Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying. Which of the
following actions should the nurse take to reduce the risk of aspiration?
A. Pinch the infant's nares during administration
B. Administer the whole dose at once
C. Hold the infant in a side-lying position
D. Administer using a needleless syringe in the buccal cavity
To reduce the risk of aspiration, the nurse should administer the liquid medication using a needleless syringe in the buccal cavity. This technique allows for precise administration of small amounts of medication into the side of the infant's mouth, minimizing the risk of choking or aspiration. Pinching the infant's nares (option a) is not necessary for medication administration and can be distressing for the infant. Administering the whole dose at once (option b) increases the risk of aspiration if the infant is unable to swallow all of it. Holding the infant in a side-lying position (option c) may be appropriate for certain situations, but it does not specifically address the risk of aspiration during medication administration.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Similar Questions
A nurse is assisting with developing a discharge plan for a client who has a new diagnosis of diabetes mellitus. The client is independent and lives alone. Which of the following interventions should the nurse plan to include?
A. Provide the client with 1 week's supply of insulin syringes
B. Arrange for a home health nurse to visit the client daily.
The nurse should plan to arrange for a home health nurse to visit the client daily. Since the client is independent and lives alone, having a home health nurse visit regularly can provide essential support, education, and monitoring of the client's diabetes management. Providing the client with a 1 week's supply of insulin syringes (option a) is important, but it alone does not address the need for ongoing care and support. Notifying the family (option c) may be appropriate, but it is not the primary intervention for ensuring the client's immediate post-discharge needs are met. Referring the client to a diabetic support group (option d) is beneficial for long-term management, but it does not address the immediate need for support and education after discharge.
C. Notify the family of the client's health status.
D. Refer the client to a diabetic support group
A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?
A. Check the client's heart rate on the oximeter
A. Check the client's heart rate on the oximeter: Although checking the heart rate may provide context for assessing the client's overall status, it does not address the primary concern of the low oxygen saturation. Understanding the client's baseline saturation level takes priority to guide further actions effectively.
B. Compare the result with the baseline reading
B. Compare the result with the baseline reading: Comparing the reading with the client's baseline is essential. For clients with chronic respiratory conditions, baseline oxygen levels may naturally be lower. Identifying if this 88% saturation is typical or unusual for the client helps determine the need for further intervention or adjustment.
C. Decrease the amount of oxygen administered
C. Decrease the amount of oxygen administered: Reducing oxygen flow when the saturation is low is contraindicated, as it could worsen hypoxia. Instead, increasing oxygen may be warranted if the reading remains below the baseline after further assessment.
D. Perform another reading while the client ambulates
D. Perform another reading while the client ambulates: Repeating the reading during ambulation may worsen hypoxia and is not ideal without understanding baseline oxygenation at rest. Re-evaluation at rest or in a different position may be more appropriate for accurate assessment.
Full Explanation
Answer: B. Compare the result with the baseline reading
Rationale:
A. Check the client's heart rate on the oximeter:
Although checking the heart rate may provide context for assessing the client's overall status, it does not address the primary concern of the low oxygen saturation. Understanding the client's baseline saturation level takes priority to guide further actions effectively.
B. Compare the result with the baseline reading:
Comparing the reading with the client's baseline is essential. For clients with chronic respiratory conditions, baseline oxygen levels may naturally be lower. Identifying if this 88% saturation is typical or unusual for the client helps determine the need for further intervention or adjustment.
C. Decrease the amount of oxygen administered:
Reducing oxygen flow when the saturation is low is contraindicated, as it could worsen hypoxia. Instead, increasing oxygen may be warranted if the reading remains below the baseline after further assessment.
D. Perform another reading while the client ambulates:
Repeating the reading during ambulation may worsen hypoxia and is not ideal without understanding baseline oxygenation at rest. Re-evaluation at rest or in a different position may be more appropriate for accurate assessment.
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following actions by the nurse demonstrates cost-effective care?
A. Flexes the client's affected hip to 120
B. Adducts the client's affected leg
C. Checks the neurovascular status of the client's lower extremities every 6 hr
D. Applies a sequential compression device to the client's lower extremities
Applying a sequential compression device to the client's lower extremities demonstrates cost-effective care. This intervention helps prevent venous thromboembolism (VTE) and is a cost-effective method compared to other measures like administering prophylactic anticoagulation medications or performing Doppler studies. Flexing the client's affected hip to 120 (option a) and adducting the affected leg (option b) are specific positioning techniques for a total hip arthroplasty but do not directly address cost- effectiveness. Checking the neurovascular status every 6 hours (option c) is important for postoperative monitoring but does not specifically demonstrate cost-effective care in this context.