Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Heart rate 90/min
Heart rate 90/min: A heart rate of 90/min is within the normal range, and it is not an abnormal finding postoperatively.
B. Serum potassium 3.7 g/dL
Serum potassium 3.7 g/dL: The serum potassium level of 3.7 g/dL is within the normal range, and it is not an abnormal finding postoperatively.
C. Bowel sounds 10/min
Bowel sounds 10/min: Bowel sounds of 10/min are within the normal range and indicate return of bowel function postoperatively.
D. Urine output 48 m/2 hr
Urine output 48 m/2 hr: A urine output of 48 m/2 hr is less than the expected urine output (30 mL/hr), and it may indicate inadequate renal perfusion or function. This finding should bereported to the provider.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Medsurg Final Proctored Exam. Take the full exam now
Full Explanation
a. Heart rate 90/min: A heart rate of 90/min is within the normal range, and it is not an abnormal finding postoperatively.
b. Serum potassium 3.7 g/dL: The serum potassium level of 3.7 g/dL is within the normal range, and it is not an abnormal finding postoperatively.
c. Bowel sounds 10/min: Bowel sounds of 10/min are within the normal range and indicate return of bowel function postoperatively.
d. Urine output 48 m/2 hr: A urine output of 48 m/2 hr is less than the expected urine output (30 mL/hr), and it may indicate inadequate renal perfusion or function. This finding should be
reported to the provider.
Similar Questions
A nurse is assigned care of a client who has HIV. Which of the following infection control precautions should the nurse plan to use while caring for this client?
A. Droplet precautions
Droplet precautions: Droplet precautions are used for diseases that are transmitted byrespiratory droplets, such as influenza or pneumonia. HIV is not transmitted through respiratory droplets.
B. Airborne precautions
Airborne precautions: Airborne precautions are used for diseases that are transmitted through the airborne route, such as tuberculosis. HIV is not transmitted through the airborne route.
C. Standard precautions
Standard precautions: Standard precautions are used for the care of all patients, regardless of their diagnosis. These precautions include hand hygiene, use of personal protective equipment (PPE) as needed, and safe injection practices.
D. Contact precautions
Contact precautions: Contact precautions are used for diseases that are spread by direct or indirect contact, such as methicillin-resistant Staphylococcus aureus (MRSA). HIV is nottransmitted through contact with intact skin.
Full Explanation
a. Droplet precautions: Droplet precautions are used for diseases that are transmitted by
respiratory droplets, such as influenza or pneumonia. HIV is not transmitted through respiratory droplets.
b. Airborne precautions: Airborne precautions are used for diseases that are transmitted through the airborne route, such as tuberculosis. HIV is not transmitted through the airborne route.
c. Standard precautions: Standard precautions are used for the care of all patients, regardless of their diagnosis. These precautions include hand hygiene, use of personal protective equipment (PPE) as needed, and safe injection practices.
d. Contact precautions: Contact precautions are used for diseases that are spread by direct or indirect contact, such as methicillin-resistant Staphylococcus aureus (MRSA). HIV is not
transmitted through contact with intact skin.
A nurse is preparing to collect a specimen from a client for a guaiac test. The client asks what the test will detect in his stool. Which of the following responses should the nurse make?
A. Bile
Bile: The guaiac test is not used to detect bile in the stool.
B. Lipids
Lipids: The guaiac test is not used to detect lipids in the stool.
C. Blood
Blood: The guaiac test, also known as the fecal occult blood test (FOBT), is used to detect hidden (occult) blood in the stool. It is commonly used as a screening test for colorectal cancer.
D. Bacteria
Bacteria: The guaiac test is not used to detect bacteria in the stool.
Full Explanation
a. Bile: The guaiac test is not used to detect bile in the stool.
b. Lipids: The guaiac test is not used to detect lipids in the stool.
c. Blood: The guaiac test, also known as the fecal occult blood test (FOBT), is used to detect hidden (occult) blood in the stool. It is commonly used as a screening test for colorectal cancer.
d. Bacteria: The guaiac test is not used to detect bacteria in the stool.
charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene?
A. "Use the provided towelette to cleanse the area by moving in a back-and-forth motion."
"Use the provided towelette to cleanse the area by moving in a back-and-forth motion." - This is a correct instruction for cleaning the genital area before collecting a midstream urinespecimen.
B. "It will be easier to use your nondominant hand to spread the labia."
"It will be easier to use your nondominant hand to spread the labia." - This is a correct instruction to facilitate the collection of a midstream urine specimen.
C. "Start the flow of urine before passing the container under the stream to collect the specimen."
"Start the flow of urine before passing the container under the stream to collect the specimen."- This statement is incorrect. The container should be in place before the client begins to urinate to ensure an accurate midstream specimen.
D. "Remove the specimen container before stopping the stream of urine"
"Remove the specimen container before stopping the stream of urine." - This statement is incorrect. The container should be kept in place until the client has finished urinating to avoid contamination of the specimen.
Full Explanation
Choice A Rationale: The correct method for cleansing the area before collecting a midstream urine specimen is to wipe from front to back, not back-and-forth. This is to avoid contamination of the specimen with bacteria from the anal area. The towelette should be used in a single stroke and then discarded to ensure cleanliness.
Choice B Rationale: Using the nondominant hand to spread the labia is a standard practice that allows the dominant hand to manipulate the collection container. This technique helps to prevent contamination of the specimen by keeping the container away from the body and ensuring a clean catch.
Choice C Rationale: It is important to start the flow of urine before collecting the specimen to ensure that the 'midstream' urine is captured. This helps to flush out any bacteria that may be present at the opening of the urethra, reducing the risk of contaminating the sample.
Choice D Rationale: The specimen container should be removed from the stream before stopping the flow of urine to avoid contamination. The initial and final parts of the urine stream can carry bacteria from the urethra and skin, so only the midstream should be collected in the container.