Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to administer vancomycin IV to an adult client.
The client asks the nurse if the medication can be given 2 hr earlier.
Which of the following statements should the nurse make?
A. “I can adjust the time and schedule for when it’s convenient for you.”.
“I can adjust the time and schedule for when it’s convenient for you.” This statement is incorrect because vancomycin administration requires strict adherence to timing to maintain therapeutic levels and prevent resistance. Adjusting the schedule based on convenience could lead to suboptimal dosing and potential treatment failure.
B. “I can start the medication 30 minutes earlier.”.
Vancomycin is an antibiotic that requires careful timing and administration to maintain its therapeutic levels and minimize side effects like nephrotoxicity. While some medications allow for more flexibility in timing, vancomycin dosing must adhere to strict guidelines.
C. “I have up to 2 hours after the usual schedule time to give you this medication.”.
Vancomycin should be given as close to the prescribed time as possible—having a 2-hour window is too broad.
D. “I can infuse the medication at a faster rate.”.
“I can infuse the medication at a faster rate.” This statement is incorrect and potentially dangerous. Vancomycin should be infused slowly, typically over at least 60 minutes, to prevent adverse reactions such as “red man syndrome,” which is characterized by flushing, rash, and hypotension.
E. None
None
F. None
None
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is choice b. "I can start the medication 30 minutes earlier."Choice A rationale: This is an inappropriate response, as the nurse should not adjust the time and schedule for the administration of alteplase recombinant, which is a time-sensitive medication used to treat a thrombus in the coronary artery. The administration of this medication must be done within a specific time frame to be effective.Choice B rationale: This is the correct answer. Alteplase recombinant is a thrombolytic medication used to dissolve blood clots in the coronary artery. It is a time-sensitive medication, and it is crucial to administer it as soon as possible to minimize the damage to the heart muscle. Starting the medication 30 minutes earlier is an appropriate action to include in the plan of care, as it can help ensure the medication is administered within the recommended time frame.Choice C rationale: This is an inappropriate response. Alteplase recombinant should be administered within a specific time frame, typically within 3 to 4.5 hours of the onset of symptoms. Waiting up to 2 hours after the usual schedule time to give the medication would be outside the recommended time frame and could potentially reduce the effectiveness of the treatment.Choice D rationale: This is an inappropriate response. Alteplase recombinant should be infused at a specific rate, as recommended by the manufacturer or healthcare provider. Infusing the medication at a faster rate could increase the risk of adverse effects and should not be included in the plan of care without specific instructions from the healthcare provider.
Similar Questions
A nurse in an emergency department is caring for a child who reports being sexually abused by a family member.
Which of the following actions should the nurse take?
A. Reassure the child that no one will be told about the abuse.
because reassuring the child that no one will be told about the abuse is unethical and illegal. The nurse has a mandatory duty to report any suspected or confirmed cases of child abuse to the appropriate authorities, such as child protective services or law enforcement. Keeping the abuse a secret can also endanger the child’s safety and well-being, as well as prevent them from receiving the necessary medical and psychological care.
B. Ensure that multiple nurses are present for the physical examination.
wrong because ensuring that multiple nurses are present for the physical examination can increase the child’s fear, embarrassment, or discomfort. The nurse should minimize the number of people involved in the examination and only include those who are essential for providing care or collecting evidence. The nurse should also explain to the child what will be done during the examination and obtain their consent before proceeding.
C. Explain to the child what will happen when the abuse is reported.
Explain to the child what will happen when the abuse is reported. This is because the nurse should provide honest and accurate information to the child about the reporting process and the possible outcomes, such as legal actions, investigations, or removal from the home. This can help the child feel more prepared and less anxious about what will happen next. The nurse should also reassure the child that the abuse is not their fault and that they did the right thing by telling someone.
D. Use leading statements to obtain information from the child.
is wrong because using leading statements to obtain information from the child can influence their responses and affect the validity of their testimony. The nurse should use open-ended questions and avoid suggesting or implying any details about the abuse. The nurse should also document the child’s statements verbatim and avoid interpreting or paraphrasing them.
Full Explanation
The correct answer is C. Explain to the child what will happen when the abuse is reported.
This is because the nurse should provide honest and accurate information to the child about the reporting process and the possible outcomes, such as legal actions, investigations, or removal from the home.
This can help the child feel more prepared and less anxious about what will happen next. The nurse should also reassure the child that the abuse is not their fault and that they did the right thing by telling someone.
Choice A is wrong because reassuring the child that no one will be told about the abuse is unethical and illegal.
The nurse has a mandatory duty to report any suspected or confirmed cases of child abuse to the appropriate authorities, such as child protective services or law enforcement. Keeping the abuse a secret can also endanger the child’s safety and well-being, as well as prevent them from receiving the necessary medical and psychological care.
Choice B is wrong because ensuring that multiple nurses are present for the physical examination can increase the child’s fear, embarrassment, or discomfort.
The nurse should minimize the number of people involved in the examination and only include those who are essential for providing care or collecting evidence. The nurse should also explain to the child what will be done during the examination and obtain their consent before proceeding.
Choice D is wrong because using leading statements to obtain information from the child can influence their responses and affect the validity of their testimony.
The nurse should use open-ended questions and avoid suggesting or implying any details about the abuse. The nurse should also document the child’s statements verbatim and avoid interpreting or paraphrasing them.
A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min.
The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
A. Maternal hypoglycemia.
Maternal hypoglycemia can lead to fetal bradycardia, causing a sustained low fetal heart rate. Hypoglycemia in the mother can affect the fetus by reducing the availability of glucose, which is essential for fetal metabolism and heart function. -
B. Maternal fever.
Maternal fever is more commonly associated with fetal tachycardia rather than bradycardia. Fever in the mother can lead to an increased fetal heart rate, not a decreased one. -
C. Chorioamnionitis.
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, which can lead to fetal distress and tachycardia rather than bradycardia.
D. Fetal anemia.
Fetal anemia can also cause bradycardia, but in this scenario, maternal hypoglycemia is a more immediate concern as it directly affects the fetal heart rate by impacting the fetal metabolic processes.
Full Explanation
The correct answer is choice a. Maternal hypoglycemia.
Choice A rationale:
Maternal hypoglycemia can lead to fetal bradycardia, causing a sustained low fetal heart rate. Hypoglycemia in the mother can affect the fetus by reducing the availability of glucose, which is essential for fetal metabolism and heart function.
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Choice B rationale:
Maternal fever is more commonly associated with fetal tachycardia rather than bradycardia. Fever in the mother can lead to an increased fetal heart rate, not a decreased one.
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Choice C rationale:
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, which can lead to fetal distress and tachycardia rather than bradycardia.
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Choice D rationale:
Fetal anemia can also cause bradycardia, but in this scenario, maternal hypoglycemia is a more immediate concern as it directly affects the fetal heart rate by impacting the fetal metabolic processes.
A nurse is assessing a client who is in active labor.
Which of the following findings should the nurse report to the provider?
A. Early decelerations in the FHR.
wrong because early decelerations in the FHR are normal and benign, and indicate head compression during contractions. They do not require any intervention or reporting.
B. Contractions lasting 80 seconds.
wrong because contractions lasting 80 seconds are within the normal range for active labor, which is 40 to 90 seconds per contraction. They do not indicate any complication or abnormality.
C. FHR baseline 170/min.
FHR baseline 170/min. This is because a normal FHR baseline is between 110 and 160 bpm, and anything above or below this range indicates fetal distress and should be reported to the provider. A FHR baseline of 170/min could indicate fetal tachycardia, which could be caused by maternal fever, infection, dehydration, fetal anemia, or fetal hypoxia.
D. Temperature 37.4° C (99.3° F).
wrong because a temperature of 37.4° C (99.3° F) is slightly elevated but not considered a fever. A fever is defined as a temperature of 38° C (100.4° F) or higher. A mild increase in temperature could be due to dehydration, exertion, or environmental factors, and does not necessarily indicate infection or inflammation.
Full Explanation
The correct answer is C. FHR baseline 170/min. This is because a normal FHR baseline is between 110 and 160 bpm, and anything above or below this range indicates fetal distress and should be reported to the provider. A FHR baseline of 170/min could indicate fetal tachycardia, which could be caused by maternal fever, infection, dehydration, fetal anemia, or fetal hypoxia.
Choice A is wrong because early decelerations in the FHR are normal and benign, and indicate head compression during contractions.
They do not require any intervention or reporting.
Choice B is wrong because contractions lasting 80 seconds are within the normal range for active labor, which is 40 to 90 seconds per contraction.
They do not indicate any complication or abnormality.
Choice D is wrong because a temperature of 37.4° C (99.3° F) is slightly elevated but not considered a fever. A fever is defined as a temperature of 38° C (100.4° F) or higher.
A mild increase in temperature could be due to dehydration, exertion, or environmental factors, and does not necessarily indicate infection or inflammation.