Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing the medical record of an older adult client who is confused to place and time. Which of the following actions should the nurse plan to take?
A. Place the client on a low-protein diet
Placing the client on a low-protein diet is not appropriate based solely on the provided information.
B. Restrict the client's intake of dietary sodium.
Restricting dietary sodium might be considered for specific conditions but is not directly related to the client's confusion.
C. Ask the provider to decrease the magnesium hydroxide dosage.
A high magnesium level can contribute to confusion in older adults. Requesting a reduction in the magnesium hydroxide dosage can help address this issue.
D. Request a prescription to discontinue diphenhydramine.
Discontinuing diphenhydramine might be considered if it is contributing to the client's confusion, but there is no specific information provided to support this action.
This question is an excerpt from Nurse Dive's nursing test bank - RN ati Concept-based assessment level proctored exam. Take the full exam now
Full Explanation
Choice A rationale:
Placing the client on a low-protein diet is not appropriate based solely on the provided information.
Choice B rationale:
Restricting dietary sodium might be considered for specific conditions but is not directly related to the client's confusion.
Choice C rationale:
A high magnesium level can contribute to confusion in older adults. Requesting a reduction in the magnesium hydroxide dosage can help address this issue.
Choice D rationale:
Discontinuing diphenhydramine might be considered if it is contributing to the client's confusion, but there is no specific information provided to support this action.
Similar Questions
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse plan to take? (Select all that apply.)
A. Ask the client to explain what she is hearing.
Asking the client to explain what she is hearing may not be helpful, as the client's perception of the hallucinations may not match reality.
B. Convey empathy toward the client.
Conveying empathy is important to establish a therapeutic relationship and provide emotional support.
C. Encourage the client to listen to music through headphones.
Encouraging the client to listen to music through headphones can help distract from auditory hallucinations.
D. Speak simply when communicating with the client.
Speaking simply and clearly when communicating helps the client understand and process information more effectively.
E. Use therapeutic touch when caring for the client.
Using therapeutic touch might not be appropriate for all clients and should be based on the client's preferences and comfort level.
Full Explanation
Choice A rationale:
Asking the client to explain what she is hearing may not be helpful, as the client's perception of the hallucinations may not match reality.
Choice B rationale:
Conveying empathy is important to establish a therapeutic relationship and provide emotional support.
Choice C rationale:
Encouraging the client to listen to music through headphones can help distract from auditory hallucinations.
Choice D rationale:
Speaking simply and clearly when communicating helps the client understand and process information more effectively.
Choice E rationale:
Using therapeutic touch might not be appropriate for all clients and should be based on the client's preferences and comfort level.
A nurse is caring for a client who is receiving mechanical ventilation following a stroke.
Which of the following actions should the nurse take?
A. Cluster nursing care activities.
Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.
B. Hyperoxygenate the client before suctioning.
Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.
C. Keep the room well lit to orient the client.
Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.
D. Maintain the client's PaCO2 at 50 mm Hg.
Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.
Full Explanation
Choice A rationale:
Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.
Choice B rationale:
Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.
Choice C rationale:
Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.
Choice D rationale:
Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?
A. Absent deep tendon reflexes
Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.
B. Fetal heart rate of 120/min
A fetal heart rate of 120/min is within a normal range and is not concerning.
C. Blood pressure 150/92 mm Hg
Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.
D. Facial flushing
Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.
Full Explanation
Choice A rationale:
Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.
Choice B rationale:
A fetal heart rate of 120/min is within a normal range and is not concerning.
Choice C rationale:
Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.
Choice D rationale:
Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.