
Choice A rationale:
Newborns typically lose some weight after birth, but 15 percent loss would be excessive and concerning. A normal weight loss range is about 5 to 10 percent.
Choice B rationale:
Newborns should be fed on demand rather than adhering to strict schedules to ensure they are adequately nourished.
Choice C rationale:
Breastfeeding requires additional energy, and mothers are generally advised to consume around 500 extra calories a day to support milk production and their own energy needs.
Choice D rationale:
Offering a pacifier before sleep can reduce the risk of sudden infant death syndrome (SIDS), but this recommendation usually starts at around 1 to 2 months of age.
A nurse is providing information to an adult client about obesity management. Which of the following changes in behavior should the nurse include in the client's wellness plan?
A. Hold the fork through the entire meal.
Holding the fork through the entire meal can lead to mindless eating and overeating. The client should put down the fork between bites and chew slowly to savor the food and feel full faster.
B. Plan meals day by day.
Planning meals day by day can be stressful and impractical for the client. The client might not have enough time or resources to prepare healthy meals every day, or might be tempted by unhealthy options when hungry. The client should plan meals ahead of time, such as weekly or monthly, and stock up on nutritious foods that are easy to prepare.
C. Schedule three times to eat each day.
Scheduling three times to eat each day can be too rigid and unrealistic for the client. The client might not feel hungry at the scheduled times, or might feel hungry in between meals and snack on junk food. The client should listen to their body and eat when they are hungry, but not too hungry. The client should also eat slowly and stop when they are full, but not too full.
D. Eat off a smaller plate
Eating off a smaller plate can help reduce the portion size and calorie intake of the client. This is a simple and effective way to manage obesity without feeling deprived or hungry. A smaller plate can also create an illusion of having more food, which can increase the satisfaction of the meal.
Full Explanation
Choice A rationale:
Holding the fork through the entire meal can lead to mindless eating and overeating. The client should put down the fork between bites and chew slowly to savor the food and feel full faster.
Choice B rationale:
Planning meals day by day can be stressful and impractical for the client. The client might not have enough time or resources to prepare healthy meals every day, or might be tempted by unhealthy options when hungry. The client should plan meals ahead of time, such as weekly or monthly, and stock up on nutritious foods that are easy to prepare.
Choice C rationale:
Scheduling three times to eat each day can be too rigid and unrealistic for the client. The client might not feel hungry at the scheduled times, or might feel hungry in between meals and snack
on junk food. The client should listen to their body and eat when they are hungry, but not too hungry. The client should also eat slowly and stop when they are full, but not too full.
Choice D rationale:
Eating off a smaller plate can help reduce the portion size and calorie intake of the client. This is a simple and effective way to manage obesity without feeling deprived or hungry. A smaller plate can also create an illusion of having more food, which can increase the satisfaction of the meal.
A nurse is assessing a client who is experiencing opioid intoxication. Which of the following findings should the nurse expect?
A. Abdominal cramps
Abdominal cramps are not typically associated with opioid intoxication.
B. Slurred speech
Opioid intoxication can cause symptoms such as slowed or slurred speech, drowsiness, and altered mental status.
C. Tachycardia
Opioid intoxication often leads to bradycardia (slower heart rate), not tachycardia (faster heart rate).
D. Diaphoresis
Diaphoresis (excessive sweating) is a symptom of opioid withdrawal, not intoxication.
Full Explanation
Choice A rationale:
Abdominal cramps are not typically associated with opioid intoxication. Choice B rationale:
Opioid intoxication can cause symptoms such as slowed or slurred speech, drowsiness, and altered mental status.
Choice C rationale:
Opioid intoxication often leads to bradycardia (slower heart rate), not tachycardia (faster heart rate).
Choice D rationale:
Diaphoresis (excessive sweating) is a symptom of opioid withdrawal, not intoxication.