Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data on a client who received an opioid narcotic for incisional pain.
Which of the following findings is the priority?
A. Pulse oximetry.
Pulse oximetry. Pulse oximetry is the top priority in this situation. Opioid narcotics can cause respiratory depression, which can lead to decreased oxygen saturation in the blood. Monitoring oxygen saturation through pulse oximetry allows the nurse to quickly assess the client's respiratory status and intervene if oxygen levels drop below an acceptable range. Ensuring adequate oxygenation is crucial for the client's safety, making choice A the correct answer.
B. Blood pressure.
Blood pressure. Monitoring blood pressure is important when assessing a client's overall condition and response to medications. However, in the context of a client who received an opioid narcotic for incisional pain, monitoring blood pressure is not the top priority. Opioid narcotics primarily affect respiratory and central nervous system function, making respiratory and sedation assessment more critical in this scenario.
C. Level of sedation.
Level of sedation. Assessing the level of sedation is important when a client has received an opioid narcotic, as opioids can cause respiratory depression and sedation. However, in this case, the client received the opioid for incisional pain, and the priority is to ensure adequate oxygenation and respiratory function. Therefore, assessing sedation level, while important, is not the top priority.
D. Pain level.
Pain level. Assessing the client's pain level is important, but it is not the top priority in this scenario. The client received an opioid narcotic for incisional pain, and the primary concern now is to monitor for potential side effects of the medication, such as respiratory depression. Pain assessment should still be done, but it is not the priority.
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 collecting data on a client following administration of an opioid narcotic.
Which of the following findings indicates a decrease in the client's pain?
A. The client is asleep.
The client is asleep. The correct choice is A because the client being asleep can be a significant indicator of pain relief. It suggests that the client is comfortable enough to rest and may not be experiencing severe pain. Opioid narcotics often cause sedation as a side effect, and this sedation can contribute to the client falling asleep. While it is not the only indicator of pain relief, it is a valuable sign to consider in assessing the effectiveness of pain management.
B. The client has an elevated blood pressure.
The client has an elevated blood pressure. An elevated blood pressure may be a response to pain or other stressors. While monitoring blood pressure is important, it is not the primary indicator of pain relief in this context. Opioid narcotics can cause changes in blood pressure, and pain relief can sometimes lead to a decrease in blood pressure. Therefore, an elevated blood pressure alone does not necessarily indicate a decrease in pain.
C. The client has an increased respiratory rate.
The client has an increased respiratory rate. An increased respiratory rate may be a response to pain or distress. However, it is not a reliable indicator of pain relief when a client has received an opioid narcotic. Opioids can depress the respiratory rate, and an increased respiratory rate may persist even after pain relief is achieved. Therefore, an increased respiratory rate alone does not necessarily indicate a decrease in pain.
D. The client is diaphoretic.
The client is diaphoretic. Diaphoresis (excessive sweating) can occur for various reasons, including pain, fever, anxiety, or side effects of medications. While it is essential to assess for signs of discomfort or distress, diaphoresis alone is not a specific indicator of pain relief. It is possible for a client to be diaphoretic even when pain relief has been achieved.
A nurse is calculating the protein needs of a client who is a physical trainer.
The client weighs 220 lb and requires an increase of protein by 2.0 g/kg/day.
The client has taken 0.8 g of protein/kg/day in the past.
How much total protein/day should the nurse recommend?
A. 80 g of protein/day.
This choice suggests that the client needs 80 g of protein/day. However, this is not correct because the client’s weight is 220 lb (which is approximately 100 kg), and they require an increase of protein by 2.0 g/kg/day. This means they need an additional 200 g of protein per day. Adding this to their past intake of 0.8 g/kg/day (which is 80 g/day), the total comes to 280 g/day.
B. 120 g of protein/day.
This choice suggests that the client needs 120 g of protein/day. The client’s total protein requirement per day is more than this.
C. 280 g of protein/day.
Given: - The client's weight is 220 lb. - The client requires an increase of protein by 2.0 g/kg/day. - The client has taken 0.8 g of protein/kg/day in the past. We know that 1 kg = 2.2 lbs. So, we first need to convert the client's weight from lbs to kg. Step 1: Convert the client's weight from lbs to kg 220 lb ÷ 2.2 lb/kg = 100 kg Next, we calculate the increased protein requirement. Step 2: Calculate the increased protein requirement 100 kg × 2.0 g/kg/day = 200 g/day Then, we calculate the past protein intake in g/day. Step 3: Calculate the past protein intake 100 kg × 0.8 g/kg/day = 80 g/day Finally, we add the past protein intake to the increased protein requirement to get the total protein/day the nurse should recommend. Step 4: Calculate the total protein/day 200 g/day + 80 g/day = 280 g/day
D. 400 g of protein/day.
This choice suggests that the client needs 400 g of protein/day. However, this is not correct because it exceeds the client’s total protein requirement per day, which is 280 g/day.
Full Explanation
The correct answer is © 280 g of protein/day.
Choice A reason: This choice suggests that the client needs 80 g of protein/day. However, this is not correct because the client’s weight is 220 lb (which is approximately 100 kg), and they require an increase of protein by 2.0 g/kg/day. This means they need an additional 200 g of protein per day. Adding this to their past intake of 0.8 g/kg/day (which is 80 g/day), the total comes to 280 g/day.
Choice B reason: This choice suggests that the client needs 120 g of protein/day. The client’s total protein requirement per day is more than this.
Choice C reason:
Given:
- The client's weight is 220 lb.
- The client requires an increase of protein by 2.0 g/kg/day.
- The client has taken 0.8 g of protein/kg/day in the past.
We know that 1 kg = 2.2 lbs. So, we first need to convert the client's weight from lbs to kg.
Step 1: Convert the client's weight from lbs to kg
220 lb ÷ 2.2 lb/kg = 100 kg
Next, we calculate the increased protein requirement.
Step 2: Calculate the increased protein requirement
100 kg × 2.0 g/kg/day = 200 g/day
Then, we calculate the past protein intake in g/day.
Step 3: Calculate the past protein intake
100 kg × 0.8 g/kg/day = 80 g/day
Finally, we add the past protein intake to the increased protein requirement to get the total protein/day the nurse should recommend.
Step 4: Calculate the total protein/day
200 g/day + 80 g/day = 280 g/day
Choice D reason: This choice suggests that the client needs 400 g of protein/day. However, this is not correct because it exceeds the client’s total protein requirement per day, which is 280 g/day.
A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis.
Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown?
A. Implement a turning schedule every 4 hr.
Implement a turning schedule every 4 hr. Rationale: Turning schedules are essential for preventing skin breakdown in clients with limited mobility, such as those with spinal cord injuries. However, the recommended turning interval is generally every 2 hours, not every 4 hours. Prolonged pressure on the skin can lead to tissue damage and pressure ulcers. Therefore, choice A is not the best option for decreasing the client's risk of skin breakdown.
B. Minimize skin exposure to moisture.
Minimize skin exposure to moisture. Rationale: Moisture can increase the risk of skin breakdown, especially in areas with skin-to-skin contact or incontinence. Keeping the skin dry is crucial in preventing pressure ulcers. Moisture can soften the skin, making it more susceptible to damage. Therefore, choice B is a vital action to include in the plan of care to decrease the client's risk of skin breakdown.
C. Massage erythematous bony prominences.
Massage erythematous bony prominences. Rationale: Massaging erythematous (red) bony prominences is contraindicated in clients at risk of pressure ulcers. This can further damage the already compromised skin and underlying tissue. It is important to avoid friction and pressure on these areas. Therefore, choice C is not appropriate for preventing skin breakdown.
D. Keep environmental humidity less than 30%.
Keep environmental humidity less than 30%. Rationale: Environmental humidity levels do not significantly impact the risk of skin breakdown in clients with spinal cord injuries. Maintaining appropriate humidity levels is important for general comfort and respiratory health, but it does not directly address the prevention of pressure ulcers. Therefore, choice D is not the best action for this purpose.
E. Use pillows to keep heels off the bed surface.
Use pillows to keep heels off the bed surface. Rationale: Elevating the heels with pillows is an effective preventive measure to reduce pressure on the heels, which are common sites for pressure ulcers in immobile clients. This action helps to distribute pressure more evenly and reduces the risk of skin breakdown. Therefore, choice E is a suitable action to include in the plan of care to decrease the client's risk of skin breakdown.