Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a client whose Hgb is 8.8 mg/dL. Which of the following statements should the nurse expect?
A. "I feel tired all the time."
A hemoglobin (Hgb) level of 8.8 mg/dL indicates anemia, which is a decrease in the oxygen-carrying capacity of the blood. Fatigue and tiredness are common symptoms of anemia. When the body does not have enough hemoglobin to transport oxygen effectively, it can lead to feelings of fatigue and a lack of energy.
B. "I have noticed that my fingernails are becoming thicker."
"I have noticed that my fingernails are becoming thicker." Thicker fingernails are not typically associated with a low hemoglobin level. Changes in fingernails can be atributed to various factors, but they are not directly related to anemia.
C. "I have to go to the bathroom all the time."
"I have to go to the bathroom all the time." Frequent urination is not typically associated with a low hemoglobin level. It can be related to other factors such as urinary tract infections, diabetes, or diuretic use, among others.
D. "I notice that my hands are always shaky."
"I notice that my hands are always shaky." Hand tremors are not directly associated with a low hemoglobin level. Tremors can have various causes, such as neurological conditions, medication side effects, or excessive caffeine intake, but they are not directly linked to anemia.
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Full Explanation
A hemoglobin (Hgb) level of 8.8 mg/dL indicates anemia, which is a decrease in the oxygen-carrying capacity of the blood. Fatigue and tiredness are common symptoms of anemia. When the body does not have enough hemoglobin to transport oxygen effectively, it can lead to feelings of fatigue and a lack of energy.
The other options are not directly associated with a low hemoglobin level:
b) "I have noticed that my fingernails are becoming thicker." Thicker fingernails are not typically associated with a low hemoglobin level. Changes in fingernails can be atributed to various factors, but they are not directly related to anemia.
c) "I have to go to the bathroom all the time." Frequent urination is not typically associated with a low hemoglobin level. It can be related to other factors such as urinary tract infections, diabetes, or diuretic use, among others.
d) "I notice that my hands are always shaky." Hand tremors are not directly associated with a low hemoglobin level. Tremors can have various causes, such as neurological conditions, medication side effects, or excessive caffeine intake, but they are not directly linked to anemia.
Similar Questions
A nurse is caring for a client who atempted suicide. Which of the following actions should the nurse take?
A. Serve meals with plastic utensils.
A) Serve meals with plastic utensils: Serving meals with plastic utensils is essential to reduce the risk of self-harm. Metal utensils could be used by the client to inflict injury upon themselves, so providing plastic utensils is a necessary safety measure to prevent potential harm.
B. Assign another client to accompany the client to therapy sessions
B) Assign another client to accompany the client to therapy sessions: Assigning another client to accompany the client to therapy sessions is not appropriate as it places an undue burden on another client and may not ensure the safety of the at-risk client. Professional staff should provide supervision and support.
C. Assign the client to a private room
C) Assign the client to a private room: Assigning the client to a private room might increase the risk of self-harm due to reduced supervision. It is generally better to place the client in a more observable setting where staff can frequently monitor their condition.
D. Check on the client every 4 hr
D) Check on the client every 4 hr: Checking on the client every 4 hours is insufficient for someone who has recently attempted suicide. More frequent monitoring, such as constant or every 15-minute checks, is necessary to ensure the client's safety and provide immediate intervention if needed.
Full Explanation
Answer: A
Rationale:
A) Serve meals with plastic utensils: Serving meals with plastic utensils is essential to reduce the risk of self-harm. Metal utensils could be used by the client to inflict injury upon themselves, so providing plastic utensils is a necessary safety measure to prevent potential harm.
B) Assign another client to accompany the client to therapy sessions: Assigning another client to accompany the client to therapy sessions is not appropriate as it places an undue burden on another client and may not ensure the safety of the at-risk client. Professional staff should provide supervision and support.
C) Assign the client to a private room: Assigning the client to a private room might increase the risk of self-harm due to reduced supervision. It is generally better to place the client in a more observable setting where staff can frequently monitor their condition.
D) Check on the client every 4 hr: Checking on the client every 4 hours is insufficient for someone who has recently attempted suicide. More frequent monitoring, such as constant or every 15-minute checks, is necessary to ensure the client's safety and provide immediate intervention if needed.
A nurse is reinforcing teaching about confidentiality with a client. Which of the following statements should the nurse include in the teaching?
A. "Your nurse will provide information about the risks and benefits of surgical procedures."
While it is important for the nurse to provide information about surgical procedures, this statement does not specifically address confidentiality.
B. "Only health care staff providing care will see your medical record."
The nurse should include the statement that only health care staff providing care will see the client's medical record when reinforcing teaching about confidentiality. This statement emphasizes the importance of maintaining the privacy and confidentiality of the client's personal health information.
C. "The provider must grant you access to your personal health information."
This statement is related to the client's rights regarding access to their personal health information. While it is important to educate clients about their rights, it is not specifically focused on confidentiality.
D. "You have to authorize our providers to prescribe treatments for your condition."
This statement is related to obtaining the client's consent for treatment, which is important but not directly addressing confidentiality.
Full Explanation
The nurse should include the statement that only health care staff providing care will see the client's medical record when reinforcing teaching about confidentiality. This statement emphasizes the importance of maintaining the privacy and confidentiality of the client's personal health information.
Explanation for the other options:
a. "Your nurse will provide information about the risks and benefits of surgical procedures." While it is important for the nurse to provide information about surgical procedures, this statement does not specifically address confidentiality.
c. "The provider must grant you access to your personal health information." This statement is related to the client's rights regarding access to their personal health information. While it is important to educate clients about their rights, it is not specifically focused on confidentiality.
d. "You have to authorize our providers to prescribe treatments for your condition." This statement is related to obtaining the client's consent for treatment, which is important but not directly addressing confidentiality.
A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric
decompression. Which of the following supplies should the nurse obtain prior to the procedure?
A. Oil-based lubricant
A) Oil-based lubricant: Using oil-based lubricants for nasogastric tube insertion is inappropriate as they can increase the risk of respiratory complications if aspirated. Water-soluble lubricants are preferred because they reduce friction and dissolve easily, minimizing the risk of respiratory aspiration and facilitating a smoother insertion.
B. Enteric feeding pump
B) Enteric feeding pump: An enteric feeding pump is used for administering enteral nutrition, not for gastric decompression. Gastric decompression involves removing gastric contents to relieve pressure, often using a syringe or gravity drainage, making a feeding pump unnecessary for this procedure.
C. Sterile gloves
C) Sterile gloves: Sterile gloves are not required for inserting a nasogastric tube, as this is a clean, not sterile, procedure. Clean gloves are sufficient to maintain infection control standards, ensuring protection against pathogens while allowing for safe tube insertion.
D. pH strips
D) pH strips: pH strips are crucial for verifying the correct placement of a nasogastric tube by checking the acidity of aspirated stomach contents. Ensuring the tube is in the stomach and not the lungs is vital for patient safety, and pH strips provide a reliable method to confirm gastric placement.
Full Explanation
a. Oil-based lubricant
Explanation:
The correct answer is a. Oil-based lubricant.
When preparing to insert a nasogastric tube for gastric decompression, the nurse should obtain an oil- based lubricant. Lubricating the nasogastric tube before insertion helps facilitate smooth passage through the nasal passages and into the stomach, reducing discomfort and potential trauma to the client.
Option b, an enteric feeding pump, is not necessary for the insertion of a nasogastric tube for gastric decompression. An enteric feeding pump is used for administering enteral feedings, which is a different procedure and indication
Option c, sterile gloves, may be needed depending on the facility's policy and the specific circumstances of the client. While maintaining aseptic technique is important during the procedure, sterile gloves may not always be required for nasogastric tube insertion. Clean gloves or a clean hand hygiene practice may be sufficient in some cases.
Option d, pH strips, are not typically needed for nasogastric tube insertion for gastric decompression. pH strips are more commonly used to check the acidity or alkalinity of body fluids, such as gastric aspirate, to confirm placement of the nasogastric tube in the stomach.
By obtaining an oil-based lubricant, the nurse ensures the appropriate preparation for the nasogastric tube insertion, promoting the client's comfort and safety during the procedure.