Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis.
Which of the following actions should the nurse take?
A. Cover the area of percussion with a towel.
This is because chest percussion uses clapping of the chest using a cupped hand to vibrate the airways of the lungs and move and break apart the mucus inside the lungs. Covering the area of percussion with a towel can help to reduce discomfort during the procedure.
B. Schedule postural drainage after meals.
Choice B is wrong because postural drainage should not be scheduled after meals. It is best to schedule postural drainage before meals or at least 1-2 hours after meals to prevent discomfort or vomiting.
C. Instruct the client to exhale quickly during vibration.
Choice D is wrong because, during vibration, the client should inhale deeply and exhale slowly.
D. Perform percussion over the lower back.
Choice C is wrong because percussion should not be performed over the lower back. It should be performed over the chest and back, avoiding areas such as the spine and breastbone.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Fundamentals 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
This is because chest percussion uses clapping of the chest using a cupped hand to vibrate the airways of the lungs and move and break apart the mucus inside the lungs.
Covering the area of percussion with a towel can help to reduce discomfort during the procedure.
Choice B is wrong because postural drainage should not be scheduled after meals.
It is best to schedule postural drainage before meals or at least 1-2 hours after meals to prevent discomfort or vomiting.
Choice C is wrong because, during vibration, the client should inhale deeply and exhale slowly.
Choice D is wrong because percussion should not be performed over the lower back.
It should be performed over the chest and back, avoiding areas such as the spine and breastbone.
Similar Questions
A nurse is preparing to administer a controlled substance to a client for pain management.
Which of the following actions should the nurse take?
A. Verify the count total of the controlled substance after removing the amount needed.
Choice A is wrong because the count total of the controlled substance should be verified before removing the amount needed, not after.
B. Place the wasted portion of the controlled substance in the sharps container.
Choice B is wrong because the wasted portion of the controlled substance should not be placed in the sharps container. It should be disposed of according to facility/agency policy.
C. Report any discrepancy in the count total of the controlled substance after administration.
Choice C is wrong because any discrepancy in the count total of the controlled substance should be reported immediately, not after administration 1.
D. Ask a second nurse to record her signature when wasting any unused portion of the controlled substance.
Ask a second nurse to record her signature when wasting any unused portion of the controlled substance. This is because if a controlled substance is wasted, this waste must be witnessed by and documented by the wasting nurse and another nurse.
Full Explanation
Ask a second nurse to record her signature when wasting any unused portion of the controlled substance.
This is because if a controlled substance is wasted, this waste must be witnessed by and documented by the wasting nurse and another nurse.
Choice A is wrong because the count total of the controlled substance should be verified before removing the amount needed, not after.
Choice B is wrong because the wasted portion of the controlled substance should not be placed in the sharps container.
It should be disposed of according to facility/agency policy.
Choice C is wrong because any discrepancy in the count total of the controlled substance should be reported immediately, not after administration 1.
A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse.
The nurse should identify that which of the following manifestations occurs during the alarm reaction stage.
A. Depression.
Choice A is wrong because depression is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
B. Dilated pupils.
This is because during the alarm reaction stage of general adaptation syndrome, which is also known as the fight-or-flight response, the sympathetic nervous system is activated by the sudden release of hormones. This hormone release causes physical symptoms such as dilated pupils.
C. Bradycardia.
Choice C is wrong because bradycardia, or a slow heart rate, is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome. Instead, an increase in heart rate is a common physical sign during this stage.
D. Physical exhaustion.
Choice D is wrong because physical exhaustion is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome. Physical exhaustion occurs during the final stage of general adaptation syndrome, which is known as the exhaustion stage.
Full Explanation
This is because during the alarm reaction stage of general adaptation syndrome, which is also known as the fight-or-flight response, the sympathetic nervous system is activated by the sudden release of hormones.
This hormone release causes physical symptoms such as dilated pupils.
Choice A is wrong because depression is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Choice C is wrong because bradycardia, or a slow heart rate, is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Instead, an increase in heart rate is a common physical sign during this stage.
Choice D is wrong because physical exhaustion is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Physical exhaustion occurs during the final stage of general adaptation syndrome, which is known as the exhaustion stage.
A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first?
A. Make a copy of the medication reconciliation form for the client.
Choice A is wrong because making a copy of the medication reconciliation form for the client is not the first action that should be taken. While it is important to provide the client with a copy of their medication reconciliation form, this should be done after determining whether the client can afford the insulin administration supplies.
B. Obtain printed information about insulin self-administration.
Choice B is wrong because obtaining printed information about insulin self-administration is not the first action that should be taken. While it is important to provide the client with information about insulin self-administration, this should be done after determining whether the client can afford the insulin administration supplies.
C. Provide the client with the contact number for a diabetes education specialist.
Choice C is wrong because providing the client with the contact number for a diabetes education specialist is not the first action that should be taken. While it is important to provide the client with resources for diabetes education, this should be done after determining whether the client can afford insulin administration supplies.
D. Determine whether the client can afford the insulin administration supplies.
This is because before providing the client with information about insulin self-administration and other resources, it is important to first determine whether the client can afford the insulin administration supplies. This will help to ensure that the client has access to the necessary supplies for managing their diabetes mellitus.
Full Explanation
This is because before providing the client with information about insulin self-administration and other resources, it is important to first determine whether the client can afford the insulin administration supplies.
This will help to ensure that the client has access to the necessary supplies for managing their diabetes mellitus.
Choice A is wrong because making a copy of the medication reconciliation form for the client is not the first action that should be taken.
While it is important to provide the client with a copy of their medication reconciliation form, this should be done after determining whether the client can afford the insulin administration supplies.
Choice B is wrong because obtaining printed information about insulin self-administration is not the first action that should be taken.
While it is important to provide the client with information about insulin self-administration, this should be done after determining whether the client can afford the insulin administration supplies.
Choice C is wrong because providing the client with the contact number for a diabetes education specialist is not the first action that should be taken.
While it is important to provide the client with resources for diabetes education, this should be done after determining whether the client can afford insulin administration supplies.