Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
A. Request that the provider prescribe a stool softener.
Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.
B. Add fluid and fiber to the diet.
Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.
C. Promote active range-of-motion activities.
Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.
D. Avoid gas-producing foods.
Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.
This question is an excerpt from Nurse Dive's nursing test bank - NS117 T Winter 2023 Monroe college NY PN Fundamental of nursing proctored exam 2. Take the full exam now
Full Explanation
Choice A reason: Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.
Choice B reason: Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.
Choice C reason: Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.
Choice D reason: Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.
Similar Questions
A nurse is collecting data on a client who has a pleural effusion. Which of the following findings should the nurse expect?
A. Crackles auscultated over the client's lung fields
Crackles auscultated over the client's lung fields are not a sign of pleural effusion. Crackles are abnormal breath sounds that indicate fluid or secretions in the alveoli. They can be heard in conditions such as pneumonia, heart failure, or pulmonary edema.
B. Crepitus palpated on the client's chest
Crepitus palpated on the client's chest is not a sign of pleural effusion. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It can be felt in conditions such as pneumothorax, chest trauma, or chest surgery.
C. Substernal retractions noted on the client's chest
Substernal retractions noted on the client's chest are not a sign of pleural effusion. Substernal retractions are inward movements of the chest wall below the sternum that indicate increased respiratory effort. They can be seen in conditions such as asthma, bronchiolitis, or croup.
D. Dullness percussed over the client's lung fields
Dullness percussed over the client's lung fields is a sign of pleural effusion. Dullness is a flat sound that indicates the presence of a solid or liquid mass in the thoracic cavity. It can be detected in conditions such as pleural effusion, atelectasis, or consolidation.
Full Explanation
Choice A reason: Crackles auscultated over the client's lung fields are not a sign of pleural effusion. Crackles are abnormal breath sounds that indicate fluid or secretions in the alveoli. They can be heard in conditions such as pneumonia, heart failure, or pulmonary edema.
Choice B reason: Crepitus palpated on the client's chest is not a sign of pleural effusion. Crepitus is a crackling sensation that occurs when air leaks into the subcutaneous tissue. It can be felt in conditions such as pneumothorax, chest trauma, or chest surgery.
Choice C reason: Substernal retractions noted on the client's chest are not a sign of pleural effusion. Substernal retractions are inward movements of the chest wall below the sternum that indicate increased respiratory effort. They can be seen in conditions such as asthma, bronchiolitis, or croup.
Choice D reason: Dullness percussed over the client's lung fields is a sign of pleural effusion. Dullness is a flat sound that indicates the presence of a solid or liquid mass in the thoracic cavity. It can be detected in conditions such as pleural effusion, atelectasis, or consolidation.
A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?
A. Strip the client's chest tube every 2 hours.
Stripping the client's chest tube every 2 hours is not a recommended action, as it can cause excessive negative pressure, tissue trauma, and pain. The nurse should only strip the chest tube if there is a clot or obstruction in the tubing, and only with the provider's order.
B. Loop the tubing of the chest tube on the client's bed.
Looping the tubing of the chest tube on the client's bed is a correct action, as it prevents kinking, tension, or pulling on the chest tube. The nurse should also secure the tubing to the bed sheet with a safety pin.
C. Place the chest tube drainage system above the level of the client's heart.
Placing the chest tube drainage system above the level of the client's heart is not a correct action, as it can cause the fluid to flow back into the chest cavity and impair lung expansion. The nurse should place the chest tube drainage system below the level of the client's chest.
D. Tape the connections on the client's chest tube.
Taping the connections on the client's chest tube is a correct action, as it prevents air leaks, disconnections, or accidental removal of the chest tube. The nurse should also check the connections regularly for tightness and patency.
Full Explanation
Choice A reason: Stripping the client's chest tube every 2 hours is not a recommended action, as it can cause excessive negative pressure, tissue trauma, and pain. The nurse should only strip the chest tube if there is a clot or obstruction in the tubing, and only with the provider's order.
Choice B reason: Looping the tubing of the chest tube on the client's bed is a correct action, as it prevents kinking, tension, or pulling on the chest tube. The nurse should also secure the tubing to the bed sheet with a safety pin.
Choice C reason: Placing the chest tube drainage system above the level of the client's heart is not a correct action, as it can cause the fluid to flow back into the chest cavity and impair lung expansion. The nurse should place the chest tube drainage system below the level of the client's chest.
Choice D reason: Taping the connections on the client's chest tube is a correct action, as it prevents air leaks, disconnections, or accidental removal of the chest tube. The nurse should also check the connections regularly for tightness and patency.
A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?
A. Leakage of urine
Leakage of urine is a sign of urinary retention, as it indicates that the bladder is overdistended and unable to empty completely. The urine may leak around the urethra or through a catheter.
B. Dark-colored urine
Dark-colored urine is not a sign of urinary retention. It can be caused by dehydration, certain foods or medications, or liver or kidney problems.
C. Cloudy urine
Cloudy urine is not a sign of urinary retention. It can be caused by infection, inflammation, or stones in the urinary tract.
D. Blood in urine
Blood in urine is not a sign of urinary retention. It can be caused by trauma, infection, cancer, or coagulation disorders in the urinary tract.
Full Explanation
Choice A reason: Leakage of urine is a sign of urinary retention, as it indicates that the bladder is overdistended and unable to empty completely. The urine may leak around the urethra or through a catheter.
Choice B reason: Dark-colored urine is not a sign of urinary retention. It can be caused by dehydration, certain foods or medications, or liver or kidney problems.
Choice C reason: Cloudy urine is not a sign of urinary retention. It can be caused by infection, inflammation, or stones in the urinary tract.
Choice D reason: Blood in urine is not a sign of urinary retention. It can be caused by trauma, infection, cancer, or coagulation disorders in the urinary tract.