Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider?
A. Apply mitten restraints to prevent the client from disconnecting their tube feeding.
In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
B. Apply a vest restraint daily at bedtime to prevent nighttime wandering.
Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
C. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation.
The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Apply soft heel protectors bilaterally while client is in bed.
Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.
Similar Questions
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
A. Weight gain
Weight gain occurs due to accumulation of fluid in the body due to back pressure into the system circulation.
B. Distended abdomen
Distended abdomen occurs due to fluid accumulation due to reduced stroke volume.
C. Confusion
While confusion can be a symptom of decreased cardiac output, it's not as specific as dyspnea in this case. Confusion can have various causes, including hypoxia, electrolyte imbalances, or medication side effects.
D. Dyspnea
This is a common symptom of left-sided heart failure. When the left ventricle fails to pump blood effectively, fluid backs up into the lungs, causing shortness of breath.
Full Explanation
A. Weight gain occurs due to accumulation of fluid in the body due to back pressure into the system circulation.
B. Distended abdomen occurs due to fluid accumulation due to reduced stroke volume.
C. While confusion can be a symptom of decreased cardiac output, it's not as specific as dyspnea in this case. Confusion can have various causes, including hypoxia, electrolyte imbalances, or medication side effects.
D. This is a common symptom of left-sided heart failure. When the left ventricle fails to pump blood effectively, fluid backs up into the lungs, causing shortness of breath.
A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
A. Alopecia
Malnutrition can lead to inadequate intake of essential nutrients, such as vitamins and minerals, which are necessary for maintaining healthy hair growth.
B. Diplopia
Double vision, or diplopia, is more commonly associated with neurological or ocular conditions rather than malnutrition.
C. Oily skin
Malnutrition may result in dry, flaky skin due to deficiencies in essential fatty acids and other nutrients.
D. Increased salivation
While malnutrition can affect various physiological processes, increased salivation is not a common manifestation of mal
Full Explanation
A. Malnutrition can lead to inadequate intake of essential nutrients, such as vitamins and minerals, which are necessary for maintaining healthy hair growth.
B. Double vision, or diplopia, is more commonly associated with neurological or ocular conditions rather than malnutrition.
C. Malnutrition may result in dry, flaky skin due to deficiencies in essential fatty acids and other nutrients.
D. While malnutrition can affect various physiological processes, increased salivation is not a common manifestation of mal
A charge nurse is observing a newly licensed nurse care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA). Which of the following observations of the newly licensed nurse indicates an understanding of infection control precautions?
A. Remains 3 feet away from the client
Keeping a safe distance is important but 3 feet away is not enough precaution.
B. Wears an N95 mask when providing wound care
MRSA is not airborne and hence not prevented through wearing of masks
C. Disposes of isolation gown outside of the client's room
The isolation gowns should be disposed in designated areas to prevent the spread of the infection.
D. Wears clean gloves when caring for the client
MRSA is spread through direct contact with infected persons or infectious droplets.
Full Explanation
MRSA is spread through direct contact with infected persons or infectious droplets.
A. Keeping a safe distance is important but 3 feet away is not enough precaution.
B. MRSA is not airborne and hence not prevented through wearing of masks
C. The isolation gowns should be disposed in designated areas to prevent the spread of the infection.