Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for four clients. Which of the following clients should the nurse assess first?
A. A client who is 3 days postoperative following abdominal surgery is ready for discharge
A client ready for discharge, if stable and prepared for discharge, does not require immediate assessment.
B. A client who has Alzheimer's disease and bacterial pneumonia with newly onset restlessness
Restlessness in a client with Alzheimer's and bacterial pneumonia could indicate a change in condition, potentially signaling an urgent issue that needs immediate assessment.
C. A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7
While pain management is important, the sudden onset of restlessness in a client with cognitive impairment and pneumonia takes priority.
D. A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL
An elevated fasting blood glucose level in a newly admitted diabetic client requires attention but might not be as immediately critical as the acute change in behavior seen in option B.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Leadership 2019 Proctored Exam. Take the full exam now
Full Explanation
A. A client ready for discharge, if stable and prepared for discharge, does not require immediate assessment.
B. Restlessness in a client with Alzheimer's and bacterial pneumonia could indicate a change in condition, potentially signaling an urgent issue that needs immediate assessment.
C. While pain management is important, the sudden onset of restlessness in a client with cognitive impairment and pneumonia takes priority.
D. An elevated fasting blood glucose level in a newly admitted diabetic client requires attention but might not be as immediately critical as the acute change in behavior seen in option B.
Similar Questions
A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take?
A. Report the infection to the local health department.
Reporting infections like chlamydia to the local health department is crucial for public health monitoring and contact tracing to prevent further spread of the infection.
B. Apply an antiviral cream to lesions.
Chlamydia is a bacterial infection, and antiviral creams are not effective against it.
C. Instruct the client to use condoms until the treatment is completed.
While advising the client about preventive measures like condom use is important, reporting the infection is the priority for public health purposes.
D. Initiate contact precautions.
Contact precautions are not necessary for chlamydia as it is primarily spread through sexual contact and not through casual contact or airborne transmission.
Full Explanation
A. Reporting infections like chlamydia to the local health department is crucial for public health monitoring and contact tracing to prevent further spread of the infection.
B. Chlamydia is a bacterial infection, and antiviral creams are not effective against it.
C. While advising the client about preventive measures like condom use is important, reporting the infection is the priority for public health purposes.
D. Contact precautions are not necessary for chlamydia as it is primarily spread through sexual contact and not through casual contact or airborne transmission.
A nurse in a long-term care facility is caring for a client who reports the assistive personnel repositioned him in bed using excessive force. Which of the following actions should the nurse take?
A. Contact the nurse manager.
Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Call risk management to interview the client.
Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassure the client that the staff is well trained.
Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Document in the client's chart that an incident report has been filed.
Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.
Full Explanation
A. Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.
A nurse is caring for a client who is unconscious, and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
A. "You should contact the provider about your wishes for your family member."
Directing the family member to contact the provider might not resolve the conflict between differing wishes of the family members.
B. "You should speak with the facility's ethics committee about your concerns."
In situations of conflicting decisions regarding a client's care, involving the ethics committee can provide a forum for discussion and resolution while considering ethical, legal, and moral aspects.
C. "As the health care surrogate, the client's partner can make this decision."
While the health care surrogate typically has decision-making authority, if there'sdisagreement among family members, involving an ethics committee or legal advisors can help navigate the situation.
D. "We'll need to have the nursing supervisor review the client's advance directives."
Reviewing advance directives might provide information, but the situation here involves conflicting wishes among family members that require a more nuanced approach, potentially involving ethical considerations.
Full Explanation
A. Contacting the provider may be part of the process, but it does not directly address the conflict between the family members' wishes and the health care surrogate's legal authority.
B. While the ethics committee can be a valuable resource in resolving disputes, it is not the first step in this situation, as the health care surrogate has the legal right to make decisions on behalf of the unconscious client.
C. The health care surrogate is legally designated to make health care decisions for the client when they are unable to do so themselves. This includes decisions about life-sustaining treatments such as a feeding tube.
D. Reviewing the client's advance directives is important, but it does not supersede the authority of the health care surrogate unless the directives explicitly limit the surrogate's decision-making power.