Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus.
Which of the following actions should the nurse plan to take first?
A. Give the client access to a video about diabetes.
Giving the client access to a video about diabetes is a good teaching tool, but it should come after assessing the client’s knowledge.
B. Determine what the client knows about managing diabetes.
The first step in patient education is to assess the client’s learning needs. This includes determining what the client already knows about managing diabetes.
C. Establish short-term, realistic goals for the client.
Establishing short-term, realistic goals for the client is important, but it should be done after assessing the client’s knowledge.
D. Evaluate the effectiveness of the client's admission teaching plan.
Evaluating the effectiveness of the client’s admission teaching plan is a later step, after assessing the client’s knowledge and teaching them about their condition.
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Full Explanation
Choice A rationale:
Giving the client access to a video about diabetes is a good teaching tool, but it should come after assessing the client’s knowledge.
Choice B rationale:
The first step in patient education is to assess the client’s learning needs. This includes determining what the client already knows about managing diabetes.
Choice C rationale:
Establishing short-term, realistic goals for the client is important, but it should be done after assessing the client’s knowledge.
Choice D rationale:
Evaluating the effectiveness of the client’s admission teaching plan is a later step, after assessing the client’s knowledge and teaching them about their condition.
Similar Questions
A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
A. Turn the client's head to the side.
Turning the client’s head to the side is important to prevent aspiration, but it should be done after documenting the time the seizure began.
B. Document the time the seizure began.
The first action when a client begins having a tonic-clonic seizure is to document the time the seizure began. This helps in determining the duration of the seizure, which is critical information for the healthcare team.
C. Loosen the clothing around the client's waist.
Loosening the clothing around the client’s waist is important for the client’s comfort and safety during a seizure, but it should be done after documenting the time the seizure began.
D. Check the client's motor strength.
Checking the client’s motor strength is not the first action to take when a client begins having a tonic-clonic seizure.
Full Explanation
Choice A rationale:
Turning the client’s head to the side is important to prevent aspiration, but it should be done after documenting the time the seizure began.
Choice B rationale:
The first action when a client begins having a tonic-clonic seizure is to document the time the seizure began. This helps in determining the duration of the seizure, which is critical information for the healthcare team.
Choice C rationale:
Loosening the clothing around the client’s waist is important for the client’s comfort and safety during a seizure, but it should be done after documenting the time the seizure began.
Choice D rationale:
Checking the client’s motor strength is not the first action to take when a client begins having a tonic-clonic seizure.
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns on the head, neck, and chest.
While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention.
A. Paralytic ileus.
Paralytic ileus can occur due to stress response but it’s not the immediate life-threatening issue.
B. Airway obstruction.
Airway obstruction is the immediate life-threatening issue due to swelling from burns in the head, neck, and chest area.
C. Infection.
Infection is a risk with burns but it’s not the immediate concern.
D. Fluid imbalance.
Fluid imbalance is a concern due to loss from damaged skin but airway patency is the priority.
Full Explanation
Choice A rationale:
Paralytic ileus can occur due to stress response but it’s not the immediate life-threatening issue.
Choice B rationale:
Airway obstruction is the immediate life-threatening issue due to swelling from burns in the head, neck, and chest area.
Choice C rationale:
Infection is a risk with burns but it’s not the immediate concern.
Choice D rationale:
Fluid imbalance is a concern due to loss from damaged skin but airway patency is the priority.
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
Lifting heavy objects can increase intraocular pressure, which should be avoided after cataract surgery.
B. Notify the surgeon if white drainage develops on the eyelids.
Any drainage should be reported, not just white.
C. Sleep on the abdomen to facilitate wound healing.
Sleeping position won’t necessarily affect wound healing in this case.
D. Bend at the waist to pick objects up from the floor.
Bending at the waist can increase intraocular pressure, which should be avoided.
Full Explanation
Choice A rationale:
Lifting heavy objects can increase intraocular pressure, which should be avoided after cataract surgery.
Choice B rationale:
Any drainage should be reported, not just white.
Choice C rationale:
Sleeping position won’t necessarily affect wound healing in this case.
Choice D rationale:
Bending at the waist can increase intraocular pressure, which should be avoided.