Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
A. The client who has a chest tube to water seal
A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.
B. The client who has a tracheostomy tube attached to humidified oxygen
A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.
C. The client who has an indwelling urinary catheter to gravity drainage
An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.
D. The client who has a nasogastric (NG) tube to suction
A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.
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Full Explanation
A. A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.
B. A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.
C. An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.
D. A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.
Similar Questions
A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?
A. Using a computer terminal in a non-public area
Using a computer terminal in a non-public area is appropriate and helps maintain client confidentiality.
B. Sharing computer passwords with coworkers
Sharing computer passwords with coworkers is a serious breach of client confidentiality and security. Each individual should have their own unique login credentials to ensure accountability and protect sensitive information.
C. Logging out of the computer before leaving a terminal
Logging out of the computer before leaving a terminal is a standard practice to protect client information from unauthorized access.
D. Preventing an unidentified health care worker from viewing a health record on the computer screen
Preventing an unidentified healthcare worker from viewing a health record on the computer screen is a responsible action to protect client confidentiality.
Full Explanation
A. Using a computer terminal in a non-public area is appropriate and helps maintain client confidentiality.
B. Sharing computer passwords with coworkers is a serious breach of client confidentiality and security. Each individual should have their own unique login credentials to ensure accountability and protect sensitive information.
C. Logging out of the computer before leaving a terminal is a standard practice to protect client information from unauthorized access.
D. Preventing an unidentified healthcare worker from viewing a health record on the computer screen is a responsible action to protect client confidentiality.
A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?
A. Report the incident to the charge nurse.
Reporting the incident to the charge nurse is an important step, but it should come after the immediate action of washing the affected area.
B. Wash the area of the puncture thoroughly with soap and water.
Washing the area of the puncture thoroughly with soap and water is the initial step in managing a needlestick injury to minimize the risk of infection.
C. Go to employee health services.
Going to employee health services is important for further assessment and follow-up, but it should be done after washing the area of the puncture.
D. Complete an incident report.
Completing an incident report is an essential part of documenting the needlestick injury, but it is a secondary step that should be taken after the initial action of washing the area.
Full Explanation
A. Reporting the incident to the charge nurse is an important step, but it should come after the immediate action of washing the affected area.
B. Washing the area of the puncture thoroughly with soap and water is the initial step in managing a needlestick injury to minimize the risk of infection.
C. Going to employee health services is important for further assessment and follow-up, but it should be done after washing the area of the puncture.
D. Completing an incident report is an essential part of documenting the needlestick injury, but it is a secondary step that should be taken after the initial action of washing the area.
The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling.
Which of the following factors should the nurse identify as a likely explanation for the client's behavior?
A. He is hard of hearing.
This is unlikely. While hearing impairment could explain some difficulty in communication, it would not explain the flinching upon abdominal palpation or the wandering behavior. Hearing-impaired clients typically respond to nonverbal cues or attempt to communicate their understanding in other ways.
B. Confusion
This is correct. The client's wandering behavior, lack of verbal response, and smiling/nodding without clear understanding are indicative of confusion, which is common in older adults experiencing delirium, dementia, or other cognitive impairments. The flinching during abdominal palpation suggests a physical issue, but the client's inability to articulate his discomfort further supports confusion as a contributing factor.
C. Pain
While pain could explain the flinching during palpation, it does not account for the wandering behavior or the lack of meaningful verbal communication. Pain may coexist with confusion but is not the primary explanation for his overall behavior.
D. Language barrier
A language barrier could explain difficulty in verbal communication, but it does not account for the wandering behavior or the flinching upon palpation. Additionally, the family’s ability to communicate with the healthcare team suggests this is not the most likely factor.
E. None
None
F. None
None
Full Explanation
A. He is hard of hearing:
This is unlikely. While hearing impairment could explain some difficulty in communication, it would not explain the flinching upon abdominal palpation or the wandering behavior. Hearing-impaired clients typically respond to nonverbal cues or attempt to communicate their understanding in other ways.
B. Confusion:
This is correct. The client's wandering behavior, lack of verbal response, and smiling/nodding without clear understanding are indicative of confusion, which is common in older adults experiencing delirium, dementia, or other cognitive impairments. The flinching during abdominal palpation suggests a physical issue, but the client's inability to articulate his discomfort further supports confusion as a contributing factor.
C. Pain:
While pain could explain the flinching during palpation, it does not account for the wandering behavior or the lack of meaningful verbal communication. Pain may coexist with confusion but is not the primary explanation for his overall behavior.
D. Language barrier:
A language barrier could explain difficulty in verbal communication, but it does not account for the wandering behavior or the flinching upon palpation. Additionally, the family’s ability to communicate with the healthcare team suggests this is not the most likely factor