Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a client who is African-American. Which of the following areas should the nurse check to determine the presence of pallor?
A. Conjunctiva
The nurse should check the conjunctiva to determine the presence of pallor in a client who is African-American
B. Pinna of the ear
correct because pallor is not expected in the pinna of the ear
C. Abdomen
This is not correct because pallor is not expected in the abdomen
D. Antecubital space
Choice D is not correct because pallor is not expected in the antecubital space.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice A. The nurse should check the conjunctiva to determine the presence of pallor in a client who is African-American. Choices B, C, and D are incorrect because pallor is not expected in these areas. Choice B is not correct because pallor is not expected in the pinna of the ear. Choice C is not correct because pallor is not expected in the abdomen. Choice D is not correct because pallor is not expected in the antecubital space.
Similar Questions
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will perform breast exams every other month."
This is not correct because the recommended frequency for performing breast exams is every month, not every other month.
B. "It is common for the skin on my breasts to dimple."
This is not correct because skin dimpling can be a sign of breast cancer and should be reported to a healthcare provider.
C. "It is common for one breast to be larger than the other."
It is indeed common for one breast to be slightly larger than the other. This is a normal variation and not usually a cause for concern.
D. "I will perform breast exams the day my period begins."
Breast self-examinations should be performed several days after the menstrual period ends, not the day the period begins. This timing helps to reduce the likelihood of hormonal changes affecting breast tissue.
Full Explanation
Choice A rationale: Breast self-examinations should be performed monthly, not every other month. This regularity helps with early detection of any changes.
Choice B rationale: Dimpling of the skin on the breasts is not common and can be a sign of breast cancer or other conditions. This statement indicates a misunderstanding.
Choice C rationale: It is indeed common for one breast to be slightly larger than the other. This is a normal variation and not usually a cause for concern.
Choice D rationale: Breast self-examinations should be performed several days after the menstrual period ends, not the day the period begins. This timing helps to reduce the likelihood of hormonal changes affecting breast tissue.
A nurse is reinforcing teaching about decreasing the risk of osteoporosis to a client who is postmenopausal. Which of the following instructions should the nurse include?
A. Add a weight-bearing exercise regimen.
Weight-bearing exercise is an important way to decrease the risk of osteoporosis in a postmenopausal client.
B. Take calcium carbonate supplements once a day with breakfast.
Choice B is incorrect because calcium carbonate supplements should be taken multiple times throughout the day for better absorption
C. Limit vitamin D intake.
Choice C is incorrect because vitamin D intake should be increased
D. Increase daily intake of vitamin E.
Choice D is incorrect because there is no evidence that vitamin E intake decreases the risk of osteoporosis
Full Explanation
The correct answer is choice A. Weight-bearing exercise is an important way to decrease the risk of osteoporosis in a postmenopausal client. Choice B is incorrect because calcium carbonate supplements should be taken multiple times throughout the day for better absorption. Choice C is incorrect because vitamin D intake should be increased. Choice D is incorrect because there is no evidence that vitamin E intake decreases the risk of osteoporosis. Choice B is not correct because calcium carbonate supplements should be taken multiple times throughout the day for better absorption. Choice C is not correct because vitamin D intake should be increased.
A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
A. Elevate the head of the client's bed for 1 hr after the feeding.
Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux
B. Administer the feeding solution at a cold temperature.
Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea
C. Rotate the jejunostomy tube once per day.
incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site
D. Flush the tube with 90 mL of sterile water before and after the feeding.
Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after
Full Explanation
The correct answer is choice A: Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux. Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea. Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site. Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.
Explanation for why the other choices are not answers: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.