Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing teaching to a client who is at risk for thrombus formation.
Which of the following statements made by the client indicates an understanding of the teaching?
A. "I will keep my legs crossed while sitting."
Choice A is wrong because crossing the legs while sitting can impede blood flow and increase the risk of thrombus formation.
B. "I will perform leg exercises once every 4 hours while I am awake."
Choice B is wrong because leg exercises should be performed more frequently than once every 4 hours while awake.
C. "I should limit the time that I spend sitting in a chair."
“I should limit the time that I spend sitting in a chair.” This is important because sitting for long periods of time can increase the risk of thrombus formation.
D. "I should massage my legs when they hurt.".
Choice D is wrong because massaging the legs when they hurt can dislodge a thrombus and cause it to travel to other parts of the body.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Fundamentals 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
“I should limit the time that I spend sitting in a chair.” This is important because sitting for long periods of time can increase the risk of thrombus formation.
Choice A is wrong because crossing the legs while sitting can impede blood flow and increase the risk of thrombus formation.
Choice B is wrong because leg exercises should be performed more frequently than once every 4 hours while awake.
Choice D is wrong because massaging the legs when they hurt can dislodge a thrombus and cause it to travel to other parts of the body.
Similar Questions
A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change.
Which of the following actions should the nurse plan to take during this stage?
A. Develop a plan for the client to integrate the change into her lifestyle.
Choice A is wrong because developing a plan for the client to integrate the change into her lifestyle is more appropriate for the preparation stage.
B. Recommend small changes for the client to make to change her behavior over time.
Choice B is wrong because recommending small changes for the client to make to change her behavior over time is more appropriate for the action stage.
C. Assist the client in setting goals to make the change.
Choice C is wrong because assisting the client in setting goals to make the change is more appropriate for the preparation stage.
D. Present information about the benefits of quitting smoking.
During the contemplation stage of health behavior change, the client is thinking about change and becoming motivated to get started. The nurse should present information about the benefits of quitting smoking to help the client assess the benefits of change.
Full Explanation
During the contemplation stage of health behavior change, the client is thinking about change and becoming motivated to get started.
The nurse should present information about the benefits of quitting smoking to help the client assess the benefits of change.
Choice A is not correct because developing a plan for the client to integrate the change into her lifestyle is more appropriate for the preparation stage.
Choice B is not correct because recommending small changes for the client to make to change her behavior over time is more appropriate for the action stage.
Choice C is not correct because assisting the client in setting goals to make the change is more appropriate for the preparation stage.
A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?
A. "Delirium does not affect a client's perception of her environment.".
Choice A is wrong because delirium does affect a client’s perception of her environment.
B. "Delirium has a slow progression.".
Choice B is wrong because delirium does not have a slow progression, but rather an abrupt onset.
C. "Delirium does not affect a client's sleep cycle.".
Choice C is wrong because delirium can affect a client’s sleep cycle.
D. "Delirium has an abrupt onset.".
“Delirium has an abrupt onset.” Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of someone’s surroundings. The disorder usually comes on fast — within hours or a few days.
Full Explanation
“Delirium has an abrupt onset.” Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of someone’s surroundings.
The disorder usually comes on fast — within hours or a few days.
Choice A is wrong because delirium does affect a client’s perception of her environment.
Choice B is wrong because delirium does not have a slow progression, but rather an abrupt onset.
Choice C is wrong because delirium can affect a client’s sleep cycle.
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions.
Which of the following is an appropriate action to include in the plan of care?
A. Change the PN infusion bag every 48 hr.
Choice A is wrong because the PN infusion bag should be changed every 24 hours, not every 48 hours.
B. Prepare the client for a central venous line.
Parenteral nutrition (PN) with 20% dextrose and fat emulsions is a hypertonic solution that requires infusion through a central venous line to prevent damage to peripheral veins.
C. Obtain random blood glucose daily.
Choice Cis wrong because blood glucose should be monitored more frequently than once daily when initiating PN therapy.
D. Administer the PN and fat emulsion separately.
Choice Dis wrong because PN and fat emulsions can be administered together in a total nutrient admixture (TNA)1.
Full Explanation
Prepare the client for a central venous line.
Parenteral nutrition (PN) with 20% dextrose and fat emulsions is a hypertonic solution that requires infusion through a central venous line to prevent damage to peripheral veins.
Choice A is wrong because the PN infusion bag should be changed every 24 hours, not every 48 hours.
Choice C is wrong because blood glucose should be monitored more frequently than once daily when initiating PN therapy.
Choice D is wrong because PN and fat emulsions can be administered together in a total nutrient admixture (TNA)1.