Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse should identify that which of the following actions by the AP indicates an understanding of the procedure.
A. Elevates the client's legs before applying the stockings
The action by the AP that indicates an understanding of the procedure is elevating the client's legs before applying the stockings. Elevating the legs can help reduce swelling and make it easier to apply the stockings.
B. Instructs the client to dorsiflex their feet while applying the stockings
Instructing the client to dorsiflex their feet while applying the stockings may not be necessary.
C. Massages the client's legs before applying the stockings
Massaging the client's legs before applying the stockings may not be necessary or appropriate.
D. Folds the top of the stockings over after applying them
Folding the top of the stockings over after applying them may not be necessary or appropriate.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
The action by the AP that indicates an understanding of the procedure is elevating the client's legs before applying the stockings. Elevating the legs can help reduce swelling and make it easier to apply the stockings.
Option b is incorrect because instructing the client to dorsiflex their feet while applying the stockings may not be necessary.
Option c is incorrect because massaging the client's legs before applying the stockings may not be necessary or appropriate.
Option d is incorrect because folding the top of the stockings over after applying them may not be necessary or appropriate.
Similar Questions
A nurse is reinforcing teaching with the parents of a preschool-age child who has a new diagnosis of celiac disease.
Which of the following foods should the nurse recommend?
A. Wheat toast and jelly
Should be avoided as they contain wheat or barley.
B. Graham crackers with peanut buter
Should be avoided as they contain wheat or barley.
C. Beef barley soup
Should be avoided as they contain wheat or barley.
D. Corn tortillas with black beans
Is a suitable choice because corn is a gluten-free grain and black beans are also gluten-free. This option provides a balanced and nutritious meal for a child with celiac disease. It is important for individuals with celiac disease to carefully read food labels and choose gluten- free alternatives to ensure their diet is free of gluten-containing ingredients.
Full Explanation
d. Corn tortillas with black beans.
Explanation:
Celiac disease is an autoimmune disorder that requires strict adherence to a gluten-free diet. Gluten is a protein found in wheat, barley, and rye. Therefore, options a, b, and c should be avoided as they contain wheat or barley.
Option d, corn tortillas with black beans, is a suitable choice because corn is a gluten-free grain and black beans are also gluten-free. This option provides a balanced and nutritious meal for a child with celiac disease. It is important for individuals with celiac disease to carefully read food labels and choose gluten- free alternatives to ensure their diet is free of gluten-containing ingredients.
A nurse is contributing to the discharge plans for four clients. The nurse should identify that which of the following clients requires an interdisciplinary care conference?
A. A client who had surgery for cataract removal and lives in a rural location.
Clients who had surgery for cataract removal and live in a rural location (option a) may require support with transportation and follow-up appointments, but it does not necessarily warrant an interdisciplinary care conference.
B. A client who has hemiparesis and lives alone
An interdisciplinary care conference involves the collaboration of multiple healthcare professionals from different disciplines to develop a comprehensive care plan for a client. In this scenario, the client with hemiparesis who lives alone requires an interdisciplinary care conference because their condition and living situation present complex challenges.
C. A client who requires assistance to pay for dressing supplies
A client who requires assistance to pay for dressing supplies (option c) may benefit from financial counseling or resources, but it does not typically require the involvement of multiple healthcare professionals in a care conference.
D. A client who requires instruction regarding medication administration
A client who requires instruction regarding medication administration (option d) can typically receive education from a nurse or pharmacist without the need for an interdisciplinary care conference.
Full Explanation
b. A client who has hemiparesis and lives alone.
Explanation:
The correct answer is b. A client who has hemiparesis and lives alone.
An interdisciplinary care conference involves the collaboration of multiple healthcare professionals from different disciplines to develop a comprehensive care plan for a client. In this scenario, the client with hemiparesis who lives alone requires an interdisciplinary care conference because their condition and living situation present complex challenges.
Clients who had surgery for cataract removal and live in a rural location (option a) may require support with transportation and follow-up appointments, but it does not necessarily warrant an interdisciplinary care conference.
A client who requires assistance to pay for dressing supplies (option c) may benefit from financial counseling or resources, but it does not typically require the involvement of multiple healthcare professionals in a care conference.
A client who requires instruction regarding medication administration (option d) can typically receive education from a nurse or pharmacist without the need for an interdisciplinary care conference.
In contrast, the client with hemiparesis who lives alone may require input from various professionals such as physical therapists, occupational therapists, social workers, and home healthcare providers to address their physical limitations, safety concerns, and support needs. Therefore, an interdisciplinary care conference is necessary to develop a comprehensive discharge plan that addresses all aspects of their care and promotes their well-being in the community.
A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The nurse is preparing to change the client's surgical dressing. Which of the following actions should the nurse take to demonstrate sensitivity to age-related changes?
A. Ask the client to help with the dressing change
A. Asking the client to assist with a surgical dressing change following a total hip arthroplasty may be inappropriate due to the client's postoperative physical limitations and hip precautions. While fostering independence is generally positive, it does not specifically address the physiological age-related changes of the integumentary system. The primary concern in this scenario is protecting the integrity of the client's fragile skin during adhesive removal.
B. Wait for the client to approach the nurse for assistance
B. Waiting for a client to request assistance for a scheduled postoperative dressing change is a deviation from the standard plan of care and proactive nursing management. Postoperative wound care is a scheduled clinical priority to monitor for infection and promote healing. This action does not demonstrate sensitivity to age-related physiological changes and could potentially lead to delayed detection of surgical site complications or wound dehiscence.
C. Use paper tape for securing the new dressing
C. Using paper tape is the most appropriate action because older adults possess a thinner stratum corneum and diminished cohesion between the dermis and epidermis. Traditional plastic or silk adhesives can cause epidermal stripping and skin tears upon removal due to their high tackiness. Paper tape provides sufficient securement for the surgical dressing while minimizing the risk of mechanical injury to the sensitive, translucent skin of an elderly patient.
D. Apply the dressing loosely over the incision
D. Applying a dressing loosely over a fresh surgical incision is contraindicated as it fails to provide an adequate microbial barrier and does not support wound healing. A loose dressing may shift, causing friction against the incision line or allowing contaminants to reach the surgical site. To demonstrate age-related sensitivity, the nurse must ensure the dressing is secure while using materials that are gentle on the surrounding atrophic skin.
Full Explanation
Rationale:
A. Asking the client to assist with a surgical dressing change following a total hip arthroplasty may be inappropriate due to the client's postoperative physical limitations and hip precautions. While fostering independence is generally positive, it does not specifically address the physiological age-related changes of the integumentary system. The primary concern in this scenario is protecting the integrity of the client's fragile skin during adhesive removal.
B. Waiting for a client to request assistance for a scheduled postoperative dressing change is a deviation from the standard plan of care and proactive nursing management. Postoperative wound care is a scheduled clinical priority to monitor for infection and promote healing. This action does not demonstrate sensitivity to age-related physiological changes and could potentially lead to delayed detection of surgical site complications or wound dehiscence.
C. Using paper tape is the most appropriate action because older adults possess a thinner stratum corneum and diminished cohesion between the dermis and epidermis. Traditional plastic or silk adhesives can cause epidermal stripping and skin tears upon removal due to their high tackiness. Paper tape provides sufficient securement for the surgical dressing while minimizing the risk of mechanical injury to the sensitive, translucent skin of an elderly patient.
D. Applying a dressing loosely over a fresh surgical incision is contraindicated as it fails to provide an adequate microbial barrier and does not support wound healing. A loose dressing may shift, causing friction against the incision line or allowing contaminants to reach the surgical site. To demonstrate age-related sensitivity, the nurse must ensure the dressing is secure while using materials that are gentle on the surrounding atrophic skin.