Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?
A. "You cannot drink fluids for 4 hours after the procedure."
B. "You will need to urinate before the procedure."
The rationale for this information is that intermittent catheterization is a method of draining urine from the bladder using a thin, flexible tube called a catheter. It is used to measure residual urine, which is the amount of urine left in the bladder after voiding. Residual urine can indicate problems with bladder function, such as obstruction, infection, or nerve damage. To measure residual urine, the client should first empty their bladder by urinating normally. Then, the nurse will insert the catheter into the urethra and advance it into the bladder.The nurse will measure the amount of urine that drains out of the catheter and record it as residual urine. The nurse will then remove the catheter and dispose of it .
C. "You will feel pressure when I inflate the catheter balloon."
D. "You will have a leg bag to collect the urine."
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 correct answer is B. "You will need to urinate before the procedure." The rationale for this information is that intermittent catheterization is a method of draining urine from the bladder using a thin, flexible tube called a catheter. It is used to measure residual urine, which is the amount of urine left in the bladder after voiding. Residual urine can indicate problems with bladder function, such as obstruction, infection, or nerve damage .
To measure residual urine, the client should first empty their bladder by urinating normally. Then, the nurse will insert the catheter into the urethra and advance it into the bladder.The nurse will measure the amount of urine that drains out of the catheter and record it as residual urine. The nurse will then remove the catheter and dispose of it .
Similar Questions
A nurse is planning care for four clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN?
A. Administering a subcutaneous insulin injection
Administering a subcutaneous insulin injection is a task that can be delegated to a licensed practical nurse (LPN) or a trained unlicensed assistive personnel (UAP) under the supervision of an RN, as it is a routine and straightforward procedure.
B. Collecting a sputum culture
Collecting a sputum culture is also a task that can be performed by an LPN or a trained UAP. It does not require the advanced assessment skills of an RN.
C. Providing discharge teaching about home IV medication therapy
Providing discharge teaching about home IV medication therapy requires the advanced knowledge and skills of an RN. This task involves comprehensive education, assessment of the patient’s understanding, and ensuring the patient can safely manage their IV medication at home. It is critical for patient safety and effective care management.
D. Removing an NG tube
Removing an NG tube is a procedure that can be performed by an LPN or a trained UAP. It is a relatively simple task that does not require the advanced skills of an RN.
Full Explanation
The correct answer is choice C. Providing discharge teaching about home IV medication therapy.
Choice A rationale:
Administering a subcutaneous insulin injection is a task that can be delegated to a licensed practical nurse (LPN) or a trained unlicensed assistive personnel (UAP) under the supervision of an RN, as it is a routine and straightforward procedure.
Choice B rationale:
Collecting a sputum culture is also a task that can be performed by an LPN or a trained UAP. It does not require the advanced assessment skills of an RN.
Choice C rationale:
Providing discharge teaching about home IV medication therapy requires the advanced knowledge and skills of an RN. This task involves comprehensive education, assessment of the patient’s understanding, and ensuring the patient can safely manage their IV medication at home. It is critical for patient safety and effective care management.
Choice D rationale:
Removing an NG tube is a procedure that can be performed by an LPN or a trained UAP. It is a relatively simple task that does not require the advanced skills of an RN.
A nurse is caring for a client who has a femur fracture with the leg in Buck's traction. Which of the following actions should the nurse take?
A. Remove the weights for 20 min for the client's report of severe pain.
B. Position the knot of the rope at the top of the pulley
C. Apply 6.8 kg (15 lb) of weight for use in traction
D. Compare bilateral pedal pulses.
Rationale: The nurse should compare bilateral pedal pulses to assess for adequate circulation and perfusion to the lower extremities. Buck's traction is a type of skin traction that is widely used for broken femurs and hips, as well as fractures in the socket portion of the "ball-and-socket" hip joint (acetabular fractures). It uses splints, bandages, and adhesive tapes to position a limb near the fracture, then weights and pulleys are attached and pressure is applied. The nurse should not remove the weights for 20 min for the client's report of severe pain, as this would disrupt the alignment and traction of the fracture. The nurse should not position the knot of the rope at the top of the pulley, as this would interfere with the smooth movement of the rope and reduce the effectiveness of traction. The nurse should not apply 6.8 kg (15 lb) of weight for use in traction, as this would exceed the recommended weight limit for skin traction and could cause skin damage or nerve injury. The weight should not exceed 4.5 kilograms at any point.
Full Explanation
The correct answer is D. Compare bilateral pedal pulses.
Rationale: The nurse should compare bilateral pedal pulses to assess for adequate circulation and perfusion to the lower extremities. Buck's traction is a type of skin traction that is widely used for broken femurs and hips, as well as fractures in the socket portion of the "ball-and-socket" hip joint (acetabular fractures). It uses splints, bandages, and adhesive tapes to position a limb near the fracture, then weights and pulleys are attached and pressure is applied. The nurse should not remove the weights for 20 min for the client's report of severe pain, as this would disrupt the alignment and traction of the fracture .
The nurse should not position the knot of the rope at the top of the pulley, as this would interfere with the smooth movement of the rope and reduce the effectiveness of traction. The nurse should not apply 6.8 kg (15 lb) of weight for use in traction, as this would exceed the recommended weight limit for skin traction and could cause skin damage or nerve injury. The weight should not exceed 4.5 kilograms at any point.
A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?
A. Irrigation of a wound with antibiotic solution
B. Placement of a central venous catheter
Rationale: The nurse should identify that informed consent is required for the placement of a central venous catheter, as this is an invasive procedure that carries significant risks and benefits that need to be explained to the client before obtaining consent. Informed consent is not required for irrigation of a wound with antibiotic solution, as this is a routine nursing intervention that does not involve significant risks or benefits. Informed consent is not required for the insertion of a nasogastric tube, as this is a common nursing procedure that does not involve significant risks or benefits. Informed consent is not required for the administration of an iron injection using the Z-track technique, as this is a standard medication administration technique that does not involve significant risks or benefits.
C. Insertion of a nasogastric tube
D. Administration of an iron injection using the Z-track technique
Full Explanation
The correct answer is B. Placement of a central venous catheter.
Rationale: The nurse should identify that informed consent is required for the placement of a central venous catheter, as this is an invasive procedure that carries significant risks and benefits that need to be explained to the client before obtaining consent. Informed consent is not required for irrigation of a wound with antibiotic solution, as this is a routine nursing intervention that does not involve significant risks or benefits.
Informed consent is not required for the insertion of a nasogastric tube, as this is a common nursing procedure that does not involve significant risks or benefits. Informed consent is not required for the administration of an iron injection using the Z-track technique, as this is a standard medication administration technique that does not involve significant risks or benefits.