Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching about a safety plan for a client who reports partner violence. Which of the following instructions should the nurse include?
A. "Call a shelter in another county."
Calling a shelter in another county may not be the most practical or effective option for the client.
B. "Leave your partner immediately."
Leaving an abusive partner immediately may not always be the safest option for the client.
C. "Keep a packed bag by your front door."
Keeping a packed bag by the front door may not be the most practical or effective option for the client.
D. "Rehearse your escape route."
The nurse should include the instruction to "Rehearse your escape route" in the safety plan for a client who reports partner violence. A safety plan is a personalized and practical plan on how to remain safe in an abusive relationship while preparing to leave when the timing is right and safe to do so. Rehearsing an escape route can help the client be prepared and know what to do in case they need to leave quickly.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
The nurse should include the instruction to "Rehearse your escape route" in the safety plan for a client who reports partner violence. A safety plan is a personalized and practical plan on how to remain safe in an abusive relationship while preparing to leave when the timing is right and safe to do so . Rehearsing an escape route can help the client be prepared and know what to do in case they need to leave quickly.
Option a is incorrect because calling a shelter in another county may not be the most practical or effective option for the client.
Option b is incorrect because leaving an abusive partner immediately may not always be the safest option for the client.
Option c is incorrect because keeping a packed bag by the front door may not be the most practical or effective option for the client.
Similar Questions
A nurse is collecting data from an 18-month-old toddler at a well-child visit.
Which of the following findings should the nurse report to the provider?
A. The toddler can remove her own socks.
Is an examples of normal developmental skills for a toddler of this age.
B. The toddler has a security blanket.
Is an examples of normal developmental skills for a toddler of this age.
C. The toddler can say four words.
The nurse should report to the provider that the toddler can say four words. At 18 months, a toddler typically has a vocabulary of about 6 to 20 words and is beginning to combine words into simple phrases. If the toddler is only able to say four words or has a delay in language development, it could be a cause for concern and warrant further evaluation.
D. The toddler throws a ball without falling.
Is an examples of normal developmental skills for a toddler of this age.
Full Explanation
c. The toddler can say four words.
Explanation:
The nurse should report to the provider that the toddler can say four words. At 18 months, a toddler typically has a vocabulary of about 6 to 20 words and is beginning to combine words into simple phrases. If the toddler is only able to say four words or has a delay in language development, it could be a cause for concern and warrant further evaluation.
The other options are age-appropriate developmental milestones for an 18-month-old toddler and do not require immediate reporting to the provider. The ability to remove socks, having a security blanket, and throwing a ball without falling are all examples of normal developmental skills for a toddler of this age.
A nurse is reinforcing teaching with a client who is about to undergo a thoracentesis. Which of the
following statements by the client indicates an understanding of the information?
A. I will have general anesthesia during the procedure.
I will have general anesthesia during the procedure": This statement is incorrect. Thoracentesis is typically performed using local anesthesia, which numbs the area where the needle will be inserted. General anesthesia, which induces a state of unconsciousness, is not usually required for this procedure.
B. I will lie flat for 6 hours following the procedure.
This statement is incorrect. While the client may be advised to lie still for a short period after the thoracentesis, it is not necessary for them to lie flat for a full 6 hours. The specific post-procedure instructions may vary depending on the client's condition and the healthcare provider's preferences.
C. I will have a chest x-ray following the procedure
The statement that indicates an understanding of the information provided is "I will have a chest x-ray following the procedure."
D. I will breathe deeply through my nose during the procedure
Full Explanation
c. "I will have a chest x-ray following the procedure."
Explanation:
The statement that indicates an understanding of the information provided is "I will have a chest x-ray following the procedure."
Explanation for the other options:
a. "I will have general anesthesia during the procedure":
This statement is incorrect. Thoracentesis is typically performed using local anesthesia, which numbs the area where the needle will be inserted. General anesthesia, which induces a state of unconsciousness, is not usually required for this procedure.
b. "I will lie flat for 6 hours following the procedure":
This statement is incorrect. While the client may be advised to lie still for a short period after the thoracentesis, it is not necessary for them to lie flat for a full 6 hours. The specific post-procedure instructions may vary depending on the client's condition and the healthcare provider's preferences.
d. "I will breathe deeply through my nose during the procedure":
This statement is incorrect. During a thoracentesis, the client is typically asked to sit upright and lean forward to allow beter access to the space between the lungs and chest wall. They may be instructed to take slow, deep breaths and hold their breath for short periods as needed during the procedure to help maintain proper positioning and reduce the risk of complications.
In summary, the statement that demonstrates an understanding of the thoracentesis procedure is "I will have a chest x-ray following the procedure." This indicates the client's awareness of the need for a post- procedure chest x-ray to evaluate the results and ensure the absence of any complications.
A nurse is collecting data from a client who is postoperative and received hydromorphone 4 mg PO 15 min ago. The client tells the nurse, "My pain level is still 8 on a 0 to 10 scale." Which of the following actions should the nurse take first?
A. Contact the provider to prescribe more pain medication for the client.
It may not be necessary to contact the provider for more pain medication until after reevaluating the client's response to the medication.
B. Teach the client relaxation techniques for the treatment of acute pain.
Teaching relaxation techniques may not provide immediate relief for acute pain.
C. Document the client's reaction to the administration of medication.
Documenting the client's reaction to the administration of medication should be done after reevaluating their response to the medication.
D. Reevaluate the client's response to the medication in 30 min.
The first action the nurse should take is to reevaluate the client's response to the medication in 30 min. Hydromorphone has an onset of action of 15 to 30 minutes when taken orally. Therefore, it may take some time for the medication to reach its full effect.
Full Explanation
The first action the nurse should take is to reevaluate the client's response to the medication in 30 min. Hydromorphone has an onset of action of 15 to 30 minutes when taken orally ¹. Therefore, it may take some time for the medication to reach its full effect.
Option a is incorrect because it may not be necessary to contact the provider for more pain medication until after reevaluating the client's response to the medication.
Option b is incorrect because teaching relaxation techniques may not provide immediate relief for acute pain.
Option c is incorrect because documenting the client's reaction to the administration of medication should be done after reevaluating their response to the medication.