Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?
A. A client who has diminished vision ambulating in well-lit areas
A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B. A client who received a diuretic 30 min ago
A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C. A client who requires assistance with ambulation
A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D. A client who had a tonic-clonic seizure 2 hr ago
A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Fundamentals Proctored Exam 6. Take the full exam now
Full Explanation
A. A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B. A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C. A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D. A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.
Similar Questions
A nurse is teaching a client proper use of an albuterol inhaler during acute asthma exacerbations. Which of the following client statements indicates an understanding of the teaching?
A. "I will tilt my head forward while inhaling the medication."
Tilted head forward is not necessary during inhaler use. The client should maintain an upright position.
B. “I will shake the inhaler well right before I use it."
Shaking the inhaler before use is correct to ensure proper dispersion of the medication.
C. “I should rinse my mouth out right before I use it."
Rinsing the mouth out before using the inhaler is not necessary for proper technique.
D. "After the first puff, I will wait 10 seconds before taking the second puff."
Waiting 10 seconds between puffs allows for optimal delivery of the medication to the airways.
Full Explanation
A. Tilted head forward is not necessary during inhaler use. The client should maintain an upright position.
B. Shaking the inhaler before use is correct to ensure proper dispersion of the medication.
C. Rinsing the mouth out before using the inhaler is not necessary for proper technique.
D. Waiting 10 seconds between puffs allows for optimal delivery of the medication to the airways.
A nurse is providing care for a client who is scheduled for a total laryngectomy. Which of the following is the nurse's priority intervention?
A. Show the client how to use an artificial larynx.
Showing the client how to use an artificial larynx is an important aspect of post-laryngectomy care, but determining the client's reading ability takes precedence as it will significantly impact communication options.
B. Arrange a support session for the client.
Arranging a support session is important for emotional support, but assessing the client's reading ability is more immediate in addressing communication needs.
C. Demonstrate the use of esophageal speech.
Demonstrating the use of esophageal speech is relevant, but understanding the client's reading ability is a priority before exploring communication alternatives.
D. Determine the client's reading ability.
Full Explanation
A. Showing the client how to use an artificial larynx is an important aspect of post-laryngectomy care, but determining the client's reading ability takes precedence as it will significantly impact communication options.
B. Arranging a support session is important for emotional support, but assessing the client's reading ability is more immediate in addressing communication needs.
C. Demonstrating the use of esophageal speech is relevant, but understanding the client's reading ability is a priority before exploring communication alternatives.
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
A. Eat a light carbohydrate snack before bedtime.
Eating a light carbohydrate snack before bedtime can promote sleep by providing a small increase in insulin, which facilitates the entry of tryptophan into the brain, promoting the production of serotonin and melatonin.
B. Take a 30 min daily nap.
Taking a 30-minute daily nap, especially close to bedtime, may interfere with nighttime sleep.
C. Exercise 1 hr before bedtime.
Exercising 1 hour before bedtime can be stimulating and may disrupt sleep patterns.
D. Drink a cup of hot cocoa before bedtime.
Drinking a cup of hot cocoa before bedtime may not be recommended as it contains caffeine, which can interfere with sleep.
Full Explanation
A. Eating a light carbohydrate snack before bedtime can promote sleep by providing a small increase in insulin, which facilitates the entry of tryptophan into the brain, promoting the production of serotonin and melatonin.
B. Taking a 30-minute daily nap, especially close to bedtime, may interfere with nighttime sleep.
C. Exercising 1 hour before bedtime can be stimulating and may disrupt sleep patterns.
D. Drinking a cup of hot cocoa before bedtime may not be recommended as it contains caffeine, which can interfere with sleep.