Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
A. A client who had a renal biopsy 3 hr ago and has pink-tinged urine
B. A client who has a femur fracture and reports numbness of the toes
Numbness of the toes in a client with a femur fracture may indicate neurovascular compromise, which requires immediate attention. It could be a sign of impaired circulation or nerve damage, and prompt assessment is needed to prevent further complications or permanent damage.
C. A client who has cirrhosis and severe pruritus
D. A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
Numbness of the toes in a client with a femur fracture may indicate neurovascular compromise, which requires immediate attention.
It could be a sign of impaired circulation or nerve damage, and prompt assessment is needed to prevent further complications or permanent damage.
Similar Questions
A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?
A. Place the shoulder harnesses at the level of the infant's shoulders.
The shoulder harnesses of the car seat should be positioned at or slightly below the level of the infant's shoulders. This helps secure the infant properly in the car seat and provides appropriate protection in the event of a crash.
B. Position the car seat at a 90° angle.
Car seats for infants should not be positioned at a 90° angle. Instead, they should be installed at a reclined angle, as recommended by the car seat manufacturer. The specific recline angle can vary depending on the car seat model and the age of the child.
C. Put a small cushion under the newborn's head for support.
Additional cushions or support devices should not be placed in the car seat unless specifically recommended by the car seat manufacturer. Extra padding or cushions can interfere with the proper fit of the harness and compromise the safety of the infant.
D. D. Keep the airbag on if the car seat is in the front seat.
It is not safe to have an infant's car seat in the front seat if there is an active airbag. The safest place for an infant's car seat is in the rear seat, preferably in the middle position. If the car does not have a rear seat, it is important to disable the airbag if the car seat must be placed in the front seat.
Full Explanation
The shoulder harnesses of the car seat should be positioned at or slightly below the level of the infant's shoulders. This helps secure the infant properly in the car seat and provides appropriate protection in the event of a crash.
Car seats for infants should not be positioned at a 90° angle. Instead, they should be installed at a reclined angle, as recommended by the car seat manufacturer. The specific recline angle can vary depending on the car seat model and the age of the child.
Additional cushions or support devices should not be placed in the car seat unless specifically recommended by the car seat manufacturer. Extra padding or cushions can interfere with the proper fit of the harness and compromise the safety of the infant.
It is not safe to have an infant's car seat in the front seat if there is an active airbag. The safest place for an infant's car seat is in the rear seat, preferably in the middle position. If the car does not have a rear seat, it is important to disable the airbag if the car seat must be placed in the front seat.
A nurse is preparing to administer morphine 30 mg PO to a client who reports pain. Available is morphine solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the required mL of morphine solution needed to administer 30 mg of morphine orally (PO), you can use the following formula:
Volume (in mL) = Amount (in mg) / Concentration (in mg/mL)
In this case, the amount of morphine is 30 mg, and the concentration of the morphine solution is 20 mg/mL.
Volume (in mL) = 30 mg / 20 mg/mL
Volume (in mL) = 1.5 mL
Therefore, the nurse should administer 1.5 mL of the morphine solution to deliver 30 mg of morphine to the client orally.
A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?
A. Report the incident to the charge nurse.
While reporting the incident is important, the priority is to stop the confidentiality breach immediately to protect the client's privacy.
B. Participate in an in-service about client confidentiality.
Participating in training is important for long-term education, but it does not address the immediate issue of the confidentiality breach.
C. Tell the staff members to stop their discussion.
c. Tell the staff members to stop their discussion: This action stops the breach immediately and protects the client's confidential information, which is the first and most crucial step.
D. Speak to the staff members in private about client confidentiality.
d. Speak to the staff members in private about client confidentiality: While this is a good follow-up action to educate and prevent future breaches, the immediate need is to stop the ongoing discussion.
Full Explanation
a. While reporting the incident is important, the priority is to stop the confidentiality breach immediately to protect the client's privacy.
b. Participating in training is important for long-term education, but it does not address the immediate issue of the confidentiality breach.
c. Tell the staff members to stop their discussion: This action stops the breach immediately and protects the client's confidential information, which is the first and most crucial step.
d. Speak to the staff members in private about client confidentiality: While this is a good follow-up action to educate and prevent future breaches, the immediate need is to stop the ongoing discussion