Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a client who is receiving chemotherapy and has neutropenia.
Which of the following interventions should the nurse include in the plan?
A. Avoid including raw fruits in the client's diet.
The nurse should discourage raw fruits due to risk of infection.
B. Restrict visits from young children to 2 hr per day.
There is no standard recommendation against exposure to young children.
C. Measure the client's temperature once per shift.
The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated, because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.
D. Use disposable gloves from a box outside the client's room.
The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
- A. The nurse should discourage raw fruits due to risk of infection.
- B. There is no standard recommendation against exposure to young children.
- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.
- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.
Similar Questions
A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?
A. The frequency in which the client presses the call button
The frequency in which the client presses the call button:While this could be relevant to assess the client's overall well-being or potential anxiety, it's not as crucial as pain management in this specific scenario.
B. The client's most recent ventilator settings
The client's most recent ventilator settings:Since the client is already weaned from ventilation, this information is no longer pertinent.
C. The time of the client's last dose of pain medication
The time of the client's last dose of pain medication:Pain management is paramount after a pneumonectomy. Knowing the timing of the last dose allows the receiving nurse to assess the need for further medication and potential for breakthrough pain management. Additionally, it provides a baseline for monitoring pain trends and potential complications related to pain, such as decreased mobility or respiratory compromise.
D. The last time the provider evaluated the client
The last time the provider evaluated the client:While provider updates are important, especially after major procedures like a pneumonectomy, knowing the exact timing isn't as critical as pain management, especially considering the potential for increased pain after surgery and weaning from ventilation.
Full Explanation
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Out of the provided options, the most important information for the nurse to include in the change-of-shift report is:
c. The time of the client's last dose of pain medication
Here's why:
- a. The frequency in which the client presses the call button: While this could be relevant to assess the client's overall well-being or potential anxiety, it's not as crucial as pain management in this specific scenario.
- b. The client's most recent ventilator settings: Since the client is already weaned from ventilation, this information is no longer pertinent.
- d. The last time the provider evaluated the client: While provider updates are important, especially after major procedures like a pneumonectomy, knowing the exact timing isn't as critical as pain management, especially considering the potential for increased pain after surgery and weaning from ventilation.
- c. The time of the client's last dose of pain medication: Pain management is paramount after a pneumonectomy. Knowing the timing of the last dose allows the receiving nurse to assess the need for further medication and potential for breakthrough pain management. Additionally, it provides a baseline for monitoring pain trends and potential complications related to pain, such as decreased mobility or respiratory compromise.
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Therefore, while all the information listed could be relevant at some point, knowing the time of the last pain medication dose is the most crucial for immediate patient care and should be prioritized in the change-of-shift report for a post-pneumonectomy client transitioning from ICU to the medical floor.
A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy.
Which of the following information should the nurse not include in the change-of-shift report?
A. The last time the provider evaluated the client
The time of the provider’s last evaluation provides important clinical context regarding the client’s current status and any recent changes in the plan of care. This helps the receiving team anticipate follow-up assessments and interventions.
B. The client's most recent ventilator settings
The client’s most recent ventilator settings are relevant because the client was recently weaned from mechanical ventilation. This information helps evaluate respiratory stability and guides ongoing monitoring for complications after a pneumonectomy.
C. The time of the client's last dose of pain medication
The timing of the last dose of pain medication is essential for safe and effective pain management. It allows the receiving nurse to plan subsequent doses and monitor for effectiveness or adverse effects.
D. The frequency in which the client presses the call button
The frequency with which the client presses the call button does not contribute meaningful clinical information for the transfer report. It does not directly affect physiological status, treatment decisions, or continuity of care.
E. None
None
F. None
None
Full Explanation
A. The time of the provider’s last evaluation provides important clinical context regarding the client’s current status and any recent changes in the plan of care. This helps the receiving team anticipate follow-up assessments and interventions.
B. The client’s most recent ventilator settings are relevant because the client was recently weaned from mechanical ventilation. This information helps evaluate respiratory stability and guides ongoing monitoring for complications after a pneumonectomy.
C. The timing of the last dose of pain medication is essential for safe and effective pain management. It allows the receiving nurse to plan subsequent doses and monitor for effectiveness or adverse effects.
D. The frequency with which the client presses the call button does not contribute meaningful clinical information for the transfer report. It does not directly affect physiological status, treatment decisions, or continuity of care.
An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?
A. A client who is at 33 weeks of gestation and has severe gestational hypertension
The nurse should initiate seizure precautions for a client who is at 33 weeks of gestation and has severe gestational hypertension, which is a blood pressure of 160/110 mm Hg or higher on two occasions at least 4 hr apart, or once with signs of end-organ damage. Severe gestational hypertension can lead to preeclampsia, which is a condition characterized by hypertension, proteinuria, and edema, and can progress to eclampsia, which is a lifethreatening complication that involves seizures.
B. A client who is at 16 weeks of gestation and has a hydatidiform mole
The nurse does not need to initiate seizure precautions for a client who is at 16 weeks of gestation and has a hydatidiform mole, which is an abnormal growth of placental tissue that resembles grape-like clusters. A hydatidiform mole can cause vaginal bleeding, hyperemesis gravidarum, and elevated human chorionic gonadotropin levels, but it does not increase the risk of seizures.
C. A client who is at 28 weeks of gestation and is experiencing vaginal bleeding
The nurse does not need to initiate seizure precautions for a client who is at 28 weeks of gestation and is experiencing vaginal bleeding, which can have various causes such as placenta previa, placental abruption, or cervical trauma. Vaginal bleeding can indicate a potential hemorrhage, but it does not increase the risk of seizures.
D. A client who is at 36 weeks of gestation and has a positive group B streptococcal culture
The nurse does not need to initiate seizure precautions for a client who is at 36 weeks of gestation and has a positive group B streptococcal culture, which means that the client has bacteria in their vagina or rectum that can cause infection in the newborn during delivery. A positive group B streptococcal culture requires antibiotic prophylaxis during labor, but it does not increase the risk of seizures.
Full Explanation
- A. Correct. The nurse should initiate seizure precautions for a client who is at 33 weeks of gestation and has severe gestational hypertension, which is a blood pressure of 160/110 mm Hg or higher on two occasions at least 4 hr apart, or once with signs of end-organ damage. Severe gestational hypertension can lead to preeclampsia, which is a condition characterized by hypertension, proteinuria, and edema, and can progress to eclampsia, which is a lifethreatening complication that involves seizures.
- B. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 16 weeks of gestation and has a hydatidiform mole, which is an abnormal growth of placental tissue that resembles grape-like clusters. A hydatidiform mole can cause vaginal bleeding, hyperemesis gravidarum, and elevated human chorionic gonadotropin levels, but it does not increase the risk of seizures.
- C. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 28 weeks of gestation and is experiencing vaginal bleeding, which can have various causes such as placenta previa, placental abruption, or cervical trauma. Vaginal bleeding can indicate a potential hemorrhage, but it does not increase the risk of seizures.
- D. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 36 weeks of gestation and has a positive group B streptococcal culture, which means that the client has bacteria in their vagina or rectum that can cause infection in the newborn during delivery. A positive group B streptococcal culture requires antibiotic prophylaxis during labor, but it does not increase the risk of seizures.