Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?
A. Assist the client to a prone position.
Choice A is wrong because the client should be placed in a lithotomy position, not a prone position, for a pelvic examination.
B. Ask the client to empty their bladder.
This is because a full bladder can interfere with the pelvic examination and cause discomfort to the client. The nurse should also instruct the client to avoid douching, using tampons, vaginal medications, sprays, powders, birth control foam, cream, or jelly for at least 24 hours before the exam.
C. Instruct the client to douche.
Choice C is wrong because douching can alter the normal vaginal flora and pH, and increase the risk of infection.
D. Place the client’s arms over their head.
Choice D is wrong because placing the client’s arms over their head can tighten the abdominal muscles and make the examination more difficult. The nurse should ask the client to place their arms at their sides or across their chest.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Capstone Proctored Comprehensive Assessment 2020 B. Take the full exam now
Full Explanation
Ask the client to empty their bladder.
This is because a full bladder can interfere with the pelvic examination and cause discomfort to the client. The nurse should also instruct the client to avoid douching, using tampons, vaginal medications, sprays, powders, birth control foam, cream, or jelly for at least 24 hours before the exam.
Choice A is wrong because the client should be placed in a lithotomy position, not a prone position, for a pelvic examination.
Choice C is wrong because douching can alter the normal vaginal flora and pH, and increase the risk of infection.
Choice D is wrong because placing the client’s arms over their head can tighten the abdominal muscles and make the examination more difficult. The nurse should ask the client to place their arms at their sides or across their chest.
Similar Questions
A nurse is reinforcing teaching with a client who requires a bladder-training program for urinary incontinence.
Which of the following instructions should the nurse include in the teaching?
A. “Record your urination times for 24 hours before beginning the program.”
Keeping a voiding diary can help assess patterns, but it is not the primary instruction when reinforcing an active bladder-training schedule.
B. “Drink 4 liters of fluid between 6:00 a.m. and 8:00 p.m.”
Drinking 4 liters of fluid is excessive and can worsen urinary frequency and urgency.
C. “Void every 2 hours while awake.”
Voiding every 2 hours while awake is a standard initial bladder-training strategy. It establishes a scheduled pattern and helps prevent episodes of incontinence, with intervals gradually increased as control improves.
D. “Eliminate caffeine from your diet.”
Eliminating caffeine helps reduce bladder irritation, but it is an adjunct lifestyle modification rather than the core bladder-training technique.
E. None
None
F. None
None
Full Explanation
A. Keeping a voiding diary can help assess patterns, but it is not the primary instruction when reinforcing an active bladder-training schedule.
B. Drinking 4 liters of fluid is excessive and can worsen urinary frequency and urgency.
C. Voiding every 2 hours while awake is a standard initial bladder-training strategy. It establishes a scheduled pattern and helps prevent episodes of incontinence, with intervals gradually increased as control improves.
D. Eliminating caffeine helps reduce bladder irritation, but it is an adjunct lifestyle modification rather than the core bladder-training technique.
A nurse is contributing to the plan of care for a newly admitted client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse recommend?
A. Offer the client fluids high in fiber and protein every hour.
Offer the client fluids high in fiber and protein every hour. This is because clients who have bipolar disorder and are experiencing mania are at risk of dehydration, malnutrition, and weight loss due to increased activity, poor intake, and impaired judgment. Fluids high in fiber and protein can help prevent constipation and promote satiety.
B. Monitor the client’s vital signs twice per day.
Choice B is wrong because monitoring the client’s vital signs twice per day is not enough for a client who has mania. The nurse should monitor the client’s vital signs more frequently, at least every 4 hours, to assess for signs of dehydration, infection, or cardiac complications.
C. Encourage the client to participate in group therapy activities each day.
Choice C is wrong because encouraging the client to participate in group therapy activities each day can increase the client’s stimulation and agitation. The nurse should provide a calming environment with fewer stimuli and solitary activities for a client who has mania.
D. Weigh the client three times per week.
Choice D is wrong because weighing the client three times per week is not sufficient for a client who has mania. The nurse should weigh the client daily to monitor for weight loss and fluid imbalance.
Full Explanation
Offer the client fluids high in fiber and protein every hour. This is because clients who have bipolar disorder and are experiencing mania are at risk of dehydration, malnutrition, and weight loss due to increased activity, poor intake, and impaired judgment. Fluids high in fiber and protein can help prevent constipation and promote satiety.
Choice B is wrong because monitoring the client’s vital signs twice per day is not enough for a client who has mania. The nurse should monitor the client’s vital signs more frequently, at least every 4 hours, to assess for signs of dehydration, infection, or cardiac complications.
Choice C is wrong because encouraging the client to participate in group therapy activities each day can increase the client’s stimulation and agitation. The nurse should provide a calming environment with fewer stimuli and solitary activities for a client who has mania.
Choice D is wrong because weighing the client three times per week is not sufficient for a client who has mania. The nurse should weigh the client daily to monitor for weight loss and fluid imbalance.
A nurse is reinforcing teaching with a client who has gestational diabetes mellitus.
Which of the following statements by the client indicates an understanding of the teaching?
A. “My baby will be monitored for hypoglycemia after birth.”
This statement indicates an understanding of the teaching because babies born to mothers with gestational diabetes mellitus (GDM) are at risk for low blood sugar (hypoglycemia) after birth due to high insulin levels.
B. “I will check my blood glucose once every 8 hours.”
Choice B is wrong because a client who has GDM should check their blood glucose more frequently than once every 8 hours. The American Diabetes Association recommends checking blood glucose levels before meals and one hour after the start of each meal.
C. “My baby is at risk for being underweight at birth.”
Choice C is wrong because a baby born to a mother with GDM is at risk for being overweight (macrosomia) at birth, not underweight. This can lead to complications such as shoulder dystocia, birth trauma, and cesarean delivery.
D. “I should ensure that only 5 percent of my daily calories come from protein sources.”
Choice D is wrong because a client who has GDM should ensure that about 15 to 20 percent of their daily calories come from protein sources, not 5 percent. Protein helps regulate blood glucose levels and supports fetal growth.
Full Explanation
This statement indicates an understanding of the teaching because babies born to mothers with gestational diabetes mellitus (GDM) are at risk for low blood sugar (hypoglycemia) after birth due to high insulin levels.
Choice B is wrong because a client who has GDM should check their blood glucose more frequently than once every 8 hours. The American Diabetes Association recommends checking blood glucose levels before meals and one hour after the start of each meal.
Choice C is wrong because a baby born to a mother with GDM is at risk for being overweight (macrosomia) at birth, not underweight. This can lead to complications such as shoulder dystocia, birth trauma, and cesarean delivery.
Choice D is wrong because a client who has GDM should ensure that about 15 to 20 percent of their daily calories come from protein sources, not 5 percent. Protein helps regulate blood glucose levels and supports fetal growth.