Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data on a client who has opioid toxicity.
Which of the following findings should the nurse expect?
A. Respiratory rate 10/min.
Opioid toxicity often leads to respiratory depression, which can result in a decreased respiratory rate. A respiratory rate of 10 breaths per minute is a significant finding indicative of respiratory depression, and it is associated with opioid toxicity.
B. Heart rate 112/min.
An elevated heart rate (tachycardia) is not a typical finding in opioid toxicity. Opioids tend to slow down the heart rate (bradycardia) rather than increase it.
C. Blood pressure 168/90 mm Hg.
An elevated blood pressure (hypertension) is not a typical finding in opioid toxicity. Opioids usually lead to hypotension, which is low blood pressure.
D. Temperature 38.2° C (100.8° F).
An elevated temperature of 38.2° C (100.8° F) is not a specific indicator of opioid toxicity. Opioid toxicity primarily affects the respiratory and central nervous systems, leading to symptoms such as respiratory depression, sedation, and miosis (constricted pupils).
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom T1 PM Summer 2023 Proctored Exam 5. Take the full exam now
Similar Questions
A nurse is assisting with teaching a client about how to instill eye drops.
The nurse asks the client to explain the procedure in their own words.
Which of the following types of teaching methods is the nurse using?.
A. Lecture.
Lecture is a teaching method in which the instructor delivers information to the learners without actively involving them. In this scenario, the nurse is asking the client to explain the procedure in their own words, which is a more interactive approach than a lecture.
B. Role play.
Role play involves simulated situations where the learner acts out specific roles. This method is not being used here, as the nurse is not asking the client to act out the procedure.
C. Teach-back.
Teach-back, also known as the "teach-back method" or "closing the loop," is a teaching method where the nurse asks the client to explain the information they've been provided in their own words. This approach helps assess the client's understanding and retention of the information and allows for clarification if needed. It is a patient-centered and effective method for ensuring that the client comprehends the instructions and can be considered as a form of active learning, enhancing retention and autonomy in healthcare decision-making.
Full Explanation
The correct answer is choice C.
Choice A rationale:
Lecture is a teaching method in which the instructor delivers information to the learners without actively involving them. In this scenario, the nurse is asking the client to explain the procedure in their own words, which is a more interactive approach than a lecture.
Choice B rationale:
Role play involves simulated situations where the learner acts out specific roles. This method is not being used here, as the nurse is not asking the client to act out the procedure.
Choice C rationale:
Teach-back, also known as the "teach-back method" or "closing the loop," is a teaching method where the nurse asks the client to explain the information they've been provided in their own words. This approach helps assess the client's understanding and retention of the information and allows for clarification if needed. It is a patient-centered and effective method for ensuring that the client comprehends the instructions and can be considered as a form of active learning, enhancing retention and autonomy in healthcare decision-making.
A nurse is caring for a client who had radiation therapy, prescribed by their Oncologist, and is experiencing painful dermatitis.
The nurse should identify the client is experiencing which of the following types of pain?
A. Chronic pain.
Chronic pain. Chronic pain is characterized by pain that persists over an extended period, often lasting for months or even years. It is usually associated with conditions like arthritis or fibromyalgia. However, in this scenario, the client's painful dermatitis is a result of radiation therapy, which is an acute event, not a chronic condition. Therefore, chronic pain is not the correct choice.
B. Neuropathic pain.
Neuropathic pain. Neuropathic pain is caused by damage or dysfunction of the nervous system and is often described as burning, shooting, or electrical in nature. It can result from various conditions, including radiation therapy, which can damage nerves and cause skin changes like painful dermatitis. In this case, the client's pain is likely neuropathic in nature due to the radiation therapy's effects on the skin and nerves. Therefore, choice B, neuropathic pain, is the correct answer.
C. Acute pain.
Acute pain. Acute pain is typically of sudden onset and is related to tissue damage or injury. While the client is experiencing pain, the description of "painful dermatitis" suggests that this pain is a result of the acute effects of radiation therapy. However, the question is looking for a specific type of pain, and "acute pain" does not provide enough information about the nature of the pain. Therefore, it is not the correct choice.
D. Cancer pain.
Cancer pain. Cancer pain is pain that is associated with cancer and its treatment. It can be acute or chronic, and it may result from various causes, such as tumor growth or treatment side effects. However, the client's pain is specifically described as "painful dermatitis," which is a type of skin inflammation commonly associated with radiation therapy. This type of pain is not unique to cancer, and the question is asking for a more specific type of pain. Therefore, cancer pain is not the correct choice.
A nurse is caring for a toddler who is scheduled to have a lumbar puncture.
Which of the following actions should the nurse take?
A. Restrain the toddler for 1 hr after the procedure.
Restrain the toddler for 1 hr after the procedure. Restraint of a toddler after a lumbar puncture is not a recommended practice. It can be distressing for the child and may not be necessary if appropriate positioning and comfort measures are employed. Restraint is not the correct choice in this situation.
B. Place the toddler in a side-lying, knee-chest position.
Place the toddler in a side-lying, knee-chest position. The correct choice is to place the toddler in a side-lying, knee-chest position for a lumbar puncture. This position allows for proper alignment of the spine and easy access to the lumbar area while minimizing discomfort and risk. It is a standard practice for performing lumbar punctures in pediatric patients, making choice B the correct answer.
C. Ask another nurse to assist with holding the toddler in a prone position.
Ask another nurse to assist with holding the toddler in a prone position. Placing a toddler in a prone position for a lumbar puncture is not the standard practice. It can be challenging to achieve the proper positioning and may not be comfortable or safe for the child. The prone position is not recommended for lumbar punctures, making choice C incorrect.
D. Swaddle the toddler in a warm blanket.
Swaddle the toddler in a warm blanket. Swaddling a toddler in a warm blanket may provide comfort in certain situations but is not the appropriate action for a lumbar puncture. The procedure requires specific positioning to access the lumbar area safely and accurately. Swaddling would not facilitate this positioning and would not be the correct choice.