Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a preschooler immediately following a tonsillectomy and notices the child swallowing frequently.
Which of the following actions should the nurse take?
A. Check the back of the throat with a pen light.
Frequent swallowing after a tonsillectomy may indicate postoperative bleeding. The nurse should check the back of the throat with a pen light to assess for signs of hemorrhage.
B. Obtain the child’s vital signs in 15 min.
While obtaining vital signs is important, it does not directly address the concern of potential bleeding.
C. Administer analgesia.
Administering analgesia is appropriate for pain management but does not address the priority concern of bleeding.
D. Offer the child a drink of water.
Offering water could potentially worsen bleeding if it is occurring and should not be the first action.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Capstone Proctored Comprehensive Assessment 2020 B. Take the full exam now
Full Explanation
A. Frequent swallowing after a tonsillectomy may indicate postoperative bleeding. The nurse should check the back of the throat with a pen light to assess for signs of hemorrhage.
B. While obtaining vital signs is important, it does not directly address the concern of potential bleeding.
C. Administering analgesia is appropriate for pain management but does not address the priority concern of bleeding.
D. Offering water could potentially worsen bleeding if it is occurring and should not be the first action.
Similar Questions
A nurse is reinforcing teaching about HbA1c with a client who has type 1 diabetes mellitus.
Which of the following information should the nurse include?
A. An HbA1c value greater than 8% indicates diabetic control of blood sugar.
Choice A is wrong because an HbA1c value greater than 8% indicates poor diabetic control of blood sugar. The HbA1c target for most people with type 1 diabetes is 48 mmol/mol (or 6.5%) or lower.
B. The HbA1c value is altered by eating habits the day before the test.
Choice B is wrong because the HbA1c value is not altered by eating habits the day before the test. The test does not require fasting and can be done at any time of the day.
C. The HbA1c value determines long-term blood glucose control for the past 120 days.
The HbA1c value determines long-term blood glucose control for the past 120 days. This is because the HbA1c test measures what percentage of hemoglobin proteins in your blood are coated with sugar (glycated). Hemoglobin proteins in red blood cells live for around 120 days, so the test reflects your average blood sugar level for the past two to three months.
D. An HbA1c test is performed once per year.
Choice D is wrong because an HbA1c test should be performed more than once per year. The frequency of the test depends on the type of diabetes, your treatment plan and your blood sugar level. For example, you may need the test twice a year if you have good blood sugar control, or four times a year if you take insulin or have trouble keeping your blood sugar level within your target range.
Full Explanation
The HbA1c value determines long-term blood glucose control for the past 120 days. This is because the HbA1c test measures what percentage of hemoglobin proteins in your blood are coated with sugar (glycated). Hemoglobin proteins in red blood cells live for around 120 days, so the test reflects your average blood sugar level for the past two to three months.
Choice A is wrong because an HbA1c value greater than 8% indicates poor diabetic control of blood sugar. The HbA1c target for most people with type 1 diabetes is 48 mmol/mol (or 6.5%) or lower.
Choice B is wrong because the HbA1c value is not altered by eating habits the day before the test. The test does not require fasting and can be done at any time of the day.
Choice D is wrong because an HbA1c test should be performed more than once per year.
The frequency of the test depends on the type of diabetes, your treatment plan and your blood sugar level. For example, you may need the test twice a year if you have good blood sugar control, or four times a year if you take insulin or have trouble keeping your blood sugar level within your target range.
A nurse is caring for a client who is postoperative following a mastectomy.
Which of the following actions should the nurse take to help the client cope with the body image change resulting from the surgery?
A. Encourage the client to help care for their surgical incision.
Encourage the client to help care for their surgical incision. This can help the client accept the body image change and promote healing.
B. Suggest that the client decide about reconstruction as soon as possible.
Choice B is wrong because suggesting that the client decide about reconstruction as soon as possible can pressure the client and interfere with their coping process.
C. Postpone referrals to support services until the client requests them.
Choice C is wrong because postponing referrals to support services until the client requests them can delay the client’s emotional recovery and increase their isolation.
D. Avoid talking to the client about the surgery.
Choice D is wrong because avoiding talking to the client about the surgery can indicate that the nurse is uncomfortable with the topic and discourage the client from expressing their feelings.
Full Explanation
Encourage the client to help care for their surgical incision. This can help the client accept the body image change and promote healing.
Choice B is wrong because suggesting that the client decide about reconstruction as soon as possible can pressure the client and interfere with their coping process.
Choice C is wrong because postponing referrals to support services until the client requests them can delay the client’s emotional recovery and increase their isolation.
Choice D is wrong because avoiding talking to the client about the surgery can indicate that the nurse is uncomfortable with the topic and discourage the client from expressing their feelings.
A nurse on a medical-surgical unit is caring for a client who has hearing loss. Which of the following actions should the nurse take?
A. Speak in a louder than usual tone of voice during conversation.
Choice A is wrong because speaking in a louder than usual tone of voice during conversation can distort the sound and make it harder for the client to understand. The nurse should speak in a normal tone and enunciate clearly.
B. Mute the client’s television before beginning a conversation.
C. Avoid the use of hand gestures when talking to the client.
Choice C is wrong because avoiding the use of hand gestures when talking to the client can limit nonverbal communication and reduce the client’s comprehension. The nurse should use appropriate facial expressions
D. Use short phrases when talking to the client.
Full Explanation
Use short phrases when talking to the client.
Some possible explanations for the other choices are:
Choice A is wrong because speaking in a louder than usual tone of voice during conversation can distort the sound and make it harder for the client to understand.
The nurse should speak in a normal tone and enunciate clearly.
Choice C is wrong because avoiding the use of hand gestures when talking to the client can limit nonverbal communication and reduce the client’s comprehension.
The nurse should use appropriate facial expressions