Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis.
Which of the following instructions should the nurse include?
A. “Use a nebulizer to administer a bronchodilator following airway clearance therapy.”.
is wrong because a bronchodilator should be administered before airway clearance therapy, not after. A bronchodilator helps open up the airways and make it easier to cough up mucus.
B. “Administer pancreatic enzymes on an empty stomach.”.
is wrong because pancreatic enzymes should be administered with meals and snacks, not on an empty stomach. Pancreatic enzymes help digest fats, proteins, and carbohydrates in children who have cystic fibrosis. This can prevent malnutrition and growth failure.
C. “Perform chest percussion and postural drainage at least twice daily.”.
This is because chest percussion and postural drainage are airway clearance techniques that help remove thick mucus from the lungs of children who have cystic fibrosis. This can prevent respiratory infections and improve lung function.
D. “Restrict intake of foods that contain gluten.”.
is wrong because there is no need to restrict gluten intake for children who have cystic fibrosis, unless they also have celiac disease. Gluten is a protein found in wheat, barley, and rye that can cause intestinal damage in people who have celiac disease. Cystic fibrosis does not affect the ability to tolerate gluten
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 C. “Perform chest percussion and postural drainage at least twice daily.” This is because chest percussion and postural drainage are airway clearance techniques that help remove thick mucus from the lungs of children who have cystic fibrosis. This can prevent respiratory infections and improve lung function.
Choice A is wrong because a bronchodilator should be administered before airway clearance therapy, not after. A bronchodilator helps open up the airways and make it easier to cough up mucus.
Choice B is wrong because pancreatic enzymes should be administered with meals and snacks, not on an empty stomach.
Pancreatic enzymes help digest fats, proteins, and carbohydrates in children who have cystic fibrosis. This can prevent malnutrition and growth failure.
Choice D is wrong because there is no need to restrict gluten intake for children who have cystic fibrosis, unless they also have celiac disease.
Gluten is a protein found in wheat, barley, and rye that can cause intestinal damage in people who have celiac disease. Cystic fibrosis does not affect the ability to tolerate gluten.
Similar Questions
A nurse is caring for a client who has a placenta previa.
Which of the following findings should the nurse expect?
A. Nausea.
wrong because nausea is not a specific finding of placenta previa. Nausea can occur in normal pregnancy or in other conditions such as hyperemesis gravidarum or preeclampsia.
B. Polyhydramnios.
because polyhydramnios is not a finding of placenta previa. Polyhydramnios is a condition where there is too much amniotic fluid in the uterus, which can cause complications such as preterm labor, cord prolapse, or fetal malformations.
C. Uterine tenderness.
because uterine tenderness is not a finding of placenta previa. Uterine tenderness is a sign of abruptio placentae, which is a condition where the placenta separates from the uterine wall before delivery. This can cause severe abdominal pain, dark red vaginal bleeding, and fetal distress.
D. Spotting.
Placenta previa is a condition where the placenta implants in the lower part of the uterus, partly or completely covering the cervical opening. This can cause painless, bright red vaginal bleeding, usually in the third trimester. Spotting is a sign of placenta previa and should be reported to the provider immediately.
Full Explanation
The correct answer is choice D, spotting.
Placenta previa is a condition where the placenta implants in the lower part of the uterus, partly or completely covering the cervical opening.
This can cause painless, bright red vaginal bleeding, usually in the third trimester.
Spotting is a sign of placenta previa and should be reported to the provider immediately.
Choice A is wrong because nausea is not a specific finding of placenta previa.
Nausea can occur in normal pregnancy or in other conditions such as hyperemesis gravidarum or preeclampsia.
Choice B is wrong because polyhydramnios is not a finding of placenta previa.
Polyhydramnios is a condition where there is too much amniotic fluid in the uterus, which can cause complications such as preterm labor, cord prolapse, or fetal malformations.
Choice C is wrong because uterine tenderness is not a finding of placenta previa.
Uterine tenderness is a sign of abruptio placentae, which is a condition where the placenta separates from the uterine wall before delivery.
This can cause severe abdominal pain, dark red vaginal bleeding, and fetal distress.
A nurse is planning care for an older adult client who has dementia.
Which of the following interventions should the nurse include in the plan of care? (Select all that apply.).
A. Allow the client to choose among a variety of activities each day.
is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia. The nurse should provide a structured and consistent daily routine for the client.
B. Give the client one simple direction at a time.
The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
C. Reinforce orientation to time, place, and person.
The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
D. Establish eye contact when communicating with the client.
The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
E. Refute the client’s delusions using logic.
wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.
Full Explanation
The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.
Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.
The nurse should provide a structured and consistent daily routine for the client.
Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.
The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.
A nurse is caring for a client who is immobile.
Which of the following interventions is appropriate to prevent contracture?
A. Align a trochanter wedge between the client’s legs.
because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.
B. Apply an orthotic to the client’s foot.
An orthotic is a device that supports or corrects the function of a body part. In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients. Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.
C. Place a towel roll under the client’s neck.
wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.
D. Position a pillow under the client’s knees.
pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis. Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.
E. undefined
Full Explanation
The correct answer is choice B. Applying an orthotic to the client’s foot.
An orthotic is a device that supports or corrects the function of a body part.
In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients.
Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.
Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.
Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.
Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.
Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.
Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.