Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing a client for a sigmoidoscopy. In which of the following positions should the nurse place the client?
A. Orthopneic
Orthopneic position is upright sitting with arms and elbows resting on a table or on a pillow, which helps clients who have difficulty breathing; it is not suitable for sigmoidoscopy.
B. Trendelenburg
Trendelenburg's positionis supine with the head lower than the feet, which can cause blood flow to the head and increased intracranial pressure; it is not suitable for sigmoidoscopy.
C. Prone
The prone position is lying face down, which is not suitable for sigmoidoscopy.
D. Knee-chest
During sigmoidoscopy, the client should lie on their left side with their right knee flexed slightly. The nurse should then position the client in the knee-chest (Sims) position, where the client leans forward with bent knees and support the chest and forearms on the table or a pillow. This allows better visualization and access to the rectal area for the sigmoidoscopy procedure.
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Full Explanation
knee-chest. During sigmoidoscopy, the client should lie on their left side with their right knee flexed slightly. The nurse should then position the client in the knee-chest (Sims) position, where the client leans forward with bent knees and support the chest and forearms on the table or a pillow. This allows better visualization and access to the rectal area for the sigmoidoscopy procedure.
An explanation for incorrect choices:
A. Orthopneic position is upright sitting with arms and elbows resting on a table or on a pillow, which helps clients who have difficulty breathing; it is not suitable for sigmoidoscopy.
B. Trendelenburg position
is supine with the head lower than the feet, which can cause blood flow to the head and increased intracranial pressure; it is not suitable for sigmoidoscopy.
C. Prone position is lying face down, which is not suitable for sigmoidoscopy.
Similar Questions
A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take?
A. Cover the pad prior to use.
This is a necessary precaution to prevent burns
B. Fill the pad with sterile water.
incorrect because filling the pad with sterile water is not necessary
C. Apply the pad for 45 min at a time.
incorrect because aquathermia pads should only be applied for 20-30 minutes at a time
D. Use safety pins to secure the pad in place.
incorrect because using safety pins to secure the pad in place can puncture the pad and cause burns.
Full Explanation
The correct answer is choice A, "Cover the pad prior to use." This is a necessary precaution to prevent burns. Choice B is incorrect because filling the pad with sterile water is not necessary. Choice C is incorrect because aquathermia pads should only be applied for 20-30 minutes at a time. Choice D is incorrect because using safety pins to secure the pad in place can puncture the pad and cause burns. Choice B is not correct because filling the pad with sterile water is not necessary. Choice C is not correct because aquathermia pads should only be applied for 20-30 minutes at a time. Choice D is not correct because using safety pins to secure the pad in place can puncture the pad and cause burns.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
A. Monitor the client for weight loss.
Weight loss is not a common adverse effect or risk associated with transdermal clonidine.
B. Advise the client about increased dry mouth.
Advise the client about increased dry mouth. Transdermal clonidine can cause xerostomia, or dry mouth, due to a decrease in salivary secretion. The nurse should advise the client to maintain good oral hygiene and to increase fluid intake to prevent oral and dental problems.
C. Inform the client of the adverse effect of diarrhea.
Diarrhea can occur with transdermal clonidine, but it is not a common adverse effect or risk.
D. Check the client for increased hypopigmentation under the patch.
Hypopigmentation is rare with transdermal clonidine; it is more common with corticosteroids.
Full Explanation
Advise the client about increased dry mouth. Transdermal clonidine can cause xerostomia, or dry mouth, due to a decrease in salivary secretion. The nurse should advise the client to maintain good oral hygiene and to increase fluid intake to prevent oral and dental problems.
An explanation for incorrect choices:
A. Weight loss is not a common adverse effect or risk associated with transdermal clonidine.
C. Diarrhea can occur with transdermal clonidine, but it is not a common adverse effect or risk.
D. Hypopigmentation is rare with transdermal clonidine; it is more common with corticosteroids.
A nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take? (Select all that apply.)
A. Apply ice to the larger blisters.
"Apply ice to the larger blisters" is an incorrect answer because applying ice can cause further damage to the skin and delay healing.
B. Administer ibuprofen for pain.
"Administer ibuprofen for pain" is an incorrect answer because the nurse cannot administer medications without a physician's order.
C. Maintain skin integrity over the blisters.
"Maintain skin integrity over the blisters" is an incorrect answer because maintaining skin integrity over the blisters can cause further damage and delay healing.
D. Run cool water over the affected area.
Running cool water over the affected area will help to decrease pain and prevent further tissue damage. Allowing the affected area to remain open to air will help to promote healing and prevent infection.
E. Allow the affected area to remain open to air.
Full Explanation
Running cool water over the affected area will help to decrease pain and prevent further tissue damage. Allowing the affected area to remain open to air will help to promote healing and prevent infection.
A. "Apply ice to the larger blisters" is an incorrect answer because applying ice can cause further damage to the skin and delay healing.
B. "Administer ibuprofen for pain" is an incorrect answer because the nurse cannot administer medications without a physician's order.
C. "Maintain skin integrity over the blisters" is an incorrect answer because maintaining skin integrity over the blisters can cause further damage and delay healing.
Explanation: The nurse should run cool water over the affected area and allow it to remain open to the air to promote healing and prevent infection. Applying ice or medication without a physician's order can cause further damage and delay healing.