Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an older adult client who is suspected of having septicemia.
Which of the following actions is the nurse's priority?
A. Obtain a WBC count with differential.
Choice A is incorrect because while a WBC count with differential can provide information about the presence of an infection, it does not identify the specific microorganism causing the infection.
B. Obtain a blood specimen for culture and sensitivity testing.
The priority action for a nurse caring for an older adult client who is suspected of having septicemia is to obtain a blood specimen for culture and sensitivity testing. This test will help identify the specific microorganism causing the infection and determine the most effective antibiotic treatment.
C. Obtain a history to determine recent injuries.
Choice C is incorrect because while obtaining a history to determine recent injuries can provide useful information, it is not the priority action.
D. Obtain a broad-spectrum antibiotic for rapid administration.
Choice D is incorrect because while administering a broad-spectrum antibiotic may be necessary, it should not be done before obtaining a blood specimen for culture and sensitivity testing.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
The priority action for a nurse caring for an older adult client who is suspected of having septicemia is to obtain a blood specimen for culture and sensitivity testing.
This test will help identify the specific microorganism causing the infection and determine the most effective antibiotic treatment.
Choice A is incorrect because while a WBC count with differential can provide information about the presence of an infection, it does not identify the specific microorganism causing the infection.
Choice C is incorrect because while obtaining a history to determine recent injuries can provide useful information, it is not the priority action.
Choice D is incorrect because while administering a broad-spectrum antibiotic may be necessary, it should not be done before obtaining a blood specimen for culture and sensitivity testing.
Similar Questions
A nurse is planning care for a client who has status epilepticus.
Which of the following interventions is the nurse's priority to include?
A. Administer phenytoin IV bolus to the client.
Choice A is incorrect because while phenytoin can be used to treat seizures, it is not typically used as a first-line treatment for status epilepticus.
B. Administer diazepam intravenously to the client.
The priority intervention for a nurse planning care for a client who has status epilepticus is to administer diazepam intravenously to the client. Diazepam is a benzodiazepine medication that can help stop seizure activity and is often used as a first-line treatment for status epilepticus.
C. Provide the client oxygen at 6 L/min using a nasal cannula.
Choice C is incorrect because while providing oxygen can be an important intervention for clients experiencing seizures, it is not the priority intervention.
D. Turn the client to the lateral position during seizure activity.
Choice D is incorrect because while turning the client to the lateral position during seizure activity can help prevent aspiration, it is not the priority intervention.
Full Explanation
The priority intervention for a nurse planning care for a client who has status epilepticus is to administer diazepam intravenously to the client.
Diazepam is a benzodiazepine medication that can help stop seizure activity and is often used as a first-line treatment for status epilepticus.
Choice A is incorrect because while phenytoin can be used to treat seizures, it is not typically used as a first-line treatment for status epilepticus.
Choice C is incorrect because while providing oxygen can be an important intervention for clients experiencing seizures, it is not the priority intervention.
Choice D is incorrect because while turning the client to the lateral position during seizure activity can help prevent aspiration, it is not the priority intervention.
A nurse is assessing a client who has cirrhosis.
Which of the following findings is the priority for the nurse to report?
A. Distended abdomen.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
B. Clay-colored stools.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
C. Platelets 70,000/mm.
Platelets 70,000/mm. The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm. A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding. A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
D. Alkaline phosphatase 125 units/L.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
Full Explanation
Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
A nurse is caring for a client who had a total hip arthroplasty.
Which of the following actions should the nurse take to prevent hip dislocation?
A. Place two-bed pillows between the legs when in bed.
Place two-bed pillows between the legs when in bed. To prevent hip dislocation after total hip arthroplasty, the nurse should place two-bed pillows between the client’s legs when in bed. This helps maintain proper alignment and prevent the hip from dislocating.
B. Encourage the client to lean forward when attempting to stand.
Choice B is incorrect because leaning forward when attempting to stand can increase the risk of hip dislocation.
C. Remove the wedge device when turning.
Choice C is incorrect because removing the wedge device when turning can increase the risk of hip dislocation.
D. Elevate the knees higher than the hips when sitting.
Choice D is incorrect because elevating the knees higher than the hips when sitting can increase the risk of hip dislocation.
Full Explanation
Place two-bed pillows between the legs when in bed.
To prevent hip dislocation after total hip arthroplasty, the nurse should place two-bed pillows between the client’s legs when in bed.
This helps maintain proper alignment and prevent the hip from dislocating.
Choice B is incorrect because leaning forward when attempting to stand can increase the risk of hip dislocation.
Choice C is incorrect because removing the wedge device when turning can increase the risk of hip dislocation.
Choice D is incorrect because elevating the knees higher than the hips when sitting can increase the risk of hip dislocation.