Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
A. "Yes, you are free to move around as you wish."
Allowing free movement could increase the risk of falls due to dizziness.
B. "We will have to get a prescription from your provider.
While involving the provider is important, immediate safety measures should be communicated directly.
C. "No, you are on strict bedrest and must not be up."
Strict bedrest is not typically necessary, and movement can help prevent complications like blood clots.
D. "Please ring for assistance when you wish to get out of bed."
Assisting the client when they wish to get out of bed ensures safety by preventing falls, which are a significant risk for those with Ménière's disease due to vertigo.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg pharm comprehensive proctored exam. Take the full exam now
Full Explanation
A. Allowing free movement could increase the risk of falls due to dizziness.
B. While involving the provider is important, immediate safety measures should be communicated directly.
C. Strict bedrest is not typically necessary, and movement can help prevent complications like blood clots.
D. Assisting the client when they wish to get out of bed ensures safety by preventing falls, which are a significant risk for those with Ménière's disease due to vertigo.
Similar Questions
A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?
A. Take the client's temperature once per shift.
Temperature should be monitored more frequently in immunosuppressed clients to detect early signs of infection.
B. Provide the client with fresh fruit to avoid constipation.
Fresh fruit can introduce bacteria or fungi, increasing infection risk in immunosuppressed clients.
C. Limit the number of health care workers entering the room.
Limiting the number of health care workers entering the room helps reduce the risk of infection by minimizing exposure to potential pathogens.
D. Insert an indwelling catheter to monitor sediment in the urine.
An indwelling catheter can increase the risk of infection and should be avoided unless absolutely necessary.
Full Explanation
Rationale:
A. Temperature should be monitored more frequently in immunosuppressed clients to detect early signs of infection.
B. Fresh fruit can introduce bacteria or fungi, increasing infection risk in immunosuppressed clients.
C. Limiting the number of health care workers entering the room helps reduce the risk of infection by minimizing exposure to potential pathogens.
D. An indwelling catheter can increase the risk of infection and should be avoided unless absolutely necessary.
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?
A. "Adding foods containing omega-3 fatty acids to my diet can lower my risk."
Omega-3 fatty acids are beneficial for cardiovascular health.
B. "Increasing my intake of foods containing trans-fatty acids can lower my risk."
Trans-fatty acids increase the risk of cardiovascular disease; this statement indicates a misunderstanding.
C. "Exercising regularly will increase HDL cholesterol levels."
Regular exercise is known to increase HDL cholesterol, which is protective against cardiovascular disease.
D. "A weight loss program can decrease my LDL cholesterol level."
Weight loss can help lower LDL cholesterol levels, reducing cardiovascular risk.
Full Explanation
Rationale:
A. Omega-3 fatty acids are beneficial for cardiovascular health.
B. Trans-fatty acids increase the risk of cardiovascular disease; this statement indicates a misunderstanding.
C. Regular exercise is known to increase HDL cholesterol, which is protective against cardiovascular disease.
D. Weight loss can help lower LDL cholesterol levels, reducing cardiovascular risk.
A nurse is teaching a client who has chronic obstructive pulmonary disease and is to start using fluticasone by MDI twice daily. Which of the following instructions should the nurse include?
A. "Skip the morning dose if you do not have any symptoms."
Fluticasone should be used regularly to prevent symptoms, not skipped based on symptom presence.
B. "Use this medication to relieve an acute attack."
Fluticasone is a maintenance medication and is not effective for acute attacks.
C. "Check your heart rate before each dose."
Checking heart rate is not necessary with fluticasone use.
D. "Inspect your mouth for lesions daily."
Inspecting the mouth for lesions daily is important to detect oral thrush, a potential side effect of inhaled corticosteroids.
Full Explanation
A. Fluticasone should be used regularly to prevent symptoms, not skipped based on symptom presence.
B. Fluticasone is a maintenance medication and is not effective for acute attacks.
C. Checking heart rate is not necessary with fluticasone use.
D. Inspecting the mouth for lesions daily is important to detect oral thrush, a potential side effect of inhaled corticosteroids.