Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching with a client who is 24 hours postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?
A. Apply moist heat to the incision while in bed.
The client should apply ice to the incision site, not moist heat, in the first few days postoperatively.
B. Sit in a straight-backed chair.
Sit in a straight-backed chair. After a total hip arthroplasty, the client should avoid sitting in chairs that are too low or too soft, as they can be difficult to rise from and can risk dislocating the new hip. The client should apply ice to the incision site, not moist heat, in the first few days postoperatively. The client should avoid adducting the hip as this can also risk dislocation of the new hip joint. Hydrogen peroxide should not be used to clean the surgical incision, as it can delay wound healing.
C. Perform range of motion exercises by adducting the hip.
The client should avoid adducting the hip as this can risk dislocation of the new hip joint.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
Sit in a straight-backed chair. After a total hip arthroplasty, the client should avoid sitting in chairs that are too low or too soft, as they can be difficult to rise from and can risk dislocating the new hip. The client should apply ice to the incision site, not moist heat, in the first few days postoperatively. The client should avoid adducting the hip as this can also risk dislocation of the new hip joint. Hydrogen peroxide should not be used to clean the surgical incision, as it can delay wound healing.
Choice A: The client should apply ice to the incision site, not moist heat, in the first few days postoperatively.
Choice C: The client should avoid adducting the hip as this can risk dislocation of the new hip joint.
Similar Questions
A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?
A. Restrict the diet to clear liquids for 1 to 3 days before the procedure.
A clear liquid diet 1 to 3 days before a colonoscopy minimizes residue in the colon, enhancing mucosal visualization and reducing the risk of missed lesions. Clear liquids include water, broth, tea, and gelatin, which are easily absorbed and leave minimal waste. This dietary preparation complements bowel cleansing agents like polyethylene glycol. Inadequate preparation can obscure polyps or inflammation. Normal stool consistency should be absent during the procedure to ensure optimal diagnostic accuracy.
B. Expect the provider to schedule another procedure to remove any polyps.
The provider does not schedule another procedure to remove any polyps during the colonoscopy; they may be removed during the procedure or later.
C. Do not eat or drink anything except water for 12 hours before the procedure.
Restricting intake to only water for 12 hours before the procedure is insufficient and potentially misleading. Colonoscopy preparation requires both dietary modification and pharmacologic bowel cleansing, not just fasting. Water alone does not clear the colon of fecal matter. Additionally, fasting without electrolyte replacement may lead to dehydration and electrolyte imbalance. Normal serum potassium ranges from 3.5 to 5.0 mEq/L; inadequate preparation may cause hypokalemia, especially with laxative use.
D. Administer enemas 2 days before the procedure.
While enemas may be part of bowel preparation, they are usually administered closer to the procedure, not 2 days in advance.
E. None
None
F. None
None
Full Explanation
The correct answer is Choice A.
Choice A rationale: A clear liquid diet 1 to 3 days before a colonoscopy minimizes residue in the colon, enhancing mucosal visualization and reducing the risk of missed lesions. Clear liquids include water, broth, tea, and gelatin, which are easily absorbed and leave minimal waste. This dietary preparation complements bowel cleansing agents like polyethylene glycol. Inadequate preparation can obscure polyps or inflammation. Normal stool consistency should be absent during the procedure to ensure optimal diagnostic accuracy.
Choice B rationale: Polypectomy is typically performed during the colonoscopy itself if polyps are detected. Most polyps are removed using snares or biopsy forceps during the same session, reducing the need for a second procedure. Scheduling another procedure is reserved for complex or large lesions requiring advanced techniques. Delaying removal increases the risk of progression to malignancy. Normal colonoscopy findings include pink mucosa and absence of polyps; any deviation warrants immediate intervention when feasible.
Choice C rationale: Restricting intake to only water for 12 hours before the procedure is insufficient and potentially misleading. Colonoscopy preparation requires both dietary modification and pharmacologic bowel cleansing, not just fasting. Water alone does not clear the colon of fecal matter. Additionally, fasting without electrolyte replacement may lead to dehydration and electrolyte imbalance. Normal serum potassium ranges from 3.5 to 5.0 mEq/L; inadequate preparation may cause hypokalemia, especially with laxative use.
Choice D rationale: Enemas are not routinely recommended 2 days before colonoscopy. They may be used adjunctively on the day of the procedure for distal colon cleansing but are insufficient for full bowel preparation. Oral bowel prep agents like polyethylene glycol are preferred for complete evacuation. Enemas only reach the rectosigmoid region and do not cleanse the ascending or transverse colon. Incomplete prep compromises mucosal visualization and diagnostic yield, increasing false-negative rates.
A nurse is collecting data from a client who has mitral valve regurgitation. In which of the following areas should the nurse place the stethoscope to auscultate a murmur? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A. -
is not the correct answer because the tricuspid area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The tricuspid area is located at the fifth intercostal space at the lower left sternal border, and is the site where blood flows from the right atrium to the right ventricle during systole.
B. -
The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.
C. -
is not the correct answer because the aortic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The aortic area is found at the second intercostal space at the right sternal border, and is the site where blood flows from the left ventricle to the aorta during systole. ChoiceD4 is not the correct answer because the pulmonic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The pulmonic area is located at the second intercostal space at the left sternal border, and is the site where blood flows from the right ventricle to the pulmonary artery during systole.
D. -
The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.
Full Explanation
is not the correct answer because the tricuspid area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The tricuspid area is located at the fifth intercostal space at the lower left sternal border, and is the site where blood flows from the right atrium to the right ventricle during systole.<\/p>"},"B":{"choice":"-","reason":"
The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"},"C":{"choice":"-","reason":"
is not the correct answer because the aortic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The aortic area is found at the second intercostal space at the right sternal border, and is the site where blood flows from the left ventricle to the aorta during systole.
\r\nChoiceD4 is not the correct answer because the pulmonic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The pulmonic area is located at the second intercostal space at the
\r\n
\r\nleft sternal border, and is the site where blood flows from the right ventricle to the pulmonary artery during systole.<\/p>"},"D":{"choice":"-","reason":"
The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"}}
A nurse is preparing to administer ceftriaxone using the z-track technique to a client who has gonorrhea. After the nurse performs hand hygiene and reconstitutes the medication, identify the sequence the nurse should use to administer the medication. (Move the steps, placing them in the order of performance. Use all the steps.)
A. Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally.
B. Remove the needle and release the tissue.
C. Aspirate by pulling back on the plunger and inject the medication.