Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching?
A. Maintain bed rest for 48 hr.
The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.
B. Keep legs in a dependent position.
The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.
C. Wrap the leg with an elastic bandage.
The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.
D. Implement a sodium-restricted diet.
The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.
The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.
The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.
The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.
Similar Questions
A nurse is reinforcing teaching with a newly licensed nurse about client privacy. Which of the following information should the nurse include in the teaching?
A. Unwanted printed health information can be discarded in a trash can.
B. Information regarding client health can be e-mailed if encrypted.
Information regarding client health can be e-mailed if encrypted. The nurse should follow the Health Insurance Portability and Accountability Act (HIPAA) guidelines to protect client privacy and confidentiality. According to HIPAA, health information can be transmitted electronically if it is encrypted or otherwise secured. Unwanted printed health information should be shredded or disposed of in a secure bin, not a trash can. Members of a healthcare team should not share a computer password or leave a computer unattended when accessing client information. A client has the right to access his own medical records and request amendments or corrections.
C. Members of a health care team can share a computer password.
D. A client is restricted from accessing his own medical records.
Full Explanation
The correct answer is B.
Information regarding client health can be e-mailed if encrypted. The nurse should follow the Health Insurance Portability and Accountability Act (HIPAA) guidelines to protect client privacy and confidentiality. According to HIPAA, health information can be transmitted electronically if it is encrypted or otherwise secured.
Unwanted printed health information should be shredded or disposed of in a secure bin, not a trash can. Members of a healthcare team should not share a computer password or leave a computer unattended when accessing client information. A client has the right to access his own medical records and request amendments or corrections.
A nurse and an assistive personnel (AP) are repositioning a client who is immobile up in bed using a draw sheet. The nurse should instruct the AP to take which of the following actions?
A. Lower the client's bed to the lowest position.
B. Stand next to the client's shoulders.
C. Place a small pillow under the client's head.
D. Flex his hips while pulling the client.
Flex his hips while pulling the client. The nurse and AP should use proper body mechanics when repositioning a client to prevent injury and promote comfort. Flexing the hips while pulling the client reduces strain on the back muscles and allows for greater leverage. The nurse and AP should raise the bed to a comfortable working height, not lower it to the lowest position. The nurse and AP should stand on opposite sides of the bed near the client's hips, not shoulders. The nurse and AP should remove any pillows under or around the client before repositioning him.
Full Explanation
The correct answer is D.
Flex his hips while pulling the client. The nurse and AP should use proper body mechanics when repositioning a client to prevent injury and promote comfort. Flexing the hips while pulling the client reduces strain on the back muscles and allows for greater leverage.
The nurse and AP should raise the bed to a comfortable working height, not lower it to the lowest position. The nurse and AP should stand on opposite sides of the bed near the client's hips, not shoulders. The nurse and AP should remove any pillows under or around the client before repositioning him.
A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?
A. Administer an oral antiepileptic medication
B. Place the child in a supine position.
C. Check the child for oral injuries.
Check the child for oral injuries. The rationale is that during a tonic-clonic seizure, the child may bite their tongue, cheek or lips and cause bleeding or damage to their oral tissues. The nurse should inspect the child's mouth for any injuries and provide appropriate care.
D. Offer the child sips of clear fluids.
Full Explanation
The correct answer is C.
Check the child for oral injuries. The rationale is that during a tonic-clonic seizure, the child may bite their tongue, cheek or lips and cause bleeding or damage to their oral tissues. The nurse should inspect the child's mouth for any injuries and provide appropriate care.