Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is explaining to a client who is preparing for emergency surgery due to a small bowel obstruction.
The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage.
Which of the following statements is the best response from the nurse?
A. “This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine.”.
This statement accurately explains what adhesions are. Adhesions are areas of scar tissue that form between organs or tissues in the abdomen. They often form after surgery and can cause some of these loops to stick together, resulting in abdominal pain and occasionally obstruction (blockages) in the gut. In the context of a small bowel obstruction, adhesions can cause the intestines to twist or kink, similar to how a garden hose can become kinked.
B. “The most important thing is that now you are here, and it is going to get taken care of.”.
While this statement may be intended to reassure the client, it does not provide the client with the information they are seeking about what adhesions are and how they are causing the blockage.
C. “I will be happy to go and get you some reading materials about this procedure to explain it further.”.
Offering to provide reading materials about the procedure does not directly answer the client’s question about what adhesions are. It may also be overwhelming for the client who is already anxious and preparing for emergency surgery.
D. “It’s okay. It happens all the time and I’ve seen a lot of clients with this issue.”.
This statement minimizes the client’s concerns and does not provide the necessary information about what adhesions are and how they are causing the blockage.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Lpn Med Surg Proctored Exam 1. Take the full exam now
Full Explanation
Choice A rationale
This statement accurately explains what adhesions are. Adhesions are areas of scar tissue that form between organs or tissues in the abdomen. They often form after surgery and can cause some of these loops to stick together, resulting in abdominal pain and occasionally obstruction (blockages) in the gut. In the context of a small bowel obstruction, adhesions can cause the intestines to twist or kink, similar to how a garden hose can become kinked.
Choice B rationale
While this statement may be intended to reassure the client, it does not provide the client with the information they are seeking about what adhesions are and how they are causing the blockage.
Choice C rationale
Offering to provide reading materials about the procedure does not directly answer the client’s question about what adhesions are. It may also be overwhelming for the client who is already anxious and preparing for emergency surgery.
Choice D rationale
This statement minimizes the client’s concerns and does not provide the necessary information about what adhesions are and how they are causing the blockage.
Similar Questions
A patient with a colostomy says, “My pouch blows up like a balloon when I pass gas.”. What is an appropriate response by the nurse?
A. “Empty the gas like you would if the pouch was full of stool.”.
While emptying the gas from the pouch like you would if the pouch was full of stool might seem like a logical solution, it is not the most appropriate response. This could potentially lead to messiness and odor, which could cause embarrassment and discomfort for the patient.
B. “Peel back a tiny corner of the skin barrier to allow gas to escape.”.
Peeling back a tiny corner of the skin barrier to allow gas to escape is the most appropriate response. This allows the gas to be released in a controlled manner, reducing the risk of the pouch becoming too full and uncomfortable for the patient. It also minimizes the risk of odor and messiness.
C. “Make a tiny pinhole in the top of the pouch to let air out.”.
Making a tiny pinhole in the top of the pouch to let air out is not recommended. This could potentially lead to leakage of stool, causing messiness and odor. It could also damage the pouch, requiring it to be replaced more frequently.
D. “Remove the pouch and put on a new one when it gets too full of gas.”. .
Removing the pouch and putting on a new one when it gets too full of gas is not the most appropriate response. This could be inconvenient for the patient and could potentially lead to skin irritation from frequent changes. It also does not address the issue of the pouch filling with gas.
Full Explanation
Choice A rationale
While emptying the gas from the pouch like you would if the pouch was full of stool might seem like a logical solution, it is not the most appropriate response. This could potentially lead to messiness and odor, which could cause embarrassment and discomfort for the patient.
Choice B rationale
Peeling back a tiny corner of the skin barrier to allow gas to escape is the most appropriate response. This allows the gas to be released in a controlled manner, reducing the risk of the pouch becoming too full and uncomfortable for the patient. It also minimizes the risk of odor and messiness.
Choice C rationale
Making a tiny pinhole in the top of the pouch to let air out is not recommended. This could potentially lead to leakage of stool, causing messiness and odor. It could also damage the pouch, requiring it to be replaced more frequently.
Choice D rationale
Removing the pouch and putting on a new one when it gets too full of gas is not the most appropriate response. This could be inconvenient for the patient and could potentially lead to skin irritation from frequent changes. It also does not address the issue of the pouch filling with gas.
A nurse is contributing to the plan of care for a client who has urolithiasis.
Which of the following interventions should the nurse include in the plan?
A. Maintain the client on bed rest.
Maintaining the client on bed rest is not a recommended intervention for a client with urolithiasis. Bed rest does not facilitate the passage of stones and can lead to complications such as deep vein thrombosis.
B. Encourage the client to drink 3 L of fluids per day.
Encouraging the client to drink 3 L of fluids per day is the correct intervention. Increased fluid intake can help flush out the urinary system and facilitate the passage of stones. It also helps prevent new stone formation by diluting the substances that lead to stones.
C. Provide the client a high protein diet.
Providing the client a high protein diet is not a recommended intervention for a client with urolithiasis. High protein diets can increase the amount of calcium and uric acid in urine, which can contribute to stone formation.
D. Tell the client to expect a decrease in urine output.
Telling the client to expect a decrease in urine output is not a recommended intervention for a client with urolithiasis. Decreased urine output can lead to urinary stasis and contribute to stone formation.
Full Explanation
Choice A rationale
Maintaining the client on bed rest is not a recommended intervention for a client with urolithiasis. Bed rest does not facilitate the passage of stones and can lead to complications such as deep vein thrombosis.
Choice B rationale
Encouraging the client to drink 3 L of fluids per day is the correct intervention. Increased fluid intake can help flush out the urinary system and facilitate the passage of stones. It also helps prevent new stone formation by diluting the substances that lead to stones.
Choice C rationale
Providing the client a high protein diet is not a recommended intervention for a client with urolithiasis. High protein diets can increase the amount of calcium and uric acid in urine, which can contribute to stone formation.
Choice D rationale
Telling the client to expect a decrease in urine output is not a recommended intervention for a client with urolithiasis. Decreased urine output can lead to urinary stasis and contribute to stone formation.
A nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion.
Which of the following interventions should the nurse include in the plan?
A. Assist the client to sit upright in a chair for 4 hr at a time.
Assisting the client to sit upright in a chair for 4 hr at a time is not recommended postoperatively following spinal fusion. This could put undue stress on the surgical site and potentially lead to complications.
B. Expect clear drainage on the spinal dressing.
Expecting clear drainage on the spinal dressing is not accurate. Any drainage from the surgical site should be closely monitored for signs of infection, but clear drainage is not typically expected.
C. Elevate the client’s legs when he is lying on his side.
Elevating the client’s legs when he is lying on his side is not a specific intervention related to postoperative care following spinal fusion.
D. Log roll the client every 2 hr.
Log rolling the client every 2 hr is the correct intervention. This technique is used to maintain proper alignment and prevent undue stress on the surgical site.
Full Explanation
Choice A rationale
Assisting the client to sit upright in a chair for 4 hr at a time is not recommended postoperatively following spinal fusion. This could put undue stress on the surgical site and potentially lead to complications.
Choice B rationale
Expecting clear drainage on the spinal dressing is not accurate. Any drainage from the surgical site should be closely monitored for signs of infection, but clear drainage is not typically expected.
Choice C rationale
Elevating the client’s legs when he is lying on his side is not a specific intervention related to postoperative care following spinal fusion.
Choice D rationale
Log rolling the client every 2 hr is the correct intervention. This technique is used to maintain proper alignment and prevent undue stress on the surgical site.