Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is gathering information on a patient who has pleural effusion.
What symptoms should the nurse anticipate?
A. Crackles heard over the patient’s lung fields.
Crackles are a common symptom of pleural effusion. They are abnormal lung sounds that are heard when a patient with pleural effusion breathes in. The sound is caused by the opening of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration.
B. Crepitus felt on the patient’s chest.
Crepitus is not typically associated with pleural effusion. Crepitus is a crackling or grating sound or feeling produced by air in subcutaneous tissue or by the rubbing together of fragments of broken bone. In the context of respiratory health, crepitus might be felt if there is subcutaneous emphysema, where air gets into tissues under the skin covering the chest wall or neck.
C. Substernal retractions observed on the patient’s chest.
Substernal retractions are not a typical symptom of pleural effusion. Retractions are a sign of respiratory distress, but they are more commonly associated with conditions that cause upper airway obstruction or severe lung disease, such as asthma or pneumonia. Choice D rationale: Dullness upon percussion is a classic sign of pleural effusion. When there is fluid in the pleural space, it prevents the normal resonant sound produced by the air-filled lungs from being heard. Instead, a dull sound is heard when the chest is percussed.
D. Dullness heard when percussing the patient’s lung fields.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Fundamental of nursing proctored exam 2 Custom NS_117_T Winter 2023 Monroe. Take the full exam now
Full Explanation
Choice A rationale:
Crackles are a common symptom of pleural effusion. They are abnormal lung sounds that are heard when a patient with pleural effusion breathes in. The sound is caused by the opening of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration.
Choice B rationale:
Crepitus is not typically associated with pleural effusion. Crepitus is a crackling or grating sound or feeling produced by air in subcutaneous tissue or by the rubbing together of fragments of broken bone. In the context of respiratory health, crepitus might be felt if there is subcutaneous emphysema, where air gets into tissues under the skin covering the chest wall or neck.
Choice C rationale:
Substernal retractions are not a typical symptom of pleural effusion. Retractions are a sign of respiratory distress, but they are more commonly associated with conditions that cause upper airway obstruction or severe lung disease, such as asthma or pneumonia. Choice D rationale:
Dullness upon percussion is a classic sign of pleural effusion. When there is fluid in the pleural space, it prevents the normal resonant sound produced by the air-filled lungs from being heard. Instead, a dull sound is heard when the chest is percussed.
Similar Questions
A nurse is reinforcing discharge instructions with the parents of an infant who has been prescribed home oxygen and pulse oximetry monitoring.
Which statement by the parents suggests that further instruction is needed?
A. “The pulse oximeter may not be accurate during periods of excessive movement.”
The statement “The pulse oximeter may not be accurate during periods of excessive movement” is correct. Pulse oximeters measure the amount of oxygen in the blood by shining light through the skin, and movement can cause the light to scatter, leading to inaccurate readings.
B. “We will inform the doctor if the pulse oximeter consistently reads 100%.”
The statement “We will inform the doctor if the pulse oximeter consistently reads 100%” indicates further instruction is needed. A pulse oximeter reading of 100% is not necessarily a cause for concern. It simply means that the hemoglobin is fully saturated with oxygen. However, if the oxygen level is consistently at 100%, it could indicate that the oxygen flow is too high and needs to be adjusted. It’s important to follow the healthcare provider’s instructions regarding the desired oxygen saturation level for the infant.
C. “The probe of the pulse oximeter can be attached to a finger or a toe.”
The statement “The probe of the pulse oximeter can be attached to a finger or a toe” is correct. The probe of a pulse oximeter can indeed be attached to a finger, toe, or even an earlobe. The important thing is that it’s attached to a part of the body with good blood flow. Choice D rationale: The statement “We will move the probe of the pulse oximeter every 24 hours” is correct. It’s important to move the probe periodically to prevent skin damage, such as pressure sores or burns, especially in infants who have delicate skin.
D. “We will move the probe of the pulse oximeter every 24 hours.”
Full Explanation
Choice A rationale:
The statement “The pulse oximeter may not be accurate during periods of excessive movement” is correct. Pulse oximeters measure the amount of oxygen in the blood by shining light through the skin, and movement can cause the light to scatter, leading to inaccurate readings.
Choice B rationale:
The statement “We will inform the doctor if the pulse oximeter consistently reads 100%” indicates further instruction is needed. A pulse oximeter reading of 100% is not necessarily a cause for concern. It simply means that the hemoglobin is fully saturated with oxygen. However, if the oxygen level is consistently at 100%, it could indicate that the oxygen flow is too high and needs to be adjusted. It’s important to follow the healthcare provider’s instructions regarding the desired oxygen saturation level for the infant.
Choice C rationale:
The statement “The probe of the pulse oximeter can be attached to a finger or a toe” is correct. The probe of a pulse oximeter can indeed be attached to a finger, toe, or even an earlobe. The important thing is that it’s attached to a part of the body with good blood flow. Choice D rationale:
The statement “We will move the probe of the pulse oximeter every 24 hours” is correct. It’s important to move the probe periodically to prevent skin damage, such as pressure sores or burns, especially in infants who have delicate skin.
A nurse is caring for a patient with diabetic ketoacidosis and hypoxia.
What is the first action the nurse should take?
A. Obtain a prescription to administer insulin.
Administering insulin is a crucial step in managing diabetic ketoacidosis (DKA), as insulin deficiency is a primary cause of DKA12. However, it is not the first action to take when a patient presents with both DKA and hypoxia. While insulin helps to reduce blood glucose levels and suppress the production of ketones, it does not address the immediate life-threatening condition of hypoxia.
B. Obtain a prescription for supplemental oxygen.
Hypoxia, or low levels of oxygen in the body, is a medical emergency that requires immediate attention. Supplemental oxygen can help increase the oxygen levels in the patient’s blood, thereby alleviating hypoxia. In the context of a patient with DKA and hypoxia, providing supplemental oxygen would be the first action to take to stabilize the patient’s condition before addressing the DKA12.
C. Obtain a prescription to check the patient’s glucose level.
Checking the patient’s glucose level is an important part of managing DKA, as hyperglycemia is a key feature of this condition. However, it is not the first action to take in this scenario. While monitoring glucose levels can guide the administration of insulin and other treatments for DKA, it does not address the immediate threat posed by hypoxia.
D. Obtain a prescription to administer intravenous fluids.
Administering intravenous fluids is another important step in managing DKA12. Dehydration is a common complication of DKA due to excessive urination caused by high blood sugar levels. However, similar to Choices A and C, while it is an important part of treatment, it is not the first action to take when a patient presents with both DKA and hypoxia.
Full Explanation
Choice A rationale:
Administering insulin is a crucial step in managing diabetic ketoacidosis (DKA), as insulin deficiency is a primary cause of DKA12. However, it is not the first action to take when a patient presents with both DKA and hypoxia. While insulin helps to reduce blood glucose levels and suppress the production of ketones, it does not address the immediate life-threatening condition of hypoxia.
Choice B rationale:
Hypoxia, or low levels of oxygen in the body, is a medical emergency that requires immediate attention. Supplemental oxygen can help increase the oxygen levels in the patient’s blood, thereby alleviating hypoxia. In the context of a patient with DKA and hypoxia, providing supplemental oxygen would be the first action to take to stabilize the patient’s condition before addressing the DKA12.
Choice C rationale:
Checking the patient’s glucose level is an important part of managing DKA, as hyperglycemia is a key feature of this condition. However, it is not the first action to take in this scenario. While monitoring glucose levels can guide the administration of insulin and other treatments for DKA, it does not address the immediate threat posed by hypoxia.
Choice D rationale:
Administering intravenous fluids is another important step in managing DKA12. Dehydration is a common complication of DKA due to excessive urination caused by high blood sugar levels. However, similar to Choices A and C, while it is an important part of treatment, it is not the first action to take when a patient presents with both DKA and hypoxia.
A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female patient.
Which action by the nurse should prompt the charge nurse to intervene?
A. The nurse applies the sterile drape after cleaning the perineal area.
The nurse applies the sterile drape after cleaning the perineal area. This is correct because the perineal area should be cleaned before applying the sterile drape. Applying the drape first could potentially introduce bacteria to the catheter during insertion, increasing the risk of a urinary tract infection.
B. The nurse lubricates the indwelling urinary catheter.
The nurse lubricates the indwelling urinary catheter. This is a correct procedure as it helps to minimize discomfort and trauma during catheter insertion.
C. The nurse separates the patient’s labia with her dominant hand.
The nurse separates the patient’s labia with her dominant hand. This is also a correct procedure. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and then use her dominant hand to insert the catheter.
D. The nurse provides perineal care prior to inserting the urinary catheter.
The nurse provides perineal care prior to inserting the urinary catheter. This is a correct procedure. Providing perineal care before inserting a urinary catheter is important to reduce the risk of introducing bacteria into the urinary tract. It’s part of maintaining strict aseptic technique during insertion.
Full Explanation
The correct answer is choice C.
Choice A rationale:
The nurse applies the sterile drape after cleaning the perineal area. This is correct because the perineal area should be cleaned before applying the sterile drape. Applying the drape first could potentially introduce bacteria to the catheter during insertion, increasing the risk of a urinary tract infection.
Choice B rationale:
The nurse lubricates the indwelling urinary catheter. This is a correct procedure as it helps to minimize discomfort and trauma during catheter insertion.
Choice C rationale:
The nurse separates the patient’s labia with her dominant hand. This is also a correct procedure. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and then use her dominant hand to insert the catheter.
Choice D rationale:
The nurse provides perineal care prior to inserting the urinary catheter. This is a correct procedure. Providing perineal care before inserting a urinary catheter is important to reduce the risk of introducing bacteria into the urinary tract. It’s part of maintaining strict aseptic technique during insertion.