Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following instructions should the nurse include in the teaching?
A. Begin ball squeezing exercises.
Beginning ball squeezing exercises is not advisable immediately after a modified radical mastectomy. The client's arm on the affected side needs time to heal, and strenuous exercises can strain the surgical site, increase pain, and potentially disrupt the healing process.
B. Wear a bra with wire support.
Wearing a bra with wire support is not recommended, especially in the early postoperative period. Underwire bras can irritate the surgical site and interfere with the healing process. Patients are usually advised to wear soft, non-underwire bras or special post-surgical bras designed for comfort and support.
C. Avoid using the affected arm for eating.
Avoiding the use of the affected arm for eating is the correct instruction. Protecting the surgical site and preventing strain is essential for proper healing. Encouraging the client to use the opposite arm for activities like eating can minimize movement in the affected area, reducing the risk of complications.
D. Use deodorant under the affected arm.
Using deodorant under the affected arm is not recommended immediately after surgery. The surgical site needs to be kept clean and dry to prevent infection and promote healing. Deodorants, especially those containing chemicals or fragrances, can irritate the skin and increase the risk of complications. Patients are usually advised to avoid applying any products to the surgical area until it is fully healed.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Beginning ball squeezing exercises is not advisable immediately after a modified radical mastectomy. The client's arm on the affected side needs time to heal, and strenuous exercises can strain the surgical site, increase pain, and potentially disrupt the healing process.
Choice B rationale:
Wearing a bra with wire support is not recommended, especially in the early postoperative period. Underwire bras can irritate the surgical site and interfere with the healing process. Patients are usually advised to wear soft, non-underwire bras or special post-surgical bras designed for comfort and support.
Choice C rationale:
Avoiding the use of the affected arm for eating is the correct instruction. Protecting the surgical site and preventing strain is essential for proper healing. Encouraging the client to use the opposite arm for activities like eating can minimize movement in the affected area, reducing the risk of complications.
Choice D rationale:
Using deodorant under the affected arm is not recommended immediately after surgery. The surgical site needs to be kept clean and dry to prevent infection and promote healing. Deodorants, especially those containing chemicals or fragrances, can irritate the skin and increase the risk of complications. Patients are usually advised to avoid applying any products to the surgical area until it is fully healed.
Similar Questions
A nurse is planning educational materials for a client who has a new pacemaker.
Which of the following information should the nurse include?
A. "Keep mobile phones 4 inches from the pacemaker generator.”
The nurse should include the information about keeping mobile phones at least 4 inches away from the pacemaker generator in the educational materials for the client. This is because mobile phones emit electromagnetic signals that could interfere with the functioning of the pacemaker. Maintaining a safe distance helps prevent electromagnetic interference, ensuring the pacemaker functions properly without any disruptions. It's crucial for the client to be aware of this to prevent potential complications and ensure the pacemaker's effectiveness.
B. "Limit strenuous physical activity for 8 weeks.”
Limiting strenuous physical activity for 8 weeks is not a necessary precaution for a client with a new pacemaker unless specifically advised by the healthcare provider. Patients with pacemakers are often encouraged to resume normal activities after the procedure, with the understanding that they should listen to their bodies and avoid activities that cause discomfort or strain. There is no standard guideline suggesting an 8-week restriction on strenuous physical activity for all patients with new pacemakers.
C. "Check your pulse rate for 30 seconds at different times throughout the day.”
Checking the pulse rate for 30 seconds at different times throughout the day is a general health practice and not specifically related to the presence of a pacemaker. While monitoring heart rate is essential for overall health, it is not a pacemaker-specific guideline that must be included in the educational materials for a client with a new pacemaker.
D. "Expect to have intermittent, prolonged hiccups.”
Expecting to have intermittent, prolonged hiccups is not relevant information for a client with a new pacemaker. Hiccups are a common physiological phenomenon and are not influenced by the presence of a pacemaker. Including this information in the educational materials would be irrelevant and potentially confusing for the client.
Full Explanation
Choice A rationale:
The nurse should include the information about keeping mobile phones at least 4 inches away from the pacemaker generator in the educational materials for the client. This is because mobile phones emit electromagnetic signals that could interfere with the functioning of the pacemaker. Maintaining a safe distance helps prevent electromagnetic interference, ensuring the pacemaker functions properly without any disruptions. It's crucial for the client to be aware of this to prevent potential complications and ensure the pacemaker's effectiveness.
Choice B rationale:
Limiting strenuous physical activity for 8 weeks is not a necessary precaution for a client with a new pacemaker unless specifically advised by the healthcare provider. Patients with pacemakers are often encouraged to resume normal activities after the procedure, with the understanding that they should listen to their bodies and avoid activities that cause discomfort or strain. There is no standard guideline suggesting an 8-week restriction on strenuous physical activity for all patients with new pacemakers.
Choice C rationale:
Checking the pulse rate for 30 seconds at different times throughout the day is a general health practice and not specifically related to the presence of a pacemaker. While monitoring heart rate is essential for overall health, it is not a pacemaker-specific guideline that must be included in the educational materials for a client with a new pacemaker.
Choice D rationale:
Expecting to have intermittent, prolonged hiccups is not relevant information for a client with a new pacemaker. Hiccups are a common physiological phenomenon and are not influenced by the presence of a pacemaker. Including this information in the educational materials would be irrelevant and potentially confusing for the client.
A nurse is teaching a client how to care for his behind-the-ear hearing aids.
Which of the following statements by the client indicates an understanding of the teaching?
A. "I'll use isopropyl alcohol to clean my hearing aids.”
Using isopropyl alcohol to clean hearing aids is not recommended. Isopropyl alcohol can damage the hearing aid components, especially the plastic parts. It is essential to use cleaning solutions specifically designed for hearing aids to avoid damaging them. Including this statement indicates a misunderstanding of proper hearing aid care.
B. "I'll replace the batteries every 2 weeks.”
Replacing the batteries every 2 weeks is a standard recommendation for hearing aid users. Hearing aid batteries typically last 1 to 2 weeks, depending on usage. Regular battery replacement ensures the hearing aids continue to function optimally. This statement demonstrates an understanding of the basic care required for behind-the-ear hearing aids.
C. "I'll clean my ear with cotton swabs before I insert my hearing aids.”
Cleaning the ear with cotton swabs before inserting hearing aids is not advisable. Cotton swabs can push earwax further into the ear canal, leading to impaction. Excessive earwax can interfere with hearing aid function. Instead, clients should be encouraged to clean the outer parts of the hearing aids and avoid inserting any objects, including cotton swabs, into the ear canal.
D. "I'll disconnect the battery when I remove my hearing aids.”
Disconnecting the battery when removing hearing aids is the correct practice. By disconnecting the battery, the client ensures that the hearing aids are turned off, preserving battery life and preventing unnecessary drainage. This statement indicates an understanding of proper hearing aid care and demonstrates the client's ability to maintain the device effectively.
Full Explanation
Choice A rationale:
Using isopropyl alcohol to clean hearing aids is not recommended. Isopropyl alcohol can damage the hearing aid components, especially the plastic parts. It is essential to use cleaning solutions specifically designed for hearing aids to avoid damaging them. Including this statement indicates a misunderstanding of proper hearing aid care.
Choice B rationale:
Replacing the batteries every 2 weeks is a standard recommendation for hearing aid users. Hearing aid batteries typically last 1 to 2 weeks, depending on usage. Regular battery replacement ensures the hearing aids continue to function optimally. This statement demonstrates an understanding of the basic care required for behind-the-ear hearing aids.
Choice C rationale:
Cleaning the ear with cotton swabs before inserting hearing aids is not advisable. Cotton swabs can push earwax further into the ear canal, leading to impaction. Excessive earwax can interfere with hearing aid function. Instead, clients should be encouraged to clean the outer parts of the hearing aids and avoid inserting any objects, including cotton swabs, into the ear canal.
Choice D rationale:
Disconnecting the battery when removing hearing aids is the correct practice. By disconnecting the battery, the client ensures that the hearing aids are turned off, preserving battery life and preventing unnecessary drainage. This statement indicates an understanding of proper hearing aid care and demonstrates the client's ability to maintain the device effectively.
A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles.
For which of the following actions by the newly licensed nurse should the charge nurse intervene?
A. The nurse places the client on airborne precautions.
This is appropriate, as measles is transmitted via airborne particles.
B. The nurse has the client wear a mask for transport to radiology.
A surgical mask minimizes the risk of spreading airborne pathogens during transport.
C. The nurse wears an N95 respirator when performing client care.
An N95 respirator is necessary for protection against airborne diseases like measles.
D. The nurse ensures the client's room maintains a positive airflow.
Clients with airborne infections like measles must be placed in negative pressure rooms, which prevent contaminated air from escaping into other areas. Positive airflow increases the risk of transmission to others.