Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?
A. Rotate nursing staff so he can have varied interactions.
B. Keep family members aware of his condition.
C. Talk with the client during wound care.
This is because talking with the client can help reduce anxiety, pain, and isolation, as well as build trust and rapport between the nurse and the client. Talking with the client can also provide an opportunity for education, feedback, and encouragement.
D. Assign assistive personnel to keep his room neat and clean.
This question is an excerpt from Nurse Dive's nursing test bank - ATI SP 250 Exam 3 Med Surg Proctored Exam. Take the full exam now
Full Explanation
This is because talking with the client can help reduce anxiety, pain, and isolation, as well as build trust and rapport between the nurse and the client. Talking with the client can also provide an opportunity for education, feedback, and encouragement.
Similar Questions
A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following?
A. 800 mL
B. 480 mL
This is because the recommended tidal volume for mechanical ventilation is 6 to 8 mL/kg of ideal body weight. Therefore, for a client who has an ideal weight of 60 kg, the tidal volume should be between 360 and 480 mL. A tidal volume that is too high or too low can cause lung injury or hypoventilation.
C. 950 mL
D. 300 mL
Full Explanation
This is because the recommended tidal volume for mechanical ventilation is 6 to 8 mL/kg of ideal body weight. Therefore, for a client who has an ideal weight of 60 kg, the tidal volume should be between 360 and 480 mL. A tidal volume that is too high or too low can cause lung injury or hypoventilation.
A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)
A. Administer pantoprazole as prescribed.
Stress ulcer prophylaxis (e.g., a PPI) is indicated for critically ill, ventilated patients to prevent GI bleeding from stress-related mucosal damage.
B. Reposition the endotracheal tube to the opposite side of the mouth daily.
Rotating the tube and tape from side to side prevents pressure necrosis of the lips and oral mucosa.
C. Verify the prescribed ventilator settings daily.
Verifying vent settings only once a day isn’t adequate-settings must be checked each shift or whenever the patient’s status changes.
D. Elevate the head of the bed to at least 30°.
Semi-Fowler’s positioning (≥30°) reduces aspiration risk and helps prevent ventilator-associated pneumonia.
E. Apply restraints if the client becomes agitated.
Physical restraints are a last-resort to prevent self-extubation after all less-restrictive measures (sedation, reorientation, sitter) have failed-not a routine “complication-prevention” bundle item.
Full Explanation
Correct answers: A, B ,D
A. Stress ulcer prophylaxis (e.g., a PPI) is indicated for critically ill, ventilated patients to prevent GI bleeding from stress-related mucosal damage.
B. Rotating the tube and tape from side to side prevents pressure necrosis of the lips and oral mucosa.
D. Semi-Fowler’s positioning (≥30°) reduces aspiration risk and helps prevent ventilator-associated pneumonia.
A nurse is teaching a client who has hepatitis A about preventing transmission of the disease. Which is included in the teaching?
A. Practice effective hand hygiene.
B. Avoid serving raw foods.
C. Avoid eating at fast food restaurants
D. Wear barrier protection during vaginal intercourse.
Full Explanation
Hepatitis A is an acute viral infection that affects the liver and is transmitted by fecal-oral route. It can be spread by contaminated food or water, or by close contact with an infected person. Practicing effective hand hygiene can reduce the risk of ingesting or spreading the virus. Avoiding serving raw foods, especially shellfish, can prevent exposure to contaminated food sources.