Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a client who is experiencing moderate vaginal bleeding due to a placental abruption. Which of the following interventions should the nurse include in the plan?
A. Check cervical dilation every 2 hr.
Frequent cervical examinations may increase the risk of introducing infection or causing additional bleeding. Cervical examinations are not a priority in managing placental abruption.
B. Initiate an IV with an 18-gauge catheter.
Placental abruption can lead to significant blood loss, and the client may require intravenous fluids and blood products to maintain hemodynamic stability. Initiating an IV with an 18-gauge catheter allows for rapid administration of fluids and blood products if needed.
C. Monitor FHR hourly.
Monitoring fetal heart rate hourly is important, but addressing the mother's hemodynamic stability with IV fluids takes priority.
D. Obtain vital signs every 4 hr.
Vital signs should be obtained more frequently than every 4 hours due to the risk of ongoing blood loss.
This question is an excerpt from Nurse Dive's nursing test bank - RN ati Concept-based assessment level proctored exam. Take the full exam now
Full Explanation
Choice A rationale:
Frequent cervical examinations may increase the risk of introducing infection or causing additional bleeding. Cervical examinations are not a priority in managing placental abruption.
Choice B rationale:
Placental abruption can lead to significant blood loss, and the client may require intravenous fluids and blood products to maintain hemodynamic stability. Initiating an IV with an 18-gauge catheter allows for rapid administration of fluids and blood products if needed.
Choice C rationale:
Monitoring fetal heart rate hourly is important, but addressing the mother's hemodynamic stability with IV fluids takes priority.
Choice D rationale:
Vital signs should be obtained more frequently than every 4 hours due to the risk of ongoing blood loss.
Similar Questions
A nurse is assessing a client who is experiencing postpartum hemorrhage. Which of the following findings should the nurse identify as an indication of excessive blood loss?
A. Tachycardia
Tachycardia (rapid heart rate) is a common early indicator of excessive blood loss. It is the body's compensatory response to decrease in circulating blood volume.
B. Flushed skin
Flushed skin is not necessarily indicative of excessive blood loss. Pallor may be more characteristic.
C. Polyuria
Polyuria (increased urine output) is not a reliable indicator of blood loss and is not commonly associated with postpartum hemorrhage.
D. Firm fundus
A firm fundus is a positive sign and indicates the uterus is contracting appropriately. It is not indicative of excessive blood loss.
Full Explanation
Choice A rationale:
Tachycardia (rapid heart rate) is a common early indicator of excessive blood loss. It is the body's compensatory response to decrease in circulating blood volume.
Choice B rationale:
Flushed skin is not necessarily indicative of excessive blood loss. Pallor may be more characteristic.
Choice C rationale:
Polyuria (increased urine output) is not a reliable indicator of blood loss and is not commonly associated with postpartum hemorrhage.
Choice D rationale:
A firm fundus is a positive sign and indicates the uterus is contracting appropriately. It is not indicative of excessive blood loss.
A nurse is preparing an educational program about sexual assault for a group of college students. Which of the following information should the nurse include?
A. Survivors of sexual assault exhibit similar psychological symptoms to one another.
Survivors of sexual assault can exhibit a wide range of psychological symptoms, and their experiences may vary significantly. There is no universal pattern of symptoms that applies to all survivors.
B. Survivors of sexual assault do not benefit from psychotherapy.
Psychotherapy, such as trauma-focused cognitive-behavioral therapy, has been shown to be effective in helping survivors of sexual assault cope with and heal from their experiences.
C. Survivors of sexual assault often know their offender.
It is important to emphasize that sexual assault survivors often know the perpetrator, as this information dispels the myth that most assaults are committed by strangers. Education should provide accurate and evidence-based information to address misconceptions.
D. Survivors of sexual assault are generally married living in metropolitan areas.
Survivors of sexual assault come from diverse backgrounds and living situations, and their marital status or residence in metropolitan areas is not universally applicable.
Full Explanation
Choice A rationale:
Survivors of sexual assault can exhibit a wide range of psychological symptoms, and their experiences may vary significantly. There is no universal pattern of symptoms that applies to all survivors.
Choice B rationale:
Psychotherapy, such as trauma-focused cognitive-behavioral therapy, has been shown to be effective in helping survivors of sexual assault cope with and heal from their experiences.
Choice C rationale:
Rationale:
It is important to emphasize that sexual assault survivors often know the perpetrator, as this information dispels the myth that most assaults are committed by strangers.
Education should provide accurate and evidence-based information to address misconceptions.
Choice D rationale:
Survivors of sexual assault come from diverse backgrounds and living situations, and their marital status or residence in metropolitan areas is not universally applicable.
A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.)
A. Agitation
Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.
B. Slow, flat speech
Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.
C. Visual hallucinations
Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.
D. Confusion
Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.
E. Rapid mood swings
Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.
Full Explanation
Choice A rationale:
Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.
Choice B rationale:
Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.
Choice C rationale:
Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.
Choice D rationale:
Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.
Choice E rationale:
Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.