Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?
A. The client asks for help before ambulating.
This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
B. The client has a history of urinary incontinence.
Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
C. The client lives with their caregiver.
While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. The client has bronchitis.
Bronchitis itself does not directly contribute to an increased fall risk.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
B. Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
A. This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
C. While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. Bronchitis itself does not directly contribute to an increased fall risk.
Similar Questions
A nurse is caring for a client following an insertion of a chest tube drainage system for a pneumothorax. Which of the following manifestations should the nurse expect the client to demonstrate?
A. Gentle bubbling in the water seal chamber
Bubbling indicates that the system is functioning properly and that air is being evacuated from the pleural space.
B. Drainage and warmth at tube insertion site
Drainage and warmth at the tube insertion site could indicate inflammation or infection, which are potential complications following insertion of a chest tube.
C. Crackling sensation felt around tube insertion site
Crackling sensation felt around tube insertion site could indicate subcutaneous emphysema, which occurs when air leaks into the tissues surrounding the chest tube insertion site. It's a potential complication of chest tube insertion and should be monitored closely
D. Drainage output less than 70 mL/hr
The specific amount can vary.
Full Explanation
A. Bubbling indicates that the system is functioning properly and that air is being evacuated from the pleural space.
B. Drainage and warmth at the tube insertion site could indicate inflammation or infection, which are potential complications following insertion of a chest tube.
C. Crackling sensation felt around tube insertion site could indicate subcutaneous emphysema, which occurs when air leaks into the tissues surrounding the chest tube insertion site. It's a potential complication of chest tube insertion and should be monitored closely
D. The specific amount can vary.
A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take?
A. Use an elevated toilet seat.
Use an elevated toilet seat: Using an elevated toilet seat can help prevent excessive bending of the hip joint, reducing strain and potential dislocation risk after total hip replacement surgery.
B. Log roll the client onto the operative side.
Log rolling onto the operative side is contraindicated after total hip replacement surgery. This movement could place excessive stress on the newly replaced hip joint, increasing the risk of dislocation and complications.
C. Keep client's affected heel on the bed.
Keeping the affected heel on the bed helps maintain proper alignment and precautions after total hip replacement surgery. It supports the hip joint and reduces the risk of dislocation by preventing excessive rotation or movement.
D. Perform internal and external rotation exercises of hip.
While some hip exercises are beneficial, internal and external rotation exercises are typically avoided immediately after total hip replacement surgery to prevent strain on the new joint.
Full Explanation
A. Use an elevated toilet seat: Using an elevated toilet seat can help prevent excessive bending of the hip joint, reducing strain and potential dislocation risk after total hip replacement surgery.
B. Log rolling onto the operative side is contraindicated after total hip replacement surgery. This movement could place excessive stress on the newly replaced hip joint, increasing the risk of dislocation and complications.
C. Keeping the affected heel on the bed helps maintain proper alignment and precautions after total hip replacement surgery. It supports the hip joint and reduces the risk of dislocation by preventing excessive rotation or movement.
D. While some hip exercises are beneficial, internal and external rotation exercises are typically avoided immediately after total hip replacement surgery to prevent strain on the new joint.
A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?
A. Neck stiffness
Neck stiffness is anticipated due to manipulation of neck muscles during surgery.
B. Hoarseness
Hoarseness occurs due to injury of recurrent laryngeal nerve or manipulation of the vocal cords and surrounding structures during surgery.
C. Moderate serosanguineous drainage
Some drainage from the incision site is expected after surgery, including a total thyroidectomy
D. Muscle twitching
Muscle twitching can a feature of hypocalcemia which may eventually lead to tetany. It is therefore, necessary to report muscle twitching to avoid serious complications such as bronchospasm. Muscle twitching may indicate neuromuscular irritability or electrolyte imbalances, which could be unrelated to the thyroidectomy surgery.
Full Explanation
Muscle twitching can a feature of hypocalcemia which may eventually lead to tetany. It is therefore, necessary to report muscle twitching to avoid serious complications such as bronchospasm.
A. Neck stiffness is anticipated due to manipulation of neck muscles during surgery.
B. Hoarseness occurs due to injury of recurrent laryngeal nerve or manipulation of the vocal cords and surrounding structures during surgery.
C. Some drainage from the incision site is expected after surgery, including a total thyroidectomy
D. Muscle twitching may indicate neuromuscular irritability or electrolyte imbalances, which could be unrelated to the thyroidectomy surgery.