Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to provide hydrotherapy for a client who has a burn wound. Which of the following actions should the nurse plan to take?
A. Use fingers to remove loose tissue.
Using fingers to remove loose tissue is not an appropriate action for the nurse to take when providing hydrotherapy for a burn wound. This action can cause further trauma to the wound and increase the risk of infection.
B. Open small blisters to expose air.
Opening small blisters to expose air is contraindicated in burn wound management. The blister roof provides a natural barrier against infection, and puncturing them increases the risk of infection and delays the healing process.
C. Wash the burn with a mild soap.
The correct answer is to wash the burn with a mild soap. Cleaning the burn wound with mild soap and water helps remove debris and minimize the risk of infection without causing additional damage.
D. Apply wet-to-dry dressing.
Applying wet-to-dry dressings is an outdated and inappropriate practice for burn wound care. Wet-to-dry dressings can be painful, disrupt wound healing, and increase the risk of infection. Modern burn wound care focuses on maintaining a moist environment to support optimal healing.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN VATI Adult Medical Surgical S 2019 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Using fingers to remove loose tissue is not an appropriate action for the nurse to take when providing hydrotherapy for a burn wound. This action can cause further trauma to the wound and increase the risk of infection.
Choice B rationale:
Opening small blisters to expose air is contraindicated in burn wound management. The blister roof provides a natural barrier against infection, and puncturing them increases the risk of infection and delays the healing process.
Choice C rationale:
The correct answer is to wash the burn with a mild soap. Cleaning the burn wound with mild soap and water helps remove debris and minimize the risk of infection without causing additional damage.
Choice D rationale:
Applying wet-to-dry dressings is an outdated and inappropriate practice for burn wound care. Wet-to-dry dressings can be painful, disrupt wound healing, and increase the risk of infection. Modern burn wound care focuses on maintaining a moist environment to support optimal healing.
Similar Questions
A nurse is caring for a client who is scheduled for diagnostic thoracentesis. Which of the following actions should the nurse take when assisting with this test?
A. Instruct the client to take deep breaths during the test.
Instructing the client to take deep breaths during the test is not appropriate for a thoracentesis. This procedure involves the insertion of a needle into the pleural space to drain fluid or air, and taking deep breaths could interfere with the accuracy and safety of the procedure.
B. Assist the client to a prone position prior to the test.
Assisting the client to a prone position prior to the test is also incorrect. During a thoracentesis, the client is usually seated upright or in a slightly forward-leaning position to allow better access to the pleural space and improve breathing.
C. Inform the client that the new onset of a cough is expected following the test.
Informing the client that the new onset of a cough is expected following the test is not accurate. While a cough can be a possible side effect, it is not a common or expected outcome of a thoracentesis.
D. Apply pressure to the client's puncture site after the test is complete.
Applying pressure to the client's puncture site after the test is complete is the correct action. This helps to prevent bleeding and reduce the risk of pneumothorax (collapsed lung) by promoting clot formation at the site of the needle insertion.
Full Explanation
Choice A rationale:
Instructing the client to take deep breaths during the test is not appropriate for a thoracentesis. This procedure involves the insertion of a needle into the pleural space to drain fluid or air, and taking deep breaths could interfere with the accuracy and safety of the procedure.
Choice B rationale:
Assisting the client to a prone position prior to the test is also incorrect. During a thoracentesis, the client is usually seated upright or in a slightly forward-leaning position to allow better access to the pleural space and improve breathing.
Choice C rationale:
Informing the client that the new onset of a cough is expected following the test is not accurate. While a cough can be a possible side effect, it is not a common or expected outcome of a thoracentesis.
Choice D rationale:
Applying pressure to the client's puncture site after the test is complete is the correct action. This helps to prevent bleeding and reduce the risk of pneumothorax (collapsed lung) by promoting clot formation at the site of the needle insertion.
A nurse is reviewing the medical record of a client who has developed a UTI. Which of the following findings should the nurse expect?
A. Hemoptysis.
Hemoptysis, which is the coughing up of blood, is not typically associated with a urinary tract infection (UTI). It is more commonly related to respiratory or pulmonary issues.
B. Hematuria.
Hematuria, the presence of blood in the urine, is a common finding in a UTI. Inflammation and infection in the urinary tract can lead to the presence of blood cells in the urine.
C. Hyperglycemia.
Hyperglycemia, an elevated blood glucose level, is not directly related to a UTI. It may be seen in individuals with diabetes, but it is not a typical finding in a UTI.
D. Hypocalcemia.
Hypocalcemia, a low level of calcium in the blood, is not a characteristic finding in a UTI. UTIs primarily affect the urinary system and do not directly involve calcium metabolism.
Full Explanation
Choice A rationale:
Hemoptysis, which is the coughing up of blood, is not typically associated with a urinary tract infection (UTI). It is more commonly related to respiratory or pulmonary issues.
Choice B rationale:
Hematuria, the presence of blood in the urine, is a common finding in a UTI. Inflammation and infection in the urinary tract can lead to the presence of blood cells in the urine.
Choice C rationale:
Hyperglycemia, an elevated blood glucose level, is not directly related to a UTI. It may be seen in individuals with diabetes, but it is not a typical finding in a UTI.
Choice D rationale:
Hypocalcemia, a low level of calcium in the blood, is not a characteristic finding in a UTI. UTIs primarily affect the urinary system and do not directly involve calcium metabolism.
A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).
A. 0.4 mL.
0.4 mL is not the correct dose.
B. 0.5 mL.
Let's break down the calculation: Given: Patient weight: 154 lbs Enoxaparin dosage: 0.75 mg/kg Available enoxaparin: 60 mg/0.6 mL Step 1: Convert pounds to kilograms: 1 lb is approximately 0.4536 kg So, 154 lbs = 154 * 0.4536 kg/lb = 69.85 kg (approximately 70 kg) Step 2: Calculate the total dose of enoxaparin: Desired dose = 0.75 mg/kg * 70 kg = 52.5 mg Step 3: Determine the volume to administer: We have enoxaparin 60 mg/0.6 mL To find the volume for 52.5 mg: (52.5 mg / 60 mg) * 0.6 mL = 0.525 mL Rounded to the nearest tenth, this is 0.5 mL. Therefore, the nurse should administer 0.5 mL of enoxaparin
C. 0.8 mL.
0.8 mL is not the correct dose.
D. 1.0 mL.
1.0 mL is not the correct dose.
Full Explanation
Let's break down the calculation:
Given:
- Patient weight: 154 lbs
- Enoxaparin dosage: 0.75 mg/kg
- Available enoxaparin: 60 mg/0.6 mL
Step 1: Convert pounds to kilograms:
- 1 lb is approximately 0.4536 kg
- So, 154 lbs = 154 * 0.4536 kg/lb = 69.85 kg (approximately 70 kg)
Step 2: Calculate the total dose of enoxaparin:
- Desired dose = 0.75 mg/kg * 70 kg = 52.5 mg
Step 3: Determine the volume to administer:
- We have enoxaparin 60 mg/0.6 mL
- To find the volume for 52.5 mg:
- (52.5 mg / 60 mg) * 0.6 mL = 0.525 mL
- Rounded to the nearest tenth, this is 0.5 mL.
Therefore, the nurse should administer 0.5 mL of enoxaparin