Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a visually impaired client. What action should the nurse take when delivering the client's meal tray?
A. Arrange for an assistive personnel to feed the client.
Arrange for an assistive personnel to feed the client: Arranging for an assistive personnel to feed the client may take away the client's independence.
B. Discourage conversations during the client's mealtime.
Discourage conversations during the client's mealtime: Discouraging conversations during the client's mealtime may make the client feel isolated.
C. Provide the client with small-handled adaptive utensils.
Provide the client with small-handled adaptive utensils: Providing the client with small-handled adaptive utensils may not help the client locate food on the plate.
D. Describe the food placement as though the plate were a clock.
The correct answer is choice D, Describe the food placement as though the plate were a clock. When delivering the client's meal tray, the nurse should describe the food placement as though the plate were a clock to help the client know where the food is located. This helps the client be more independent and participate actively at mealtime. Choice A is incorrect because arranging for assistive personnel to feed the client may take away the client's independence. Choice B is incorrect because discouraging conversations during the client's mealtime may make the client feel isolated. Choice C is incorrect because providing the client with small-handled adaptive utensils may not help the client locate food on the plate. Other choices:
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice D, Describe the food placement as though the plate were a clock. When delivering the client's meal tray, the nurse should describe the food placement as though the plate were a clock to help the client know where the food is located. This helps the client be more independent and participate actively at mealtime. Choice A is incorrect because arranging for assistive personnel to feed the client may take away the client's independence. Choice B is incorrect because discouraging conversations during the client's mealtime may make the client feel isolated. Choice C is incorrect because providing the client with small-handled adaptive utensils may not help the client locate food on the plate.
Other choices:
A. Arrange for assistive personnel to feed the client: Arranging for assistive personnel to feed the client may take away the client's independence.
B. Discourage conversations during the client's mealtime: Discouraging conversations during the client's mealtime may make the client feel isolated.
B. Provide the client with small-handled adaptive utensils: Providing the client with small-handled adaptive utensils may not help the client locate food on the plate.
Similar Questions
A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy. Which of the following information should the nurse include in the teaching?
A. "You will be moderately sedated during the procedure."
Colonoscopy is a common procedure used for both diagnostic and therapeutic purposes in gastroenterology. Moderate sedation, also known as conscious sedation, is typically administered to patients undergoing colonoscopy to ensure their comfort and cooperation during the procedure. This level of sedation allows the patient to maintain their protective reflexes and respond to verbal commands, while also reducing anxiety and discomfort. The sedative agents commonly used for colonoscopy include benzodiazepines such as midazolam and analgesics such as fentanyl. The nurse should emphasize the use of moderate sedation to the patient, reassuring them that they will be in a relaxed state throughout the procedure without compromising their safety.
B. "You will lie on your right side for the procedure."
The statement suggesting that the patient will lie on their right side for the procedure is incorrect. During a colonoscopy, patients are typically positioned on their left side with their knees drawn up towards their chest. This left lateral decubitus position facilitates the advancement of the colonoscope through the colon and provides better visualization for the healthcare provider performing the procedure. Placing the patient on the right side would not provide optimal positioning and may hinder the progress of the colonoscopy.
C. "You may drink full liquids until 6 hours before the procedure."
The information provided in statement c. is incorrect regarding the dietary restrictions before a colonoscopy. Prior to the procedure, patients are instructed to follow a clear liquid diet for 24 to 48 hours, depending on the healthcare provider's instructions. Clear liquids include water, clear broth, tea, coffee without milk or cream, strained fruit juices (such as apple or white grape juice), and sports drinks. Solid foods, as well as liquids that are not transparent, should be avoided during this preparatory period to ensure adequate bowel cleansing and visualization during the colonoscopy.
D. "You should warm the liquid bowel preparation before drinking it."
The recommendation to warm the liquid bowel preparation before consumption, as stated in option d., is incorrect. Bowel preparations typically consist of polyethylene glycol-based solutions, which are intended to be consumed at room temperature or chilled. Warming the solution could alter its composition and taste, potentially causing discomfort or nausea in the patient. It is essential for patients to follow the specific instructions provided by their healthcare provider or the product labeling regarding the administration of bowel preparation to ensure effective bowel cleansing before the colonoscopy.
Full Explanation
The correct answer is Choice a. "You will be moderately sedated during the procedure."
Choice A rationale: Colonoscopy is a common procedure used for both diagnostic and therapeutic purposes in gastroenterology. Moderate sedation, also known as conscious sedation, is typically administered to patients undergoing colonoscopy to ensure their comfort and cooperation during the procedure. This level of sedation allows the patient to maintain their protective reflexes and respond to verbal commands, while also reducing anxiety and discomfort. The sedative agents commonly used for colonoscopy include benzodiazepines such as midazolam and analgesics such as fentanyl. The nurse should emphasize the use of moderate sedation to the patient, reassuring them that they will be in a relaxed state throughout the procedure without compromising their safety.
Choice B rationale: The statement suggesting that the patient will lie on their right side for the procedure is incorrect. During a colonoscopy, patients are typically positioned on their left side with their knees drawn up towards their chest. This left lateral decubitus position facilitates the advancement of the colonoscope through the colon and provides better visualization for the healthcare provider performing the procedure. Placing the patient on the right side would not provide optimal positioning and may hinder the progress of the colonoscopy.
Choice C rationale: The information provided in statement c. is incorrect regarding the dietary restrictions before a colonoscopy. Prior to the procedure, patients are instructed to follow a clear liquid diet for 24 to 48 hours, depending on the healthcare provider's instructions. Clear liquids include water, clear broth, tea, coffee without milk or cream, strained fruit juices (such as apple or white grape juice), and sports drinks. Solid foods, as well as liquids that are not transparent, should be avoided during this preparatory period to ensure adequate bowel cleansing and visualization during the colonoscopy.
Choice D rationale: The recommendation to warm the liquid bowel preparation before consumption, as stated in option d., is incorrect. Bowel preparations typically consist of polyethylene glycol-based solutions, which are intended to be consumed at room temperature or chilled. Warming the solution could alter its composition and taste, potentially causing discomfort or nausea in the patient. It is essential for patients to follow the specific instructions provided by their healthcare provider or the product labeling regarding the administration of bowel preparation to ensure effective bowel cleansing before the colonoscopy.
Choice E rationale: Repeated for emphasis, the advice to warm the liquid bowel preparation before consumption is incorrect and redundant. Patients should adhere strictly to the instructions provided by their healthcare provider or the product labeling regarding the administration of bowel preparation. Warming the solution is not recommended and could compromise the effectiveness of the preparation, leading to suboptimal bowel cleansing and potentially impacting the accuracy of the colonoscopy results.
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
A. The client has a history of breast cancer.
This is incorrect because breast cancer is not associated with false-positive fecal occult blood results
B. The client takes ibuprofen for headaches.
The client takes ibuprofen for headaches. NSAIDs such as ibuprofen can cause gastrointestinal bleeding, which can result in a false positive result on a fecal occult blood test.
C. The client consumed citrus juice 3 days before the test.
This is incorrect because citrus juice does not affect the fecal occult blood test.
D. The client had a hemorrhoidectomy 1 year ago.
This is incorrect because a hemorrhoidectomy is not associated with false-positive fecal occult blood results.
E. The client had a hemorrhoidectomy 1 year ago.
Full Explanation
The client takes ibuprofen for headaches. NSAIDs such as ibuprofen can cause gastrointestinal bleeding, which can result in a false positive result on a fecal occult blood test.
Option A is incorrect because breast cancer is not associated with false-positive fecal occult blood results.
Option C is incorrect because citrus juice does not affect the fecal occult blood test.
Option D is incorrect because a hemorrhoidectomy is not associated with false-positive fecal occult blood results.
Reasons why the other options are not answered:
Option A: Breast cancer is not associated with false-positive fecal occult blood results.
Option C: Citrus juice does not affect the fecal occult blood test.
Option D: A hemorrhoidectomy is not associated with false-positive fecal occult blood results.
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
A. Obtain blood pressure readings using the client's right arm.
Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.
B. Limit range-of-motion exercises with the affected arm.
Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.
C. Keep both arms below the level of the client's heart.
Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.
D. Use the client's left arm to obtain blood samples.
The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.
Full Explanation
The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.
A: Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.
B: Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.
C: Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.