Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following actions should the nurse take first?
A. Collecting data from a client who reports unilateral calf pain when ambulating.
The nurse should prioritize collecting data from a client who reports unilateral calf pain when ambulating. This symptom could indicate the presence of a deep vein thrombosis (DVT), a potentially life-threatening condition. DVT occurs when a blood clot forms in a deep vein, often in the lower extremities. If left untreated, the clot can dislodge and travel to the lungs, causing a pulmonary embolism. Immediate assessment is crucial to rule out DVT and provide appropriate interventions. The nurse should assess the client's calf for swelling, redness, warmth, and tenderness and may also order diagnostic tests like a duplex ultrasound.
B. Taking a telephone prescription for a client who is to be transferred from PACU.
Taking a telephone prescription for a client being transferred from the PACU is important but not the top priority in this situation. While timely transfer and adequate post-operative care are essential, addressing a client with unilateral calf pain and the potential for a DVT takes precedence due to the risk of a life-threatening complication.
C. Reassuring the partner of a client who sustained a closed head injury.
Reassuring the partner of a client who sustained a closed head injury is a compassionate action but should not be the first priority. The partner's emotional support can be provided once the immediate medical concerns have been addressed.
D. Reinforcing a client's dressing on an above-the-knee amputation surgical site.
Reinforcing a client's dressing on an above-the-knee amputation surgical site is important for the client's post-operative care, but it is not the highest priority when compared to the possibility of a DVT. The nurse should address the client's calf pain first and then attend to the dressing reinforcement.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Fall NS 126 Proctored Exam 1. Take the full exam now
Full Explanation
Choice A rationale:
The nurse should prioritize collecting data from a client who reports unilateral calf pain when ambulating. This symptom could indicate the presence of a deep vein thrombosis (DVT), a potentially life-threatening condition. DVT occurs when a blood clot forms in a deep vein, often in the lower extremities. If left untreated, the clot can dislodge and travel to the lungs, causing a pulmonary embolism. Immediate assessment is crucial to rule out DVT and provide appropriate interventions. The nurse should assess the client's calf for swelling, redness, warmth, and tenderness and may also order diagnostic tests like a duplex ultrasound.
Choice B rationale:
Taking a telephone prescription for a client being transferred from the PACU is important but not the top priority in this situation. While timely transfer and adequate post-operative care are essential, addressing a client with unilateral calf pain and the potential for a DVT takes precedence due to the risk of a life-threatening complication.
Choice C rationale:
Reassuring the partner of a client who sustained a closed head injury is a compassionate action but should not be the first priority. The partner's emotional support can be provided once the immediate medical concerns have been addressed.
Choice D rationale:
Reinforcing a client's dressing on an above-the-knee amputation surgical site is important for the client's post-operative care, but it is not the highest priority when compared to the possibility of a DVT. The nurse should address the client's calf pain first and then attend to the dressing reinforcement.
Similar Questions
A nurse is caring for a client whose arterial blood gas results show the following results:. pH: 7.2. PaCO2: 50 mm Hg. HCO3: 24 mEq/L. The nurse should identify the client is experiencing which of the following acid-base conditions?
A. Respiratory acidosis.
The client's arterial blood gas (ABG) results indicate a low pH (acidemia) and high PaCO2, which is characteristic of respiratory acidosis. Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) from the body, leading to an accumulation of CO2 and a decrease in pH. In this case, the high PaCO2 (50 mm Hg) indicates that the client is retaining carbon dioxide, likely due to impaired ventilation. The normal pH range is 7.35 to 7.45, and the normal PaCO2 range is 35 to 45 mm Hg. These ABG values reflect an acid-base imbalance in the respiratory system, specifically, respiratory acidosis.
B. Metabolic alkalosis.
Metabolic alkalosis is characterized by an elevated pH and an increase in bicarbonate (HCO3) levels. This is not the condition described in the client's ABG results, as the pH is low (acidemic) and HCO3 levels are within the normal range (24 mEq/L).
C. Metabolic acidosis.
Metabolic acidosis is characterized by a low pH and a decreased HCO3 level. The client's ABG results do not align with metabolic acidosis since the pH is low (acidemic) and the HCO3 level is within the normal range (24 mEq/L).
D. Respiratory alkalosis.
Respiratory alkalosis is characterized by a high pH and low PaCO2. The client's ABG results do not match this condition as the pH is low (acidemic) and the PaCO2 is high (50 mm Hg), indicating respiratory acidosis. Therefore, choice A, respiratory acidosis, is the correct interpretation of the ABG results.
Full Explanation
Choice A rationale:
The client's arterial blood gas (ABG) results indicate a low pH (acidemia) and high PaCO2, which is characteristic of respiratory acidosis. Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) from the body, leading to an accumulation of CO2 and a decrease in pH. In this case, the high PaCO2 (50 mm Hg) indicates that the client is retaining carbon dioxide, likely due to impaired ventilation. The normal pH range is 7.35 to 7.45, and the normal PaCO2 range is 35 to 45 mm Hg. These ABG values reflect an acid-base imbalance in the respiratory system, specifically, respiratory acidosis.
Choice B rationale:
Metabolic alkalosis is characterized by an elevated pH and an increase in bicarbonate (HCO3) levels. This is not the condition described in the client's ABG results, as the pH is low (acidemic) and HCO3 levels are within the normal range (24 mEq/L).
Choice C rationale:
Metabolic acidosis is characterized by a low pH and a decreased HCO3 level. The client's ABG results do not align with metabolic acidosis since the pH is low (acidemic) and the HCO3 level is within the normal range (24 mEq/L).
Choice D rationale:
Respiratory alkalosis is characterized by a high pH and low PaCO2. The client's ABG results do not match this condition as the pH is low (acidemic) and the PaCO2 is high (50 mm Hg), indicating respiratory acidosis. Therefore, choice A, respiratory acidosis, is the correct interpretation of the ABG results.
A nurse is admitting a client who is having an exacerbation of asthma.
When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following prescribed medications?
A. Prednisone.
Prednisone is a corticosteroid commonly used to reduce inflammation and manage asthma exacerbations. It is an appropriate medication for asthma management and does not require clarification.
B. Montelukast.
Montelukast is a leukotriene receptor antagonist that is also used in the management of asthma. It helps to reduce airway inflammation and bronchoconstriction. Montelukast is an appropriate choice for asthma and does not need further clarification.
C. Aminophylline.
Aminophylline is a bronchodilator that can be used in the treatment of asthma. While it may have potential side effects and interactions, it is not the first medication that needs clarification in this scenario. Propranolol, due to its potential to worsen asthma symptoms, takes precedence.
D. Propranolol.
The nurse should seek clarification for the prescribed medication Propranolol when caring for a client with an exacerbation of asthma. Propranolol is a non-selective beta-blocker, and its use can exacerbate bronchoconstriction and potentially worsen asthma symptoms. In patients with asthma, non-selective beta-blockers are generally contraindicated. The nurse should consult with the provider to ensure that Propranolol is the appropriate choice, as there may be safer alternatives to manage the client's condition without worsening their asthma.
Full Explanation
Choice D rationale:
The nurse should seek clarification for the prescribed medication Propranolol when caring for a client with an exacerbation of asthma. Propranolol is a non-selective beta-blocker, and its use can exacerbate bronchoconstriction and potentially worsen asthma symptoms. In patients with asthma, non-selective beta-blockers are generally contraindicated. The nurse should consult with the provider to ensure that Propranolol is the appropriate choice, as there may be safer alternatives to manage the client's condition without worsening their asthma.
Choice A rationale:
Prednisone is a corticosteroid commonly used to reduce inflammation and manage asthma exacerbations. It is an appropriate medication for asthma management and does not require clarification.
Choice B rationale:
Montelukast is a leukotriene receptor antagonist that is also used in the management of asthma. It helps to reduce airway inflammation and bronchoconstriction. Montelukast is an appropriate choice for asthma and does not need further clarification.
Choice C rationale:
Aminophylline is a bronchodilator that can be used in the treatment of asthma. While it may have potential side effects and interactions, it is not the first medication that needs clarification in this scenario. Propranolol, due to its potential to worsen asthma symptoms, takes precedence.
A nurse is reinforcing discharge teaching with a client about dietary sources of potassium.
Which of the following statements by the client indicates an understanding of the teaching?
A. "I can plan to eat rice instead of baked potatoes.”.
Baked potatoes are an exceptionally high source of potassium. Replacing them with white rice, which is significantly lower in potassium, indicates a misunderstanding of how to increase dietary intake.
B. "Adding pecans will be a change I can readily make.”.
While nuts contain some potassium, pecans are not considered a primary high-potassium source compared to fruits and vegetables. Relying on pecans alone is insufficient for meaningful dietary supplementation.
C. "I will eat cantaloupe for my morning snack.”.
Cantaloupe is a high-potassium fruit. Choosing it as a regular snack demonstrates that the client correctly identified a specific food item that will help increase their potassium levels effectively.
D. "I will miss eating yogurt every day for breakfast.”.
Yogurt is actually a good source of potassium. The statement that the client will "miss" it suggests they incorrectly believe it must be avoided, rather than encouraged, in their diet.
Full Explanation
Choice A rationale:
"I can plan to eat rice instead of baked potatoes.”. This choice demonstrates an understanding of dietary sources of potassium. Baked potatoes are a good source of potassium, and the client's willingness to substitute rice for baked potatoes indicates that they are aware of alternative potassium-rich foods. Potassium is essential for various bodily functions, including maintaining proper heart and muscle function. The client's willingness to make a dietary adjustment is a positive sign.
Choice B rationale:
"Adding pecans will be a change I can readily make.”. While pecans are a good source of potassium, this choice does not directly address the client's ability to substitute a potassium-rich food for one they might need to avoid. It focuses on a new addition to their diet rather than a substitution, making it a less relevant response to the teaching.
Choice C rationale:
"I will eat cantaloupe for my morning snack.”. Cantaloupe is indeed a good source of potassium, but this choice does not indicate an understanding of how to substitute potassium-rich foods in their diet. It only mentions adding cantaloupe as a snack without addressing the potential need for replacing other foods high in potassium. Therefore, it does not fully demonstrate comprehension of the teaching.
Choice D rationale:
"I will miss eating yogurt every day for breakfast.”. This choice expresses a sentiment but does not show an understanding of the teaching regarding dietary sources of potassium. It merely states that the client will miss yogurt without providing any insight into their ability to make appropriate dietary choices to maintain adequate potassium intake.