Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?
A. "Assist her to breathe in deeply at the beginning of each contraction."
B. "Apply steady pressure with this tennis ball to her sacral area."
C. "Gently stroke her abdomen during contractions."
Effleurage is a type of massage that involves gently stroking or rubbing the abdomen during contractions to provide comfort and distraction. It can also stimulate endorphin release and reduce pain perception. Breathing deeply at the beginning of each contraction is a relaxation technique, not effleurage. Applying pressure to the sacral area with a tennis ball is a counterpressure technique, not effleurage. Focusing on an object in the room is a focal point technique, not effleurage.
D. "Help her to focus on an object in the room."
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 C. Effleurage is a type of massage that involves gently stroking or rubbing the abdomen during contractions to provide comfort and distraction. It can also stimulate endorphin release and reduce pain perception. Breathing deeply at the beginning of each contraction is a relaxation technique, not effleurage. Applying pressure to the sacral area with a tennis ball is a counterpressure technique, not effleurage. Focusing on an object in the room is a focal point technique, not effleurage.
Similar Questions
A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?
A. Changing the appliance on a new colostomy
Changing the appliance on a new colostomy is a complex task that requires assessment and education, which should be performed by a registered nurse (RN) or a licensed practical nurse (LPN).
B. Performing indwelling urinary catheter care
Performing indwelling urinary catheter care is a routine task that can be delegated to an assistive personnel (AP) as it involves basic hygiene and maintenance.
C. Demonstrating how to use an incentive spirometer
Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient’s technique, which should be done by an RN or LPN.
D. Measuring the depth of a stage 3 pressure injury
Measuring the depth of a stage 3 pressure injury requires assessment skills and clinical judgment, which are beyond the scope of practice for an AP. This task should be performed by an RN or LPN.
Full Explanation
The correct answer is choice b. Performing indwelling urinary catheter care.
Choice A rationale:
Changing the appliance on a new colostomy is a complex task that requires assessment and education, which should be performed by a registered nurse (RN) or a licensed practical nurse (LPN).
Choice B rationale:
Performing indwelling urinary catheter care is a routine task that can be delegated to an assistive personnel (AP) as it involves basic hygiene and maintenance.
Choice C rationale:
Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient’s technique, which should be done by an RN or LPN.
Choice D rationale:
Measuring the depth of a stage 3 pressure injury requires assessment skills and clinical judgment, which are beyond the scope of practice for an AP. This task should be performed by an RN or LPN.
A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?
A. Discuss alternative treatment methods with the client.
B. Support the client's decision to stop the treatment.
The nurse should respect and support the client's decision to stop dialysis treatment, as it is an expression of autonomy and self-determination. Discussing alternative treatment methods, asking the facility chaplain to visit, and telling the client she should discuss this decision with her family are all actions that may imply that the nurse does not accept or respect the client's decision.
C. Ask the facility chaplain to visit the client.
D. Tell the client she should discuss this decision with her family.
Full Explanation
Explanation: The nurse should respect and support the client's decision to stop dialysis treatment, as it is an expression of autonomy and self-determination. Discussing alternative treatment methods, asking the facility chaplain to visit, and telling the client she should discuss this decision with her family are all actions that may imply that the nurse does not accept or respect the client's decision.
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?
A. Tachycardia
B. Cramping
C. Seizures
The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.
D. Elevated temperature
Full Explanation
Explanation: The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.