Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?
A. Obtain a prescription for an indwelling urinary catheter.
Indwelling urinary catheters can actually increase the risk of UTIs.
B. Offer the client the bedpan every 2 hr.
Offering the bedpan every 2 hours may not be necessary or practical for all patients.
C. Cleanse the perineum from back to front.
Cleaning the perineum from back to front can introduce bacteria to the urinary tract, increasing UTI risk.
D. Encourage fluid intake at and between meals.
Adequate hydration can help flush bacteria out of the urinary tract, reducing UTI risk.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Custom NURSING 221 Proctored Exam 3. Take the full exam now
Full Explanation
Choice A rationale:
Indwelling urinary catheters can actually increase the risk of UTIs.
Choice B rationale:
Offering the bedpan every 2 hours may not be necessary or practical for all patients.
Choice C rationale:
Cleaning the perineum from back to front can introduce bacteria to the urinary tract, increasing UTI risk.
Choice D rationale:
Adequate hydration can help flush bacteria out of the urinary tract, reducing UTI risk.
Similar Questions
A nurse is reviewing discharge instructions with a client following a right cataract extraction.
Which of the following instructions should the nurse include?
A. Sleep on the abdomen to facilitate wound healing.
Sleeping on the abdomen could put pressure on the eye and disrupt healing.
B. Notify the surgeon if white drainage develops on the eyelids.
White drainage could indicate an infection, which should be reported immediately.
C. Avoid lifting anything heavier than 4.5 kg (10 1b) for 1 week.
Lifting heavy objects can increase intraocular pressure, potentially damaging the surgical site.
D. Bend at the waist to pick objects up from the floor.
Bending at the waist can also increase intraocular pressure.
Full Explanation
Choice A rationale:
Sleeping on the abdomen could put pressure on the eye and disrupt healing.
Choice B rationale:
White drainage could indicate an infection, which should be reported immediately.
Choice C rationale:
Lifting heavy objects can increase intraocular pressure, potentially damaging the surgical site.
Choice D rationale:
Bending at the waist can also increase intraocular pressure.
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest.
The lesion is raised and flesh-colored with pearly white borders.
The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?
A. Basal cell carcinoma.
Basal cell carcinoma often presents as a raised, flesh-colored lesion with pearly white borders. This is the most common type of skin cancer.
B. Squamous cell carcinoma.
Squamous cell carcinoma typically appears as a firm, red nodule or a flat lesion with a scaly, crusted surface, not a raised, flesh-colored lesion with pearly white borders.
C. Malignant melanoma.
Malignant melanoma is usually a large brownish spot with darker speckles, not a raised, flesh-colored lesion with pearly white borders.
D. Actinic keratosis.
Actinic keratosis appears as rough, scaly patches on sun-exposed areas of the skin, not a raised, flesh-colored lesion with pearly white borders.
Full Explanation
Choice A rationale:
Basal cell carcinoma often presents as a raised, flesh-colored lesion with pearly white borders. This is the most common type of skin cancer.
Choice B rationale:
Squamous cell carcinoma typically appears as a firm, red nodule or a flat lesion with a scaly, crusted surface, not a raised, flesh-colored lesion with pearly white borders.
Choice C rationale:
Malignant melanoma is usually a large brownish spot with darker speckles, not a raised, flesh-colored lesion with pearly white borders.
Choice D rationale:
Actinic keratosis appears as rough, scaly patches on sun-exposed areas of the skin, not a raised, flesh-colored lesion with pearly white borders.
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?
A. Antiplatelet aggregate.
Aspirin is given to clients with a history of myocardial infarction due to its antiplatelet aggregate properties. It prevents blood clots from forming, which can block the coronary arteries and cause a heart attack.
B. Anti-inflammatory.
While aspirin does have anti-inflammatory properties, this is not the primary reason it is given to clients with a history of myocardial infarction.
C. Analgesic.
Aspirin does have analgesic properties, but this is not the primary reason it is given to clients with a history of myocardial infarction.
D. Antipyretic.
Aspirin does have antipyretic properties, but this is not the primary reason it is given to clients with a history of myocardial infarction.
Full Explanation
Choice A rationale:
Aspirin is given to clients with a history of myocardial infarction due to its antiplatelet aggregate properties. It prevents blood clots from forming, which can block the coronary arteries and cause a heart attack.
Choice B rationale:
While aspirin does have anti-inflammatory properties, this is not the primary reason it is given to clients with a history of myocardial infarction.
Choice C rationale:
Aspirin does have analgesic properties, but this is not the primary reason it is given to clients with a history of myocardial infarction.
Choice D rationale:
Aspirin does have antipyretic properties, but this is not the primary reason it is given to clients with a history of myocardial infarction.