Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients.
The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?
A. A client who had blood drawn from the right antecubital area 1 hr ago.
A client who had blood drawn from the right antecubital area 1 hour ago does not require blood pressure measurement from the left arm. Blood drawing from one arm does not affect the accuracy of blood pressure measurement in the opposite arm.
B. A client who has a right peripherally inserted central catheter.
A client who has a right peripherally inserted central catheter (PICC) line should have blood pressure measured from the opposite arm to avoid disrupting the PICC line.
C. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm.
A client who had dialysis and is using an arteriovenous shunt in the left lower forearm should have blood pressure measured from the opposite arm. Using the arm with an arteriovenous shunt for blood pressure measurement can lead to inaccurate readings and potentially damage the shunt, disrupting the client's dialysis treatment.
D. A client who had a right hemisphere stroke.
A client who had a right hemisphere stroke does not necessarily require blood pressure measurement from the left arm. Stroke location does not impact the choice of the arm for blood pressure measurement; other factors, such as vascular access devices or medical procedures, are more relevant in this context.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
A client who had blood drawn from the right antecubital area 1 hour ago does not require blood pressure measurement from the left arm. Blood drawing from one arm does not affect the accuracy of blood pressure measurement in the opposite arm.
Choice B rationale:
A client who has a right peripherally inserted central catheter (PICC) line should have blood pressure measured from the opposite arm to avoid disrupting the PICC line.
Choice C rationale:
A client who had dialysis and is using an arteriovenous shunt in the left lower forearm should have blood pressure measured from the opposite arm. Using the arm with an arteriovenous shunt for blood pressure measurement can lead to inaccurate readings and potentially damage the shunt, disrupting the client's dialysis treatment.
Choice D rationale:
A client who had a right hemisphere stroke does not necessarily require blood pressure measurement from the left arm. Stroke location does not impact the choice of the arm for blood pressure measurement; other factors, such as vascular access devices or medical procedures, are more relevant in this context.
Similar Questions
A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility.
Which of the following statements by the client indicates an understanding of the teaching?
A. "I should store my personal items all together on the shelf in my bathroom.”
Storing personal items together on a shelf in the bathroom promotes organization and reduces the risk of tripping or falling over scattered items. Keeping the environment tidy and free of clutter is an essential fall prevention strategy, especially in areas where the client moves frequently.
B. "I will wear a yellow wristband so everyone knows I am at risk of falling.”
Wearing a yellow wristband to indicate a fall risk is a common practice in healthcare facilities. However, merely wearing the wristband does not demonstrate a comprehensive understanding of fall prevention strategies. While it is essential for healthcare providers to identify patients at risk of falling, educating the patient about specific strategies to prevent falls is equally important.
C. "I should keep the overhead lights on at all times while I am here.”
Keeping the overhead lights on at all times does not necessarily indicate an understanding of fall prevention strategies. While adequate lighting is important to prevent falls, leaving lights on continuously may not be necessary during daylight hours. It is more effective to ensure there is adequate lighting in commonly used areas and during nighttime hours.
D. "I will have to wear a restraint around my waist when I am sitting up in a chair.”
Wearing a restraint around the waist is not a recommended fall prevention strategy. Physical restraints are generally discouraged in healthcare settings due to ethical concerns and the potential to cause harm to the patient. Restraints can lead to complications such as pressure ulcers, loss of muscle strength, and decreased mobility.
Full Explanation
Choice A rationale:
Storing personal items together on a shelf in the bathroom promotes organization and reduces the risk of tripping or falling over scattered items. Keeping the environment tidy and free of clutter is an essential fall prevention strategy, especially in areas where the client moves frequently.
Choice B rationale:
Wearing a yellow wristband to indicate a fall risk is a common practice in healthcare facilities. However, merely wearing the wristband does not demonstrate a comprehensive understanding of fall prevention strategies. While it is essential for healthcare providers to identify patients at risk of falling, educating the patient about specific strategies to prevent falls is equally important.
Choice C rationale:
Keeping the overhead lights on at all times does not necessarily indicate an understanding of fall prevention strategies. While adequate lighting is important to prevent falls, leaving lights on continuously may not be necessary during daylight hours. It is more effective to ensure there is adequate lighting in commonly used areas and during nighttime hours.
Choice D rationale:
Wearing a restraint around the waist is not a recommended fall prevention strategy. Physical restraints are generally discouraged in healthcare settings due to ethical concerns and the potential to cause harm to the patient. Restraints can lead to complications such as pressure ulcers, loss of muscle strength, and decreased mobility.
A charge nurse is observing an assistive personnel perform delegated tasks.
Which of the following actions by the AP requires the charge nurse to intervene?
A. Providing postmortem care for a client who has recently died.
Providing postmortem care for a client who has recently died does not require immediate intervention by the charge nurse, as it is a standard nursing responsibility to provide postmortem care with dignity and respect to the deceased client. The AP can proceed with this task independently.
B. Performing a simple dressing change on a client's foot.
Performing a simple dressing change on a client's foot is within the scope of practice for an assistive personnel (AP) and does not require immediate intervention by the charge nurse, assuming the AP is competent and trained to perform this task.
C. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile.
Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile is not sufficient. Alcohol is not effective against C. Difficile spores.
D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves.
Clean gloves are sufficient for this task, as they do provide adequate protection against the transmission of infections.
Full Explanation
Choice A rationale:
Providing postmortem care for a client who has recently died does not require immediate intervention by the charge nurse, as it is a standard nursing responsibility to provide postmortem care with dignity and respect to the deceased client. The AP can proceed with this task independently.
Choice B rationale:
Performing a simple dressing change on a client's foot is within the scope of practice for an assistive personnel (AP) and does not require immediate intervention by the charge nurse, assuming the AP is competent and trained to perform this task.
Choice C rationale:
Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile is not sufficient. Alcohol is not effective against C. Difficile spores.
Choice D rationale:
Clean gloves are sufficient for this task, as they do provide adequate protection against the transmission of infections.
A nurse is performing an admission assessment of a school-age child who has spina bifida.
The parent states that the child is allergic to latex.
The nurse should assess further for cross-sensitivity to which of the following foods?
A. Almonds.
Almonds are not typically associated with latex allergy or cross-sensitivity. Latex cross-reactivity is more commonly seen with certain fruits such as bananas, avocados, kiwis, and chestnuts.
B. Bananas.
Bananas are known to be cross-reactive with latex allergy. Individuals allergic to latex are more likely to have allergies to certain fruits, including bananas. This cross-sensitivity occurs due to the structural similarity between latex proteins and proteins found in these fruits.
C. Hazelnuts.
Hazelnuts are not commonly associated with latex cross-reactivity. While some individuals with latex allergy may also be allergic to hazelnuts, it is not a high-risk food in the context of latex cross-sensitivity.
D. Strawberries.
Strawberries are not typically associated with latex allergy or cross-reactivity. Latex cross-reactivity is more commonly seen with fruits like bananas, avocados, kiwis, and chestnuts. Strawberries are not among the high-risk foods for individuals with latex allergy.
Full Explanation
Choice A rationale:
Almonds are not typically associated with latex allergy or cross-sensitivity. Latex cross-reactivity is more commonly seen with certain fruits such as bananas, avocados, kiwis, and chestnuts.
Choice B rationale:
Bananas are known to be cross-reactive with latex allergy. Individuals allergic to latex are more likely to have allergies to certain fruits, including bananas. This cross-sensitivity occurs due to the structural similarity between latex proteins and proteins found in these fruits.
Choice C rationale:
Hazelnuts are not commonly associated with latex cross-reactivity. While some individuals with latex allergy may also be allergic to hazelnuts, it is not a high-risk food in the context of latex cross-sensitivity.
Choice D rationale:
Strawberries are not typically associated with latex allergy or cross-reactivity. Latex cross-reactivity is more commonly seen with fruits like bananas, avocados, kiwis, and chestnuts. Strawberries are not among the high-risk foods for individuals with latex allergy.