Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a group of clients.
For which of the following situations should the nurse complete an incident
report? (Select all that apply.).
A. A client is unable to afford the physical therapy that the provider recommends.
A client being unable to afford physical therapy is a financial issue, not an incident that affects patient safety or care quality. This situation should be addressed through social services or financial counseling, not an incident report.
B. A client reports being dissatisfied with the temperature of the meals provided.
A client being dissatisfied with meal temperature is a service quality issue, not a safety incident. This should be reported to the dietary department or patient services for resolution, not through an incident report.
C. A client’s visitor becomes dizzy and faints in the client’s room.
A client’s visitor becoming dizzy and fainting in the client’s room is an incident that affects the safety of the visitor. An incident report should be completed to document the event, the visitor’s condition, and any actions taken to provide care or prevent future occurrences.
D. A client receives burns from a heating pad.
A client receiving burns from a heating pad is a safety incident that directly affects the client’s well-being. An incident report should be completed to document the injury, the circumstances leading to the burn, and any immediate care provided.
E. A client becomes disoriented and falls out of bed.
A client becoming disoriented and falling out of bed is a significant safety incident. An incident report should be completed to document the fall, the client’s condition, and any interventions implemented to prevent future falls.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Fundamentals 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice C, D, and E.
Choice A rationale: A client being unable to afford physical therapy is a financial issue, not an incident that affects patient safety or care quality. This situation should be addressed through social services or financial counseling, not an incident report.
Choice B rationale: A client being dissatisfied with meal temperature is a service quality issue, not a safety incident. This should be reported to the dietary department or patient services for resolution, not through an incident report.
Choice C rationale: A client’s visitor becoming dizzy and fainting in the client’s room is an incident that affects the safety of the visitor. An incident report should be completed to document the event, the visitor’s condition, and any actions taken to provide care or prevent future occurrences.
Choice D rationale: A client receiving burns from a heating pad is a safety incident that directly affects the client’s well-being. An incident report should be completed to document the injury, the circumstances leading to the burn, and any immediate care provided.
Choice E rationale: A client becoming disoriented and falling out of bed is a significant safety incident. An incident report should be completed to document the fall, the client’s condition, and any interventions implemented to prevent future falls.
Similar Questions
A nurse is inserting an indwelling urinary catheter for a female client.
In which order should the nurse perform the following steps? (Move the steps
into the box on the right, placing them in the order of performance.
Use all the steps.).
A. Separate the labia with the nondominant hand.
Choice A: Separating the labia with the nondominant hand exposes the urinary meatus and prevents contamination of the catheter tip by the labia.
B. Clean around the urinary meatus from front to back.
Choice B: Cleaning around the urinary meatus from front to back removes any bacteria or debris that may cause infection or obstruction. The front-to-back direction avoids introducing fecal matter into the urethra.
C. Insert the catheter into the urethral meatus.
Choice C: Inserting the catheter into the urethral meatus allows urine to drain from the bladder. The catheter should be inserted gently and slowly until urine flows out, then advanced another 2.5 cm (1 inch) to ensure it is in the bladder.
D. Inflate the catheter balloon.
Choice D: Inflating the catheter balloon secures the catheter in place and prevents it from slipping out. The balloon should be inflated only after urine flow is confirmed and according to the manufacturer’s instructions.
E. Secure the catheter to the client’s thigh.
Securing the catheter to the client’s thigh prevents tension or traction on the catheter that may cause discomfort, injury, or dislodgement.
A nurse is preparing to administer sucralfate 80 mg/kg/day to divide into four doses per day to a child who weighs 35 kg.
The amount available is sucralfate oral suspension 1 g/10 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
Determine the total daily dose required in milligrams:
The prescribed dose is 80 mg/kg/day.
The child's weight is 35 kg.
Total daily dose=80mg/kg/day×35kg
Calculate the total daily dose:
Total daily dose=2800mg/day
Divide the total daily dose into four doses:
Dose per administration: 2800mg/day ÷ 4 =700mg
Determine the volume of the oral suspension to administer per dose:
The available concentration of sucralfate oral suspension is 1 g/10 mL.
Convert 1 g to mg:
1g=1000mg.
Calculate the volume needed for 700 mg:
Volume (mL) = Desired dose (mg)÷Concentration (mg/mL)
Concentration = 1000mg÷10mL = 100mg/mL
Volume (mL) = 700 mg ÷ 100mg/mL
= 7 mL
Therefore, the nurse should administer 7 mL of sucralfate oral suspension per dose.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait.
Which of the following instructions should the nurse include?
A. Bear weight on the unaffected leg.
This gait pattern is used when one of the lower extremities is unable to fully bear weight due to fracture, amputation, joint replacement etc12 The client should advance both crutches and the affected leg as one unit, and then bring the unaffected leg forward to the crutches as the second unit
B. Keep the crutches at the level of the axillae.
Choice B is wrong because keeping the crutches at the level of the axillae can cause nerve damage and reduce circulation. The crutches should be positioned with 2 fingers of distance between the axilla and the axilla pad with the elbow flexed between 20-30 degrees
C. Stand with the crutch tips against the feet.
Choice C is wrong because standing with the crutch tips against the feet can cause instability and increase the risk of falling. The crutch tips should be placed about 15 cm (6 inches) in front of and 15 cm to the side of each foot
D. Hold the arms straight when walking.
Choice D is wrong because holding the arms straight when walking can cause fatigue and strain on the shoulders and wrists. The client should keep a slight bend in the elbows when walking with crutches
Full Explanation
This gait pattern is used when one of the lower extremities is unable to fully bear weight due to fracture, amputation, joint replacement etc12 The client should advance both crutches and the affected leg as one unit, and then bring the unaffected leg forward to the crutches as the second unit
Choice B is wrong because keeping the crutches at the level of the axillae can cause nerve damage and reduce circulation.
The crutches should be positioned with 2 fingers of distance between the axilla and the axilla pad with the elbow flexed between 20-30 degrees
Choice C is wrong because standing with the crutch tips against the feet can cause instability and increase the risk of falling.
The crutch tips should be placed about 15 cm (6 inches) in front of and 15 cm to the side of each foot
Choice D is wrong because holding the arms straight when walking can cause fatigue and strain on the shoulders and wrists.
The client should keep a slight bend in the elbows when walking with crutches