Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client's ring?
A. Place the client's ring in the facility safe.
Placing the client's ring in the facility safe ensures that it is securely stored and prevents loss or misplacement, which is standard procedure for valuable personal items before surgery.
B. Place the ring in the bag with the client's clothing
Placing the ring in the bag with the client’s clothing is not secure, as it increases the risk of loss or theft.
C. Tape the ring securely to the client's finger
Taping the ring to the client’s finger is not ideal because jewelry should generally be removed before surgery to prevent complications such as swelling, circulation issues, or electrical burns from cautery equipment.
D. Agree to keep the ring for the client until after surgery.
Keeping the ring for the client is inappropriate because staff should not personally hold onto a client’s valuables. Instead, valuables should be properly documented and stored per facility policy.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Leadership 2019 Proctored Exam. Take the full exam now
Full Explanation
A. Placing the client's ring in the facility safe ensures that it is securely stored and prevents loss or misplacement, which is standard procedure for valuable personal items before surgery.
B. Placing the ring in the bag with the client’s clothing is not secure, as it increases the risk of loss or theft.
C. Taping the ring to the client’s finger is not ideal because jewelry should generally be removed before surgery to prevent complications such as swelling, circulation issues, or electrical burns from cautery equipment.
D. Keeping the ring for the client is inappropriate because staff should not personally hold onto a client’s valuables. Instead, valuables should be properly documented and stored per facility policy.
Similar Questions
A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? (Select all that apply.)
A. Identify the medication name and dosage administered to the client in the report.
Identify the medication name and dosage administered to the client in the report: Providing specific details about the medication involved is crucial for accurately documenting the incident.
B. Make a copy of the incident report for personal record keeping.
Making a copy of the incident report for personal record keeping: While keeping a personal copy might seem practical, the official incident report should be filed according to institutional policies. Personal record keeping might not align with these policies.
C. Include the time the medication error occurred in the report.
Include the time the medication error occurred in the report: Documenting the time helps in understanding the sequence of events and aids in investigating the error.
D. Obtain an order from the client's provider to complete the report.
Obtaining an order from the client's provider to complete the report: Typically, healthcare providers do not need to issue an order for a nurse to complete an incident report; it's part of the facility's standard reporting process.
E. Place a copy of the completed report in the client's medical record.
It is not necessary to place a copy of the report in the client's medical record.
Full Explanation
A. Identify the medication name and dosage administered to the client in the report: Providing specific details about the medication involved is crucial for accurately documenting the incident.
B. Making a copy of the incident report for personal record keeping: While keeping a personal copy might seem practical, the official incident report should be filed according to institutional policies. Personal record keeping might not align with these policies.
C. Include the time the medication error occurred in the report: Documenting the time helps in understanding the sequence of events and aids in investigating the error.
D. Obtaining an order from the client's provider to complete the report: Typically, healthcare providers do not need to issue an order for a nurse to complete an incident report; it's part of the facility's standard reporting process.
E. It is not necessary to place a copy of the report in the client's medical record.
A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full-thickness burns on 72% of his body?
A. Black
Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
B. Yellow
Yellow tags are used for those who require observation but are not in immediate danger.
C. Red
Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
D. Green
Green tags are used for individuals with minor injuries or those who require minimal medical assistance.
Full Explanation
A. Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
B. Yellow tags are used for those who require observation but are not in immediate danger.
C. Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
D. Green tags are used for individuals with minor injuries or those who require minimal medical assistance.
A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate?
A. "You'll be fine. You'll receive a prescription for pain medication."
Dismissing the client's concerns and suggesting pain medication without addressing the client's worries isn't an empathetic or helpful response.
B. "Why didn't you discuss your concerns with your provider?"
Asking why the client didn't discuss concerns with the provider might make the client feel guilty or judged for their decision.
C. "If you have the procedure now, you won't have to deal with pain and disability later."
Pressuring the client by suggesting avoiding future pain and disability isn't respectful of the client's current concerns and decision-making.
D. "I understand, and it's not too late to change your mind,"
Acknowledging the client's worries and affirming their ability to change their mind is an appropriate and supportive response.
Full Explanation
A. Dismissing the client's concerns and suggesting pain medication without addressing the client's worries isn't an empathetic or helpful response.
B. Asking why the client didn't discuss concerns with the provider might make the client feel guilty or judged for their decision.
C. Pressuring the client by suggesting avoiding future pain and disability isn't respectful of the client's current concerns and decision-making.
D. Acknowledging the client's worries and affirming their ability to change their mind is an appropriate and supportive response.