Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing, which of the following actions should the nurse take next?
A. Maintain direct pressure over the site.
This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
B. Check whether the bleeding has stopped.
While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
C. Obtain a radial pulse.
Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
D. Reinforce the dressing over the site.
While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is: Choice A: Maintain direct pressure over the site.
Here's the rationale for each choice:
- Choice A: Maintain direct pressure over the site (CORRECT) This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
- Choice B: Check whether the bleeding has stopped While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
- Choice C: Obtain a radial pulse Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
- Choice D: Reinforce the dressing over the site While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.
Similar Questions
A nurse is reinforcing teaching about liquid iron supplements with a client who has anemia. Which of the following information should the nurse include in the teaching?
A. Take iron supplements between meals for maximum absorption.
. The nurse should instruct the client to take iron supplements between meals for maximum absorption.
B. Reduce gastric distress by taking iron supplements with an antacid.
is incorrect because antacids can decrease absorption of iron
C. Check for orange-colored stools after 4 days of treatment.
is incorrect because orange-colored stools may occur after the first dose of iron
D. Mix iron supplements with milk to prevent staining of the teeth.
is incorrect because milk can also decrease absorption of iron
Full Explanation
The correct answer is choice A. The nurse should instruct the client to take iron supplements between meals for maximum absorption. Choice B is incorrect because antacids can decrease the absorption of iron. Choice C is incorrect because orange-colored stools may occur after the first dose of iron. Choice D is incorrect because milk can also decrease the absorption of iron. Choice B is not correct because antacids can decrease the absorption of iron. Choice C is not correct because orange-colored stools may occur after the first dose of iron. Choice D is not correct because milk can also decrease the absorption of iron.
A nurse is collecting data for an older adult client who has cystitis. Which of the following findings should the nurse expect? (Select all that apply.)
A. Dysuria
Dysuria, or painful urination, is a common symptom of cystitis due to the inflammation of the bladder lining.
B. Bradycardia
Bradycardia, or slow heart rate, is not typically associated with cystitis. Cystitis primarily affects the urinary system and does not usually impact heart rate.
C. Pruritus
Pruritus, or itching, is not a common symptom of cystitis. Itching is more often associated with skin conditions or allergic reactions.
D. Hematuria
Hematuria, or blood in the urine, can occur with cystitis due to the irritation and inflammation of the bladder lining.
Full Explanation
The correct answer is a. Dysuria and d. Hematuria.
Choice A rationale:
Dysuria, or painful urination, is a common symptom of cystitis due to the inflammation of the bladder lining.
Choice B rationale:
Bradycardia, or slow heart rate, is not typically associated with cystitis. Cystitis primarily affects the urinary system and does not usually impact heart rate.
Choice C rationale:
Pruritus, or itching, is not a common symptom of cystitis. Itching is more often associated with skin conditions or allergic reactions.
Choice D rationale:
Hematuria, or blood in the urine, can occur with cystitis due to the irritation and inflammation of the bladder lining.
A nurse in a provider's office is reinforcing teaching about disease prevention with an older adult client. Which of the following immunizations should the nurse recommend to the client?
A. Tuberculosis
Choice A is incorrect because the tuberculosis vaccine is not routinely given to adults in the United States
B. Human papillomavirus (HPV)
Choice B is incorrect because the HPV vaccine is recommended primarily for young adults to prevent HPV-related cancers
C. Measles, mumps, and rubella (MMR)
. Choice C is incorrect because the MMR vaccine is recommended for children, and most adults have already received it
D. Pneumococcal
Choice A is not correct because the tuberculosis vaccine is not routinely given to adults in the United States.
Full Explanation
The nurse should recommend the pneumococcal vaccine to the client, as this is recommended for all adults over the age of 65 to prevent pneumococcal disease. Choice A is incorrect because the tuberculosis vaccine is not routinely given to adults in the United States. Choice B is incorrect because the HPV vaccine is recommended primarily for young adults to prevent HPV-related cancers. Choice C is incorrect because the MMR vaccine is recommended for children, and most adults have already received it. Choice A is not correct because the tuberculosis vaccine is not routinely given to adults in the United States.