Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to administer 800 mg of phenytoin via IV infusion to a client who is experiencing status epilepticus. Which of the following actions should the nurse take when administering the medication?
A. Administer the phenytoin infusion over 5 min.
Phenytoin should be administered slowly to avoid adverse effects. Infusing 800 mg over 5 minutes is too rapid and can lead to cardiovascular complications.
B. Flush with 0.9% sodium chloride after administration.
Rationale: After administering phenytoin via IV, it's important to flush the IV line with normal saline (0.9% sodium chloride) to ensure the medication is fully delivered to the client and to prevent any residual medication from precipitating in the IV line.
C. Flush with 100 units/mL of heparin after administration.
Flushing with heparin is not standard practice for administering phenytoin.
D. Administer the phenytoin in 100 mL of D5W
Phenytoin should be administered in normal saline, not in D5W (dextrose 5% in water), to avoid precipitation.
This question is an excerpt from Nurse Dive's nursing test bank - RN ati Concept-based assessment level proctored exam. Take the full exam now
Full Explanation
Choice A rationale:
Phenytoin should be administered slowly to avoid adverse effects. Infusing 800 mg over 5 minutes is too rapid and can lead to cardiovascular complications.
Choice B rationale:
Rationale: After administering phenytoin via IV, it's important to flush the IV line with normal saline (0.9% sodium chloride) to ensure the medication is fully delivered to the client and to prevent any residual medication from precipitating in the IV line.
Choice C rationale:
Flushing with heparin is not standard practice for administering phenytoin.
Choice D rationale:
Phenytoin should be administered in normal saline, not in D5W (dextrose 5% in water), to avoid precipitation.
Similar Questions
A nurse is teaching a client who has gambling disorder about the use of cognitive reframing. Which of the following instructions should the nurse give the client?
A. "Perform deep-breathing exercises when you feel the urge to gamble."
Deep breathing exercises can be a relaxation technique, but they don't directly address cognitive reframing.
B. "Use a journal to write down thoughts related to gambling."
Using a journal to write down thoughts related to gambling can be useful for self-reflection, but it's not specifically a cognitive reframing technique.
C. "Reward yourself for not going to the casino for 1 week."
Rewarding oneself for not going to the casino can be part of a behavioral approach to managing gambling disorder, but it's not a cognitive reframing technique.
D. "Replace thoughts of gambling with positive self-statements."
Cognitive reframing involves identifying and replacing negative or distorted thoughts with positive and more rational thoughts. In the context of gambling disorder, this technique can help the client challenge and change the cognitive patterns that contribute to their gambling behavior.
Full Explanation
Choice A rationale:
Deep breathing exercises can be a relaxation technique, but they don't directly address cognitive reframing.
Choice B rationale:
Using a journal to write down thoughts related to gambling can be useful for self-reflection, but it's not specifically a cognitive reframing technique.
Choice C rationale:
Rewarding oneself for not going to the casino can be part of a behavioral approach to managing gambling disorder, but it's not a cognitive reframing technique.
Choice D rationale:
Cognitive reframing involves identifying and replacing negative or distorted thoughts with positive and more rational thoughts. In the context of gambling disorder, this technique can help the client challenge and change the cognitive patterns that contribute to their gambling behavior.
A nurse is providing teaching about home care to the family of a client who has dementia. Which of the following statements should the nurse make?
A. "Disguise exit doors in his home with posters."
People with dementia may become disoriented and attempt to leave their homes. Disguising exit doors with posters or camouflage can help prevent wandering and promote safety.
B. "Weigh the client once per month."
Weighing the client once per month is not directly related to dementia care and safety.
C. "Keep the lights in his room off at night."
Keeping lights on at night can help prevent falls and confusion in people with dementia.
D. "Offer him several food choices prior to meal times."
Offering several food choices prior to meal times can be overwhelming for a person with dementia. A simpler approach may be more appropriate.
Full Explanation
Choice A rationale:
People with dementia may become disoriented and attempt to leave their homes. Disguising exit doors with posters or camouflage can help prevent wandering and promote safety.
Choice B rationale:
Weighing the client once per month is not directly related to dementia care and safety.
Choice C rationale:
Keeping lights on at night can help prevent falls and confusion in people with dementia.
Choice D rationale:
Offering several food choices prior to meal times can be overwhelming for a person with dementia. A simpler approach may be more appropriate.
A nurse is caring for a client who has gambling disorder. Which of the following statements should the nurse make?
A. "Why do you think you enjoy gambling so much?"
Asking why the client enjoys gambling doesn't address the underlying issues of gambling disorder.
B. "You should apologize to your family for your behavior."
Instructing the client to apologize to their family is judgmental and not therapeutic.
C. "Your family must be very angry with you right now."
Assuming the family's emotions and feelings is not appropriate and may not be accurate.
D. "Tell me about your first experience with gambling."
Asking about the client's first experience with gambling can help uncover triggers and patterns related to the disorder, which can be useful for treatment.
Full Explanation
Choice A rationale:
Asking why the client enjoys gambling doesn't address the underlying issues of gambling disorder.
Choice B rationale:
Instructing the client to apologize to their family is judgmental and not therapeutic.
Choice C rationale:
Assuming the family's emotions and feelings is not appropriate and may not be accurate.
Choice D rationale:
Asking about the client's first experience with gambling can help uncover triggers and patterns related to the disorder, which can be useful for treatment.