Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing home safety instructions with the guardian of an 18-month- old toddler.
Which of the following responses by the guardian indicates an understanding of the teaching?
A. “I will turn all pot handles toward the back of the stove.”
“I will turn all pot handles toward the back of the stove.” This indicates that the guardian understands how to prevent the toddler from pulling a pot off the stove and getting burned.
B. “I will place my child’s car seat forward-facing in the backseat.”
Choice B is wrong because a child’s car seat should be rear-facing until the child is at least 2 years old or reaches the maximum height and weight for the seat.
C. “I will set the temperature of the water heater to 130 degrees.”
Choice C is wrong because the temperature of the water heater should be set to no higher than 120 degrees to prevent scalding injuries.
D. “I will place my child in a drop-side crib for napping.”
Choice D is wrong because drop-side cribs are banned in the United States due to the risk of entrapment and suffocation.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Capstone Proctored Comprehensive Assessment 2020 B. Take the full exam now
Full Explanation
“I will turn all pot handles toward the back of the stove.” This indicates that the guardian understands how to prevent the toddler from pulling a pot off the stove and getting burned.
Choice B is wrong because a child’s car seat should be rear-facing until the child is at least 2 years old or reaches the maximum height and weight for the seat.
Choice C is wrong because the temperature of the water heater should be set to no higher than 120 degrees to prevent scalding injuries.
Choice D is wrong because drop-side cribs are banned in the United States due to the risk of entrapment and suffocation.
Similar Questions
A nurse is caring for a client who has heart failure and is taking furosemide.
Which of the following statements by the client indicates a need for the nurse to intervene?
A. “I’m urinating in larger amounts.”
Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.
B. “I have to sleep sitting up.”
This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.
C. “I suck on hard candy for my dry mouth.”
Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.
D. “I’ve lost 3 pounds in the last week.”
Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.
Full Explanation
This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.
Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.
Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.
Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure
condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.
Normal ranges for heart failure clients are:
- Blood pressure: less than 140/90 mmHg
- Heart rate: 60 to 100 beats per minute
- Respiratory rate: 12 to 20 breaths per minute
- Oxygen saturation: greater than 95%
- Weight: stable or decreasing within 2 to 4 pounds per week
A nurse is caring for a client who has dementia and is at risk for falls. Which of the following preventive measures should the nurse take?
A. Place the client’s bed in the low position.
This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.
B. Encourage the client to wear socks when ambulating.
Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.
C. Position the client’s bedside table at the foot of the bed.
Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.
D. Raise four side rails on the client’s bed.
Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.
Full Explanation
This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.
Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.
Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.
Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.
A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the following actions should the nurse take?
A. Delay the admission while the client fills out the facility’s advance directives form.
Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form. The client has the right to refuse or accept any treatment, including filling out an advance directives form. The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.
B. Confirm with the client’s family that the consent form has been signed.
Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed. The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options. The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate. The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.
C. Explain to the client that signing the facility’s consent form means they cannot refuse care.
Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care. Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery. The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.
D. Determine if the client has prepared their advance directives.
The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.
Full Explanation
The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.
Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.
The client has the right to refuse or accept any treatment, including filling out an advance directives form.
The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.
Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.
The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.
The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.
The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.
Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.
Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.
The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.