Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is obtaining a client’s manual blood pressure and is having difficulty auscultating sounds.
Which of the following actions should the nurse take?
A. Apply the largest cuff available.
is wrong because applying the largest cuff available can result in a falsely low reading. The cuff size should be appropriate for the client’s arm circumference.
B. Use the palpatory method to determine blood pressure.
Use the palpatory method to determine blood pressure. This method involves feeling the radial pulse while inflating and deflating the cuff.
C. Place the arm above the level of the client’s heart.
is wrong because placing the arm above the level of the client’s heart can also cause a falsely low reading. The arm should be at the level of the heart for an accurate measurement.
D. Deflate the cuff quickly.
is wrong because deflating the cuff quickly can lead to missing or skipping sounds, resulting in an inaccurate reading. The cuff should be deflated slowly and evenly. Normal ranges for blood pressure vary depending on age, sex, and health conditions, but generally, a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg are considered normal for adults.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The systolic pressure is estimated by noting the pressure at which the pulse disappears and reappears. The diastolic pressure is not measured by this method, but it can be useful when the sounds are difficult to hear.
Choice A is wrong because applying the largest cuff available can result in a falsely low reading. The cuff size should be appropriate for the client’s arm circumference.
Choice C is wrong because placing the arm above the level of the client’s heart can also cause a falsely low reading. The arm should be at the level of the heart for an accurate measurement.
Choice D is wrong because deflating the cuff quickly can lead to missing or skipping sounds, resulting in an inaccurate reading. The cuff should be deflated slowly and evenly.
Normal ranges for blood pressure vary depending on age, sex, and health conditions, but generally, a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg are considered normal for adults.
Similar Questions
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis.
Which of the following actions should the nurse include in the plan of care?
A. Give cromolyn nebulized solution every 6 hr.
is wrong because the child should not be given anything by mouth until bowel sounds return, which can take up to 24 hr after surgery. Giving clear liquids too soon can cause nausea, vomiting, and abdominal distension.
B. Offer small amounts of clear liquids 6 hr following surgery.
is wrong because cromolyn nebulized solution is used to prevent asthma attacks, not to treat appendicitis. There is no indication that the child has asthma or needs this medication.
C. Apply a warm compress to the operative site once daily.
because applying a warm compress to the operative site can increase inflammation and infection risk. A cold compress can be used to reduce swelling and pain, but only if prescribed by the provider.
D. Administer analgesics on a scheduled basis for the first 24 hr.
. Administer analgesics on a scheduled basis for the first 24 hr. This is because the child is at risk for developing peritonitis, which can cause severe abdominal pain.
Full Explanation
The correct answer is choice D. Administer analgesics on a scheduled basis for the first 24 hr.
This is because the child is at risk for developing peritonitis, which can cause severe abdominal pain.
Scheduled analgesics can provide better pain relief than PRN analgesics.
Choice A is wrong because the child should not be given anything by mouth until bowel sounds return, which can take up to 24 hr after surgery.
Giving clear liquids too soon can cause nausea, vomiting, and abdominal distension.
Choice B is wrong because cromolyn nebulized solution is used to prevent asthma attacks, not to treat appendicitis.
There is no indication that the child has asthma or needs this medication.
Choice C is wrong because applying a warm compress to the operative site can increase inflammation and infection risk.
A cold compress can be used to reduce swelling and pain, but only if prescribed by the provider.
A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis.
Which of the following instructions should the nurse include?
A. “Use a nebulizer to administer a bronchodilator following airway clearance therapy.”.
is wrong because a bronchodilator should be administered before airway clearance therapy, not after. A bronchodilator helps open up the airways and make it easier to cough up mucus.
B. “Administer pancreatic enzymes on an empty stomach.”.
is wrong because pancreatic enzymes should be administered with meals and snacks, not on an empty stomach. Pancreatic enzymes help digest fats, proteins, and carbohydrates in children who have cystic fibrosis. This can prevent malnutrition and growth failure.
C. “Perform chest percussion and postural drainage at least twice daily.”.
This is because chest percussion and postural drainage are airway clearance techniques that help remove thick mucus from the lungs of children who have cystic fibrosis. This can prevent respiratory infections and improve lung function.
D. “Restrict intake of foods that contain gluten.”.
is wrong because there is no need to restrict gluten intake for children who have cystic fibrosis, unless they also have celiac disease. Gluten is a protein found in wheat, barley, and rye that can cause intestinal damage in people who have celiac disease. Cystic fibrosis does not affect the ability to tolerate gluten
Full Explanation
The correct answer is choice C. “Perform chest percussion and postural drainage at least twice daily.” This is because chest percussion and postural drainage are airway clearance techniques that help remove thick mucus from the lungs of children who have cystic fibrosis. This can prevent respiratory infections and improve lung function.
Choice A is wrong because a bronchodilator should be administered before airway clearance therapy, not after. A bronchodilator helps open up the airways and make it easier to cough up mucus.
Choice B is wrong because pancreatic enzymes should be administered with meals and snacks, not on an empty stomach.
Pancreatic enzymes help digest fats, proteins, and carbohydrates in children who have cystic fibrosis. This can prevent malnutrition and growth failure.
Choice D is wrong because there is no need to restrict gluten intake for children who have cystic fibrosis, unless they also have celiac disease.
Gluten is a protein found in wheat, barley, and rye that can cause intestinal damage in people who have celiac disease. Cystic fibrosis does not affect the ability to tolerate gluten.
A nurse is caring for a client who has a placenta previa.
Which of the following findings should the nurse expect?
A. Nausea.
wrong because nausea is not a specific finding of placenta previa. Nausea can occur in normal pregnancy or in other conditions such as hyperemesis gravidarum or preeclampsia.
B. Polyhydramnios.
because polyhydramnios is not a finding of placenta previa. Polyhydramnios is a condition where there is too much amniotic fluid in the uterus, which can cause complications such as preterm labor, cord prolapse, or fetal malformations.
C. Uterine tenderness.
because uterine tenderness is not a finding of placenta previa. Uterine tenderness is a sign of abruptio placentae, which is a condition where the placenta separates from the uterine wall before delivery. This can cause severe abdominal pain, dark red vaginal bleeding, and fetal distress.
D. Spotting.
Placenta previa is a condition where the placenta implants in the lower part of the uterus, partly or completely covering the cervical opening. This can cause painless, bright red vaginal bleeding, usually in the third trimester. Spotting is a sign of placenta previa and should be reported to the provider immediately.
Full Explanation
The correct answer is choice D, spotting.
Placenta previa is a condition where the placenta implants in the lower part of the uterus, partly or completely covering the cervical opening.
This can cause painless, bright red vaginal bleeding, usually in the third trimester.
Spotting is a sign of placenta previa and should be reported to the provider immediately.
Choice A is wrong because nausea is not a specific finding of placenta previa.
Nausea can occur in normal pregnancy or in other conditions such as hyperemesis gravidarum or preeclampsia.
Choice B is wrong because polyhydramnios is not a finding of placenta previa.
Polyhydramnios is a condition where there is too much amniotic fluid in the uterus, which can cause complications such as preterm labor, cord prolapse, or fetal malformations.
Choice C is wrong because uterine tenderness is not a finding of placenta previa.
Uterine tenderness is a sign of abruptio placentae, which is a condition where the placenta separates from the uterine wall before delivery.
This can cause severe abdominal pain, dark red vaginal bleeding, and fetal distress.