Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?
A. Lubricate the suction catheter tip with sterile saline
A) Lubricate the suction catheter tip with sterile saline: Lubricating the suction catheter tip is not recommended, as it can introduce additional fluids into the airway and may contribute to complications or further secretions.
B. Suction two to three times with a 50-second pause between passes
B) Suction two to three times with a 50-second pause between passes: While it is appropriate to limit suctioning passes to minimize trauma, the pause should generally be 30 seconds to allow for reoxygenation. A 50-second pause could result in hypoxia.
C. Hyperventilate the client on 100% oxygen prior to suctioning
C) Hyperventilate the client on 100% oxygen prior to suctioning: This action is crucial as it helps to preoxygenate the client, minimizing the risk of hypoxia during the suctioning procedure. Hyperventilation with 100% oxygen helps maintain adequate oxygen levels, especially when the airway may be compromised.
D. Perform chest physiotherapy prior to suctioning
D) Perform chest physiotherapy prior to suctioning: While chest physiotherapy can help mobilize secretions, it is typically done as a separate intervention and not immediately before suctioning. The priority during suctioning is to clear secretions efficiently and safely, and chest physiotherapy may not be necessary right before this procedure.
E. None
None
F. None
None
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nursing 4650 Comprehensive Proctored Exam. Take the full exam now
Full Explanation
Correct Answer: B. Position the sterile drape leaving the perineum exposed.
Rationales
A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.
B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.
C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.
D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.
Similar Questions
A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? (Select all that apply)
A. Rotavirus (RV)
Rotavirus (RV): Rotavirus vaccine is routinely recommended for infants to protect against rotavirus infection, which can cause severe diarrhea and dehydration in young children. It is typically administered orally in multiple doses starting at around 2 months of age.
B. Human papillomavirus (HPV)
Human papillomavirus (HPV): The HPV vaccine is not routinely administered to infants at 1 year of age. It is typically recommended for preteens and adolescents to protect against HPV-related cancers and genital warts.
C. Measles, mumps rubella (MMR)
Measles, mumps rubella (MMR): The MMR vaccine is routinely given to infants around 1 year of age to protect against measles, mumps, and rubella (German measles). It is typically administered as a single injection.
D. Varicella (VAR)
Varicella (VAR): The varicella vaccine is routinely recommended for infants to protect against chickenpox (varicella) infection. It is typically administered as a single injection around 1 year of age.
E. Diphtheria, tetanus and acellular pertussis (DTaP)
Diphtheria, tetanus and acellular pertussis (DTaP): The DTaP vaccine is routinely given to infants to protect against diphtheria, tetanus, and pertussis (whooping cough). It is typically administered as a series of injections starting at around 2 months of age.
Full Explanation
A. Rotavirus (RV): Rotavirus vaccine is routinely recommended for infants to protect against rotavirus infection, which can cause severe diarrhea and dehydration in young children. It is typically administered orally in multiple doses starting at around 2 months of age.
B. Human papillomavirus (HPV): The HPV vaccine is not routinely administered to infants at 1 year of age. It is typically recommended for preteens and adolescents to protect against HPV-related cancers and genital warts.
C. Measles, mumps rubella (MMR): The MMR vaccine is routinely given to infants around 1 year of age to protect against measles, mumps, and rubella (German measles). It is typically administered as a single injection.
D. Varicella (VAR): The varicella vaccine is routinely recommended for infants to protect against chickenpox (varicella) infection. It is typically administered as a single injection around 1 year of age.
E. Diphtheria, tetanus and acellular pertussis (DTaP): The DTaP vaccine is routinely given to infants to protect against diphtheria, tetanus, and pertussis (whooping cough). It is typically administered as a series of injections starting at around 2 months of age.
A nurse is caring for a client who has diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?
A. 14 units
None
B. 28 units
None
C. 32 units
D. 42 units
To determine the total number of units of insulin to prepare in the insulin syringe, add together the prescribed doses of regular insulin and NPH insulin. Regular insulin: 14 units NPH insulin: 28 units Total: 14 units (regular insulin) + 28 units (NPH insulin) = 42 units Therefore, the nurse should prepare a total of 42 units of insulin in the insulin syringe: 14 units of regular insulin and 28 units of NPH insulin
Full Explanation
To determine the total number of units of insulin to prepare in the insulin syringe, add together the prescribed doses of regular insulin and NPH insulin.
Regular insulin: 14 units NPH insulin: 28 units
Total: 14 units (regular insulin) + 28 units (NPH insulin) = 42 units
Therefore, the nurse should prepare a total of 42 units of insulin in the insulin syringe: 14 units of regular insulin and 28 units of NPH insulin
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
A. Notify the client's provider.
Notify the client's provider: This option might be considered if there are signs of postpartum hemorrhage, such as excessive bleeding, signs of shock, or a boggy uterus that does not respond to massage. However, in this scenario, the fundus is midline and firm, which indicates appropriate uterine contraction. Therefore, notifying the provider at this point may not be necessary.
B. Encourage the client to empty her bladder.
Encourage the client to empty her bladder: Encouraging the client to empty her bladder is always important in the postpartum period, as a full bladder can impede uterine contraction. However, the presence of lochia rubra and small clots along with a midline and firm fundus suggests that uterine involution is progressing well. While encouraging the client to empty her bladder is appropriate, it may not be the priority in this situation.
C. Increase the frequency of fundal massage immediately.
Increase the frequency of fundal massage immediately: Fundal massage is typically performed to promote uterine involution and prevent postpartum hemorrhage. However, in this scenario, the fundus is already midline and firm, indicating adequate contraction. Increasing the frequency of fundal massage unnecessarily could cause discomfort to the client and is not indicated based on the current assessment findings.
D. Document the findings and continue to monitor the client.
Document the findings and continue to monitor the client: This is the most appropriate action at this time. The presence of lochia rubra and small clots along with a midline and firm fundus suggests that the uterus is involuting properly. Documenting the findings allows for accurate documentation of the client's condition and continued monitoring for any changes or developments. If the client's condition changes or if there are signs of postpartum hemorrhage, further action, such as notifying the provider, can be taken.
Full Explanation
A. Notify the client's provider: This option might be considered if there are signs of postpartum hemorrhage, such as excessive bleeding, signs of shock, or a boggy uterus that does not respond to massage. However, in this scenario, the fundus is midline and firm, which indicates appropriate uterine contraction. Therefore, notifying the provider at this point may not be necessary.
B. Encourage the client to empty her bladder: Encouraging the client to empty her bladder is always important in the postpartum period, as a full bladder can impede uterine contraction. However, the presence of lochia rubra and small clots along with a midline and firm fundus suggests that uterine involution is progressing well. While encouraging the client to empty her bladder is appropriate, it may not be the priority in this situation.
C. Increase the frequency of fundal massage immediately: Fundal massage is typically performed to promote uterine involution and prevent postpartum hemorrhage. However, in this scenario, the fundus is already midline and firm, indicating adequate contraction. Increasing the frequency of fundal massage unnecessarily could cause discomfort to the client and is not indicated based on the current assessment findings.
D. Document the findings and continue to monitor the client: This is the most appropriate action at this time. The presence of lochia rubra and small clots along with a midline and firm fundus suggests that the uterus is involuting properly. Documenting the findings allows for accurate documentation of the client's condition and continued monitoring for any changes or developments. If the client's condition changes or if there are signs of postpartum hemorrhage, further action, such as notifying the provider, can be taken.