Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?
A. A client who told an assistive personnel he is short of breath
Reason: This is correct because a client who is short of breath is in immediate danger, as it indicates a possible respiratory compromise or failure. The nurse should assess the client's oxygen saturation, respiratory rate, and lung sounds, and provide oxygen therapy as needed.
B. A client who received oral pain medication 30 min ago
Reason: This is incorrect because a client who received oral pain medication 30 min ago is not in immediate danger, as it indicates that the client's pain has been managed and the medication has had time to take effect.
C. A client who is scheduled for an abdominal x-ray and is awaiting transport
Reason: This is incorrect because a client who is scheduled for an abdominal x-ray and is awaiting transport is not in immediate danger, as it indicates that the client's condition is stable and the diagnostic test is not urgent.
D. A client who has a prescription for discharge
Reason: This is incorrect because a client who has a prescription for discharge is not in immediate danger, as it indicates that the client's condition has improved and the client is ready to leave the hospital.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Custom N235 Final Summer 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A Reason: This is correct because a client who is short of breath is in immediate danger, as it indicates a possible respiratory compromise or failure. The nurse should assess the client's oxygen saturation, respiratory rate, and lung sounds, and provide oxygen therapy as needed.
Choice B Reason: This is incorrect because a client who received oral pain medication 30 min ago is not in immediate danger, as it indicates that the client's pain has been managed and the medication has had time to take effect.
Choice C Reason: This is incorrect because a client who is scheduled for an abdominal x-ray and is awaiting transport is not in immediate danger, as it indicates that the client's condition is stable and the diagnostic test is not urgent.
Choice D Reason: This is incorrect because a client who has a prescription for discharge is not in immediate danger, as it indicates that the client's condition has improved and the client is ready to leave the hospital.
Similar Questions
A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 is 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid-base imbalances?
A. Respiratory acidosis
Reason: This is correct because respiratory acidosis is characterized by a low pH and a high PaCO2, indicating that the client has impaired ventilation and excess carbon dioxide in the blood.
B. Respiratory alkalosis
Reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2, indicating that the client has increased ventilation and reduced carbon dioxide in the blood.
C. Metabolic acidosis
Reason: This is incorrect because metabolic acidosis is characterized by a low pH and a low HCO3, indicating that the client has an excess of metabolic acids or a loss of base in the blood.
D. Metabolic alkalosis
Reason: This is incorrect because metabolic alkalosis is characterized by a high pH and a high HCO3, indicating that the client has an excess of base or a loss of metabolic acids in the blood.
Full Explanation
Choice A Reason: This is correct because respiratory acidosis is characterized by a low pH and a high PaCO2, indicating that the client has impaired ventilation and excess carbon dioxide in the blood.
Choice B Reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2, indicating that the client has increased ventilation and reduced carbon dioxide in the blood.
Choice C Reason: This is incorrect because metabolic acidosis is characterized by a low pH and a low HCO3, indicating that the client has an excess of metabolic acids or a loss of base in the blood.
Choice D Reason: This is incorrect because metabolic alkalosis is characterized by a high pH and a high HCO3, indicating that the client has an excess of base or a loss of metabolic acids in the blood.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury?
A. Dextrose 5% in 0.9% sodium chloride
Reason: This is incorrect because dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can cause fluid overload and pulmonary edema in a client who has burns.
B. Dextrose 5% in water
Reason: This is incorrect because dextrose 5% in water is a hypotonic solution that can cause fluid shifts from the intravascular space to the interstitial space, resulting in hypovolemia and hypotension in a client who has burns.
C. 0.9% sodium chloride
Reason: This is incorrect because 0.9% sodium chloride is an isotonic solution that can cause hypernatremia and hyperchloremia in a client who has burns, as the fluid loss from burns is greater than the sodium loss.
D. Lactated Ringer's
Reason: This is correct because lactated Ringer's is an isotonic solution that contains electrolytes similar to plasma, such as sodium, potassium, calcium, and chloride. It also contains lactate, which is converted to bicarbonate in the liver and helps correct the metabolic acidosis that occurs in a client who has burns.
Full Explanation
Choice A Reason: This is incorrect because dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can cause fluid overload and pulmonary edema in a client who has burns.
Choice B Reason: This is incorrect because dextrose 5% in water is a hypotonic solution that can cause fluid shifts from the intravascular space to the interstitial space, resulting in hypovolemia and hypotension in a client who has burns.
Choice C Reason: This is incorrect because 0.9% sodium chloride is an isotonic solution that can cause hypernatremia and hyperchloremia in a client who has burns, as the fluid loss from burns is greater than the sodium loss.
Choice D Reason: This is correct because lactated Ringer's is an isotonic solution that contains electrolytes similar to plasma, such as sodium, potassium, calcium, and chloride. It also contains lactate, which is converted to bicarbonate in the liver and helps correct the metabolic acidosis that occurs in a client who has burns.
A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?
A. Use log rolling to reposition the client.
Reason: This is correct because using log rolling to reposition the client helps maintain the alignment of the head and neck, which prevents further increases in ICP.
B. Place a warming blanket on the client.
Reason: This is incorrect because placing a warming blanket on the client can cause vasodilation and increase cerebral blood flow, which can raise ICP.
C. Instruct the client to cough and deep breathe.
Reason: This is incorrect because instructing the client to cough and deep breathe can increase intrathoracic pressure and impede venous return, which can elevate ICP.
D. Place the client in a supine position.
Reason: This is incorrect because placing the client in a supine position can decrease cerebral perfusion pressure and increase ICP. The client should be placed in a semi-Fowler's position with the head elevated at 30 degrees.
Full Explanation
Choice A Reason: This is correct because using log rolling to reposition the client helps maintain the alignment of the head and neck, which prevents further increases in ICP.
Choice B Reason: This is incorrect because placing a warming blanket on the client can cause vasodilation and increase cerebral blood flow, which can raise ICP.
Choice C Reason: This is incorrect because instructing the client to cough and deep breathe can increase intrathoracic pressure and impede venous return, which can elevate ICP.
Choice D Reason: This is incorrect because placing the client in a supine position can decrease cerebral perfusion pressure and increase ICP. The client should be placed in a semi-Fowler's position with the head elevated at 30 degrees.