Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following findings places the client at risk for an incisional hematoma?
A. The client has peripheral vascular disease.
Peripheral vascular disease does not directly place the client at a higher risk for an incisional hematoma. While it is a vascular condition, the use of anticoagulant medications is a more significant risk factor for bleeding complications.
B. The client has urinary incontinence.
Urinary incontinence is not directly related to an increased risk of incisional hematoma. Incontinence is a separate issue and does not influence surgical outcomes in the context of hematoma formation.
C. The client takes anticoagulant medications.
Taking anticoagulant medications is a significant risk factor for incisional hematoma. Anticoagulants reduce the blood's ability to clot, which can lead to excessive bleeding at the surgical site and the formation of hematomas.
D. The client is underweight.
Being underweight is not a primary risk factor for incisional hematoma. While poor nutrition and overall health can influence wound healing, anticoagulant use is a more direct concern for hematoma formation in surgical patients.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom NSG 240 Final Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Peripheral vascular disease does not directly place the client at a higher risk for an incisional hematoma. While it is a vascular condition, the use of anticoagulant medications is a more significant risk factor for bleeding complications.
Choice B rationale:
Urinary incontinence is not directly related to an increased risk of incisional hematoma. Incontinence is a separate issue and does not influence surgical outcomes in the context of hematoma formation.
Choice C rationale:
Taking anticoagulant medications is a significant risk factor for incisional hematoma. Anticoagulants reduce the blood's ability to clot, which can lead to excessive bleeding at the surgical site and the formation of hematomas.
Choice D rationale:
Being underweight is not a primary risk factor for incisional hematoma. While poor nutrition and overall health can influence wound healing, anticoagulant use is a more direct concern for hematoma formation in surgical patients.
Similar Questions
A nurse is teaching a class about expected changes to the skin in older adults.
Which of the following information should the nurse include?
A. Increase in skin thinning.
An increase in skin thinning is not a typical age-related change in the skin. In older adults, skin tends to become thinner due to a decrease in subcutaneous tissue, making it more fragile and susceptible to damage.
B. Increase in skin elasticity.
An increase in skin elasticity is not a common characteristic of aging skin. In fact, older adults often experience a decrease in skin elasticity, leading to wrinkles and sagging skin.
C. Decrease in subcutaneous tissue.
D. Increase in blood supply to skin.
While there may be changes in blood supply to the skin as people age, an increase in blood supply is not a well-established or typical age-related change. Decreased blood flow to the skin is more common in older adults.
E. Decrease in skin hydration.
Decrease in skin hydration is a common age-related change, but it's not the most significant change mentioned in the question. The primary focus in older adults is the decrease in subcutaneous tissue, which has a more direct impact on skin health.
Full Explanation
Choice A rationale:
An increase in skin thinning is not a typical age-related change in the skin. In older adults, skin tends to become thinner due to a decrease in subcutaneous tissue, making it more fragile and susceptible to damage.
Choice B rationale:
An increase in skin elasticity is not a common characteristic of aging skin. In fact, older adults often experience a decrease in skin elasticity, leading to wrinkles and sagging skin.
Choice D rationale:
While there may be changes in blood supply to the skin as people age, an increase in blood supply is not a well-established or typical age-related change. Decreased blood flow to the skin is more common in older adults.
Choice E rationale:
Decrease in skin hydration is a common age-related change, but it's not the most significant change mentioned in the question. The primary focus in older adults is the decrease in subcutaneous tissue, which has a more direct impact on skin health.
A nurse is teaching a newly licensed nurse about incident reports.
The nurse should include that which of the following events requires an incident report?
A. An IV medication is administered via an oral route.
Administering IV medication via an oral route is a medication error and should be reported.
B. A client vomits their morning medications.
A client vomiting their morning medications is an adverse event, but not all adverse events require an incident report. The nurse should assess the situation and report if it poses a risk to the patient's health.
C. A lipid-lowering medication is administered to a client 1 hr after the scheduled time.
Administering a lipid-lowering medication to a client one hour after the scheduled time is a medication error, but again, the need for an incident report depends on the potential harm to the patient.
D. A client has an allergic reaction to an antibiotic.
An allergic reaction can occur in clients with no known drug allergies. Unless a drug was given in known allergies, it does not require an incident report.
Full Explanation
Choice A rationale:
Administering IV medication via an oral route is a medication error and should be reported.
Choice B rationale:
A client vomiting their morning medications is an adverse event, but not all adverse events require an incident report. The nurse should assess the situation and report if it poses a risk to the patient's health.
Choice C rationale:
Administering a lipid-lowering medication to a client one hour after the scheduled time is a medication error, but again, the need for an incident report depends on the potential harm to the patient. In some cases, reporting this incident may be necessary.
Choice D rationale
An allergic reaction can occur in clients with no known drug allergies. Unless a drug was given in known allergies, it does not require an incident report.
A nurse is caring for a client who has phantom limb pain.
The nurse should identify the client is experiencing which type of pain?
A. Neuropathic pain.
B. Acute pain.
Acute pain is typically associated with a sudden injury or condition, and it is usually short-term and self-limiting. Phantom limb pain is a chronic condition that is often neuropathic in nature.
C. Cancer pain.
Cancer pain is generally associated with the presence of a tumor or cancer-related treatment. Phantom limb pain is not directly related to cancer.
D. Chronic pain.
Chronic pain is a broad category that includes various types of long-lasting pain, but in the case of phantom limb pain, it is specifically neuropathic in nature. Neuropathic pain originates from damage or dysfunction of the nervous system and is a common characteristic of phantom limb pain. .
Full Explanation
Choice B rationale:
Acute pain is typically associated with a sudden injury or condition, and it is usually short-term and self-limiting. Phantom limb pain is a chronic condition that is often neuropathic in nature.
Choice C rationale:
Cancer pain is generally associated with the presence of a tumor or cancer-related treatment. Phantom limb pain is not directly related to cancer.
Choice D rationale:
Chronic pain is a broad category that includes various types of long-lasting pain, but in the case of phantom limb pain, it is specifically neuropathic in nature. Neuropathic pain originates from damage or dysfunction of the nervous system and is a common characteristic of phantom limb pain. .