Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement.
Which symptom should the nurse address first?
A. Fatigue
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
B. Pain
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
C. Fever
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
D. Stridor
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.
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Full Explanation
Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.
Similar Questions
A nurse is attending to a client experiencing hypovolemic shock.
What findings should the nurse anticipate?
A. Hypertension
Hypertension is not typically associated with hypovolemic shock. In fact, hypotension, or low blood pressure, is more common.
B. Purpura
Purpura, or blood spots, are not typically associated with hypovolemic shock.
C. Bradypnea
Bradypnea, or slow breathing, is not typically associated with hypovolemic shock. Rapid, shallow breathing is more common.
D. Oliguria
Oliguria, or decreased urine output, is a common finding in hypovolemic shock. It occurs due to decreased blood flow to the kidneys.
Full Explanation
Choice A rationale
Hypertension is not typically associated with hypovolemic shock. In fact, hypotension, or low blood pressure, is more common.
Choice B rationale
Purpura, or blood spots, are not typically associated with hypovolemic shock.
Choice C rationale
Bradypnea, or slow breathing, is not typically associated with hypovolemic shock. Rapid, shallow breathing is more common.
Choice D rationale
Oliguria, or decreased urine output, is a common finding in hypovolemic shock. It occurs due to decreased blood flow to the kidneys.
A patient with acute pancreatitis is in severe pain.
Which position should the nurse suggest the patient to assume?
A. Semi-Fowler’s position
The Semi-Fowler’s position, while commonly used for patients with respiratory issues, is not the most effective position for relieving pain in acute pancreatitis.
B. Prone, with a pillow under the abdomen
Lying prone with a pillow under the abdomen is not typically recommended for acute pancreatitis pain relief.
C. Supine, with legs elevated and head on a small pillow
Lying supine with legs elevated and head on a small pillow is not typically recommended for acute pancreatitis pain relief.
D. Sitting in a chair, leaning forward with a pillow for back support
Sitting in a chair, leaning forward with a pillow for back support, is often recommended for pain relief in acute pancreatitis. This position can help decrease the pressure on the abdomen and relieve pain.
Full Explanation
Choice A rationale
The Semi-Fowler’s position, while commonly used for patients with respiratory issues, is not the most effective position for relieving pain in acute pancreatitis.
Choice B rationale
Lying prone with a pillow under the abdomen is not typically recommended for acute pancreatitis pain relief.
Choice C rationale
Lying supine with legs elevated and head on a small pillow is not typically recommended for acute pancreatitis pain relief.
Choice D rationale
Sitting in a chair, leaning forward with a pillow for back support, is often recommended for pain relief in acute pancreatitis. This position can help decrease the pressure on the abdomen and relieve pain.
A nurse is assisting a postoperative client.
The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.
The client is now sleeping and is difficult to arouse.
Pupils are 3 mm, equal and reactive to light.
Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.
Which documentation in the client’s medical record requires further action by the nurse?
A. Pupils are 3 mm, equal and reactive to light
Pupils being 3 mm, equal and reactive to light is a normal finding and does not require further action.
B. Client is sleeping and is difficult to arouse
The client being difficult to arouse could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
C. Respirations are 10/min
Respirations being 10/min could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
D. Pulse oximetry is 87% on room air .
Pulse oximetry reading of 87% on room air is concerning. Normal pulse oximetry readings are typically between 95% and 100%. A reading of 87% indicates the client is not getting enough oxygen, which requires immediate action.
Full Explanation
Choice A rationale
Pupils being 3 mm, equal and reactive to light is a normal finding and does not require further action.
Choice B rationale
The client being difficult to arouse could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice C rationale
Respirations being 10/min could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice D rationale
Pulse oximetry reading of 87% on room air is concerning. Normal pulse oximetry readings are typically between 95% and 100%. A reading of 87% indicates the client is not getting enough oxygen, which requires immediate action.