Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to obtain a health history from a client who is on bedrest.
Which of the following positions should the nurse take to place the client at ease?
A. Sit on the bed next to the client
is wrong because it invades the client’s privacy and comfort zone. Standing at the side of the bed
B. Sit in a chair next to the bed
The nurse should sit in a chair next to the bed to place the client at ease. This position allows the nurse to maintain eye contact, show interest, and respect the client’s personal space. Sitting on the bed next to the client
C. Stand at the foot of the bed
is wrong because it creates a power imbalance and may intimidate the client.
D. Stand at the side of the bed
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. The nurse should sit in a chair next to the bed to place the client at ease. This position allows the nurse to maintain eye contact, show interest, and respect the client’s personal space. Sitting on the bed next to the client (choice A) is wrong because it invades the client’s privacy and comfort zone. Standing at the side of the bed (choice C) or at the foot of the bed (choice D) is wrong because it creates a power imbalance and may intimidate the client.
The nurse should also consider the client’s condition and preferences when choosing a position for the interview. For example, a client who is on bedrest may have difficulty hearing or seeing the nurse if they are too far away or at an awkward angle.
Therefore, the nurse should adjust their position accordingly and ask the client if they are comfortable with it.
Similar Questions
A nurse is caring for a client who has an implanted venous access port.
Which of the following should the nurse use to access the port?
A. butterfly needle
a butterfly needle is a small, winged needle that is used for peripheral venous access, not for accessing a port. A butterfly needle can damage the port’s septum and cause leakage or infection.
B. An angiocatheter
because an angiocatheter is a thin, plastic tube that is inserted into a vein using a needle. It is used for short-term IV therapy, not for accessing a port. An angiocatheter can also damage the port’s septum and cause complications.
C. A 25-gauge needle
wrong because a 25-gauge needle is too small to access a port. A 25-gauge needle is typically used for subcutaneous injections, not for intravenous injections. A 25-gauge needle can also clog the port or cause hemolysis (breakdown of red blood cells).
D. A noncoring needle
a noncoring needle. A noncoring needle is a special type of needle that has a beveled tip and a side hole. It is designed to prevent damage to the port’s septum, which is the soft silicone top that serves as the vein access point. A noncoring needle also reduces the risk of infection and clotting.
Full Explanation
The correct answer is choice D, a noncoring needle.
A noncoring needle is a special type of needle that has a beveled tip and a side hole. It is designed to prevent damage to the port’s septum, which is the soft silicone top that serves as the vein access point.
A noncoring needle also reduces the risk of infection and clotting.
Choice A is wrong because a butterfly needle is a small, winged needle that is used for peripheral venous access, not for accessing a port. A butterfly needle can damage the port’s septum and cause leakage or infection.
Choice B is wrong because an angiocatheter is a thin, plastic tube that is inserted into a vein using a needle.
It is used for short-term IV therapy, not for accessing a port. An angiocatheter can also damage the port’s septum and cause complications.
Choice C is wrong because a 25-gauge needle is too small to access a port.
A 25-gauge needle is typically used for subcutaneous injections, not for intravenous injections. A 25-gauge needle can also clog the port or cause hemolysis (breakdown of red blood cells).
Normal ranges for ports vary depending on the type and size of the port, but generally they have a reservoir diameter of 1.5 to 2.5 cm, a catheter length of 40 to 60 cm, and a catheter diameter of 0.8 to 1.2 mm. Ports are usually flushed with saline or heparin solution every 4 to 6 weeks when not in use to prevent clotting.
A nurse is admitting a client to a medical-surgical unit.
When performing medication reconciliation for the client, which of the following actions should the nurse take?
A. A. Compare new prescriptions with the list of medications the client reports
The nurse should compare new prescriptions with the list of medications the client reports. This is part of the medication reconciliation process, which is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
B. B. Encourage the client to make his own list after he returns to his home
because the nurse should not encourage the client to make his own list after he returns to his home. The nurse should provide the client with an updated and accurate list of medications before discharge and instruct the client to keep it with him at all times.
C. Include any adverse effects of the medications the client might develop
wrong because the nurse should not include any adverse effects of the medications the client might develop. The nurse should include any known allergies or adverse reactions the client has experienced in the past, but not potential adverse effects that have not occurred.
D. Exclude nutritional supplements from the list of medications the client reports
wrong because the nurse should not exclude nutritional supplements from the list of medications the client reports. The nurse should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions in the medication reconciliation process.
Full Explanation
The correct answer is choice A. The nurse should compare new prescriptions with the list of medications the client reports. This is part of the medication reconciliation process, which is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
Choice B is wrong because the nurse should not encourage the client to make his own list after he returns to his home. The nurse should provide the client with an updated and accurate list of medications before discharge and instruct the client to keep it with him at all times.
Choice C is wrong because the nurse should not include any adverse effects of the medications the client might develop. The nurse should include any known allergies or adverse reactions the client has experienced in the past, but not potential adverse effects that have not occurred.
Choice D is wrong because the nurse should not exclude nutritional supplements from the list of medications the client reports. The nurse should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions in the medication reconciliation process.
Some of these products may interact with prescribed medications or affect laboratory results.
A nurse is assisting with food selection for a client who follows kosher dietary traditions.
Which of the following food choices should the nurse include on the client’s food tray?
A. Ham sandwich with milk.
that choices A, B, and C are not appropriate for someone following kosher dietary traditions as they all contain meat products (ham, shrimp, bacon) combined with dairy (milk). Choice D is the only option that does not contain any meat products and is therefore the most appropriate choice for someone following kosher dietary traditions.
B. Shrimp salad and tomato soup with milk
that choices A, B, and C are not appropriate for someone following kosher dietary traditions as they all contain meat products (ham, shrimp, bacon) combined with dairy (milk). Choice D is the only option that does not contain any meat products and is therefore the most appropriate choice for someone following kosher dietary traditions.
C. Bacon and cheese quiche with milk
that choices A, B, and C are not appropriate for someone following kosher dietary traditions as they all contain meat products (ham, shrimp, bacon) combined with dairy (milk). Choice D is the only option that does not contain any meat products and is therefore the most appropriate choice for someone following kosher dietary traditions.
D. Scrambled eggs and toast with milk
For a client who follows kosher dietary traditions, it's essential to adhere to the rules and restrictions that pertain to kosher food preparation and consumption. Among the given options, the only one that aligns with kosher dietary guidelines is scrambled eggs and toast with milk.
Full Explanation
D) Scrambled eggs and toast with milk.
For a client who follows kosher dietary traditions, it's essential to adhere to the rules and restrictions that pertain to kosher food preparation and consumption. Among the given options, the only one that aligns with kosher dietary guidelines is scrambled eggs and toast with milk.
The other options (A, B, and C) contain non-kosher ingredients, such as ham, shrimp, and bacon, which are not considered kosher. Additionally, mixing meat and dairy products is generally not allowed in kosher dietary practices. So, options A, B, and C would not be appropriate for someone following kosher dietary traditions.