Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?
A. Hypernatremia
Hypernatremia is not a common finding in the emergent phase of a burn.
B. Hypercalcemia
Hypercalcemia is not a common finding in the emergent phase of a burn.
C. Hypermagnesemia
Hypermagnesemia is not a common finding in the emergent phase of a burn.
D. Hyperkalemia
The nurse should expect to find hyperkalemia in the medical record of a client who has sustained a full- thickness burn and is in the emergent phase of the burn. This is due to the release of potassium from damaged cells into the bloodstream.
This question is an excerpt from Nurse Dive's nursing test bank - VATI PN Comprehensive Predictor 2020 Proctored Exam. Take the full exam now
Full Explanation
The nurse should expect to find hyperkalemia in the medical record of a client who has sustained a full- thickness burn and is in the emergent phase of the burn. This is due to the release of potassium from damaged cells into the bloodstream.
a) Hypernatremia is not a common finding in the emergent phase of a burn.
b) Hypercalcemia is not a common finding in the emergent phase of a burn.
c) Hypermagnesemia is not a common finding in the emergent phase of a burn.
Similar Questions
A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include?
A. Cleanse the perineal area from back to front.
A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.
B. Wash the perineal area with povidone-iodine twice daily
B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area
C. Change the perineal pad with each void
C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.
D. "Wipe the perineal area with a soft cloth."
D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.
Full Explanation
Answer: C. Change the perineal pad with each void.
Rationale:
A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.
B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area.
C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.
D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.
A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?
A. a) Instruct the client to report the theft to the police.
Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.
B. Report the possible abuse to adult protective services.
The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well- being of the client.
C. Ask the client if there is another family member they can call for financial help.
Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.
D. Restrict visitation for the client's family until discharge.
Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.
Full Explanation
The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well-being of the client.
a) Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.
c) Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.
d) Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.
A nurse is caring for a client who has been placed on contact isolation precautions. Which of the following interventions should the nurse implement?
A. Inform visitors to remain at least 3 feet away from the client.
While maintaining a distance of 3 feet can be helpful in reducing the transmission of some infections, it is not the primary measure for contact isolation precautions. Contact precautions are specifically designed to prevent the spread of pathogens that are transmitted through direct or indirect contact with the patient or their environment. A distance of 3 feet might not be sufficient to prevent contact with contaminated surfaces or objects, especially in a healthcare setting where close contact is often necessary for providing care. Therefore, while informing visitors to maintain some distance is a good practice, it is not the most crucial intervention for contact isolation.
B. Apply sterile gloves when entering the client's room.
Sterile gloves are not routinely required for contact isolation precautions. They are primarily used for sterile procedures or when there is a risk of exposure to blood or body fluids. For contact isolation, standard clean gloves are usually sufficient to protect against transmission via direct contact.
C. Leave all equipment that is used routinely in the client's room
Leaving equipment that is used routinely in the client's room is a crucial part of contact isolation precautions. This practice prevents the spread of infection by minimizing the movement of potentially contaminated items outside of the isolation room. Equipment like stethoscopes, blood pressure cuffs, and thermometers should be dedicated to the client's use and not shared with other patients.
D. Place the client in a negative-pressure airflow room
Negative-pressure airflow rooms are used for airborne isolation precautions, which are designed to prevent the spread of pathogens that can be transmitted through the air. Contact isolation does not specifically require a negative-pressure room, as the primary mode of transmission is through direct or indirect contact, not airborne particles.
Full Explanation
The correct answer is Choice C.
Choice A rationale:
- While maintaining a distance of 3 feet can reduce the risk of direct contact transmission, it is not the most effective measure for contact isolation precautions.
- Contact isolation aims to prevent the spread of pathogens that can be transmitted through direct or indirect contact with the infected person or contaminated objects.
- A distance of 3 feet may not be sufficient to prevent transmission via droplets or fomites (inanimate objects that can harbor infectious agents).
Choice B rationale:
- Sterile gloves are not routinely required for contact isolation precautions.
- They are primarily used for sterile procedures or when there is a risk of exposure to blood or body fluids.
- For contact isolation, standard clean gloves are usually sufficient to protect against transmission via direct contact.
Choice C rationale:
- Leaving equipment that is used routinely in the client's room is a crucial part of contact isolation precautions.
- This practice prevents the spread of infection by minimizing the movement of potentially contaminated items outside of the isolation room.
- Equipment like stethoscopes, blood pressure cuffs, and thermometers should be dedicated to the client's use and not shared with other patients.
Choice D rationale:
- Negative-pressure airflow rooms are used for airborne isolation precautions, which are designed to prevent the spread of pathogens that can be transmitted through the air.
- Contact isolation does not specifically require a negative-pressure room, as the primary mode of transmission is through direct or indirect contact, not airborne particles.