Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is receiving change-of-shift report for a group of clients.
Which of the following clients should the nurse plan to assess first?
A. client who has a hip fracture and a new onset of tachypnea
. A client who has a hip fracture and a new onset of tachypnea. This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention. Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
B. client who has diabetes mellitus and an HbA1c of 6.8%.
is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention. The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
C. A client who has epidural analgesia and weakness in the lower extremities
wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication. The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A
D. A client who has sinus arrhythmia and is receiving cardiac monitoring
wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger. Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
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 A. A client who has a hip fracture and a new onset of tachypnea.
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.
Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.
Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
Similar Questions
A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina.
Which of the following statements by the client indicates an understanding of the teaching?
A. I can lift objects that are less than 10 pounds
Lifting objects less than 10 pounds is a reasonable restriction after retinal detachment surgery to prevent strain on the eye and reduce the risk of recurrence.
B. I can resume activities, such as sewing
Sewing requires fine motor skills and close eye work, which can increase intraocular pressure and potentially worsen the detached retina.
C. I can go jogging after 2 weeks
Strenuous activities like jogging can increase blood pressure and strain the eye, potentially leading to another retinal detachment.
D. I should bend at the waist when putting on my shoes
Bending at the waist increases intraocular pressure and can strain the eye. It's recommended to sit down or use a stool to put on shoes.
Full Explanation
The correct answer is A. I can lift objects that are less than 10 pounds.
Here's a breakdown of why the other options are incorrect:
- B. I can resume activities, such as sewing. - Sewing requires fine motor skills and close eye work, which can increase intraocular pressure and potentially worsen the detached retina.
- C. I can go jogging after 2 weeks. - Strenuous activities like jogging can increase blood pressure and strain the eye, potentially leading to another retinal detachment.
- D. I should bend at the waist when putting on my shoes. - Bending at the waist increases intraocular pressure and can strain the eye. It's recommended to sit down or use a stool to put on shoes.
A charge nurse is delegating care for a group of clients.
Which of the following tasks should the charge nurse assign to a licensed practical nurse?
A. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus.
is wrong because complete discharge teaching for a client who has a new diagnosis of diabetes mellitus requires assessment, evaluation and critical thinking, which are beyond the scope of practice of an LPN. Discharge teaching is the responsibility of a registered nurse (RN) who can provide education and counseling to clients and families.
B. Complete the Glasgow Coma Scale for a client who has an evolving stroke
is wrong because completing the Glasgow Coma Scale for a client who has an evolving stroke requires assessment and interpretation of neurological status, which are complex and unpredictable tasks that only an RN can perform. The Glasgow Coma Scale is a tool that measures the level of consciousness of a client based on eye opening, verbal response and motor response. A client who has an evolving stroke may have changes in their neurological status that require frequent monitoring and intervention by an RN.
C. Perform a sterile dressing change for a client who has an abdominal wound
Perform a sterile dressing change for a client who has an abdominal wound. This is because a licensed practical nurse (LPN) can perform tasks that require technical skills and have predictable outcomes, such as dressing changes. A sterile dressing change is also within the scope of practice of an LPN.
D. Perform an admission assessment for a client who is scheduled for surgery
is wrong because performing an admission assessment for a client who is scheduled for surgery requires comprehensive data collection, analysis and synthesis, which are advanced skills that only an RN can perform. An admission assessment involves obtaining a complete health history, performing a physical examination, identifying client needs and problems, and developing a plan of care.
Full Explanation
The correct answer is choice C. Perform a sterile dressing change for a client who has an abdominal wound. This is because a licensed practical nurse (LPN) can perform tasks that require technical skills and have predictable outcomes, such as dressing changes. A sterile dressing change is also within the scope of practice of an LPN.
Choice A is wrong because complete discharge teaching for a client who has a new diagnosis of diabetes mellitus requires assessment, evaluation and critical thinking, which are beyond the scope of practice of an LPN. Discharge teaching is the responsibility of a registered nurse (RN) who can provide education and counseling to clients and families.
Choice B is wrong because completing the Glasgow Coma Scale for a client who has an evolving stroke requires assessment and interpretation of neurological status, which are complex and unpredictable tasks that only an RN can perform. The Glasgow Coma Scale is a tool that measures the level of consciousness of a client based on eye opening, verbal response and motor response. A client who has an evolving stroke may have changes in their neurological status that require frequent monitoring and intervention by an RN.
Choice D is wrong because performing an admission assessment for a client who is scheduled for surgery requires comprehensive data collection, analysis and synthesis, which are advanced skills that only an RN can perform. An admission assessment involves obtaining a complete health history, performing a physical examination, identifying client needs and problems, and developing a plan of care.
A client who is scheduled for surgery may have complex and unpredictable needs that require specialized knowledge and judgment by an RN.
A nurse is caring for a client who repeatedly refuses meals.
The nurse overhears an assistive personnel (AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
A. Assault
This is because the AP’s statement constitutes an intentional tort, which is a wrong that the defendant knew or should have known would be caused by their actions. An assault is defined as intentionally putting another person in reasonable apprehension of an imminent harmful or offensive contact. The AP’s threat of using restraints and force-feeding the client could cause the client to fear for their safety and dignity, which is an assault.
B. Battery
Battery is wrong because battery is defined as intentional causation of harmful or offensive contact with another person without that person’s consent. The AP did not actually touch the client or carry out the threat, so there was no battery.
C. Negligence
. Negligence is wrong because negligence is an unintentional tort, which occurs when the defendant’s actions or inactions were unreasonably unsafe. The AP did not act or fail to act in a way that breached the standard of care or caused harm to the client, so there was no negligence.
D. Malpractice
Malpractice is wrong because malpractice is a type of negligence that involves a professional failing to perform their duties according to the standards of their profession.
Full Explanation
This is because the AP’s statement constitutes an intentional tort, which is a wrong that the defendant knew or should have known would be caused by their actions. An assault is defined as intentionally putting another person in reasonable apprehension of an imminent harmful or offensive contact.
The AP’s threat of using restraints and force-feeding the client could cause the client to fear for their safety and dignity, which is an assault.
Choice B. Battery is wrong because battery is defined as intentional causation of harmful or offensive contact with another person without that person’s consent.
The AP did not actually touch the client or carry out the threat, so there was no battery.
Choice C. Negligence is wrong because negligence is an unintentional tort, which occurs when the defendant’s actions or inactions were unreasonably unsafe.
The AP did not act or fail to act in a way that breached the standard of care or caused harm to the client, so there was no negligence.
Choice D. Malpractice is wrong because malpractice is a type of negligence that involves a professional failing to perform their duties according to the standards of their profession.
The AP did not perform any professional duty or service that was below the standard of care or caused harm to the client, so there was no malpractice.