Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
A. The client has a history of breast cancer.
This is incorrect because breast cancer is not associated with false-positive fecal occult blood results
B. The client takes ibuprofen for headaches.
The client takes ibuprofen for headaches. NSAIDs such as ibuprofen can cause gastrointestinal bleeding, which can result in a false positive result on a fecal occult blood test.
C. The client consumed citrus juice 3 days before the test.
This is incorrect because citrus juice does not affect the fecal occult blood test.
D. The client had a hemorrhoidectomy 1 year ago.
This is incorrect because a hemorrhoidectomy is not associated with false-positive fecal occult blood results.
E. The client had a hemorrhoidectomy 1 year ago.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
The client takes ibuprofen for headaches. NSAIDs such as ibuprofen can cause gastrointestinal bleeding, which can result in a false positive result on a fecal occult blood test.
Option A is incorrect because breast cancer is not associated with false-positive fecal occult blood results.
Option C is incorrect because citrus juice does not affect the fecal occult blood test.
Option D is incorrect because a hemorrhoidectomy is not associated with false-positive fecal occult blood results.
Reasons why the other options are not answered:
Option A: Breast cancer is not associated with false-positive fecal occult blood results.
Option C: Citrus juice does not affect the fecal occult blood test.
Option D: A hemorrhoidectomy is not associated with false-positive fecal occult blood results.
Similar Questions
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
A. Obtain blood pressure readings using the client's right arm.
Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.
B. Limit range-of-motion exercises with the affected arm.
Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.
C. Keep both arms below the level of the client's heart.
Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.
D. Use the client's left arm to obtain blood samples.
The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.
Full Explanation
The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.
A: Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.
B: Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.
C: Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.
A nurse is contributing to the plan of care for a client who has an external fixation device in place to treat an open fracture of the tibia and fibula. Which of the following interventions should the nurse include?
A. Apply 4.5 kg (10 lb) traction weight to the distal end of the fixator.
Applying traction weight to the external fixator is not recommended, as it can cause excessive stress on the pins and wires, leading to complications such as infection, loosening, or breakage1.Traction is usually applied to skeletal pins that are inserted into the bone without an external frame2.
B. Monitor the neurovascular status of the client's affected limb every 8 hr.
Monitoring the neurovascular status of the affected limb is important, but every 8 hours is not frequent enough.The nurse should perform neurovascular checks every 2 to 4 hours for the first 24 hours, then every 4 to 8 hours, according to the facility policy3. This is to assess for signs of nerve damage, compartment syndrome, or impaired circulation, which can result from the injury or the device.
C. Administer pain medication 30 min prior to pin care.
Administering pain medication 30 min prior to pin care is a correct intervention, as it can help reduce the discomfort and anxiety associated with the procedure. Pin care involves cleaning the pin sites with an antiseptic solution and applying sterile dressings to prevent infection and promote healing. The frequency and technique of pin care may vary depending on the type of device, the condition of the wound, and the facility protocol.
D. Adjust the clamps on the device's frame daily.
Adjusting the clamps on the device’s frame daily is not a nursing intervention, as it can alter the alignment and stability of the fracture. The clamps should be tightened only by the orthopedic surgeon or a trained technician, and only when necessary. The nurse should inspect the device for any loose or broken parts and report any problems to the surgeon.
Full Explanation
The correct answer is Choice C.
Choice A rationale: Applying traction weight to the external fixator is not recommended, as it can cause excessive stress on the pins and wires, leading to complications such as infection, loosening, or breakage1. Traction is usually applied to skeletal pins that are inserted into the bone without an external frame2.
Choice B rationale: Monitoring the neurovascular status of the affected limb is important, but every 8 hours is not frequent enough. The nurse should perform neurovascular checks every 2 to 4 hours for the first 24 hours, then every 4 to 8 hours, according to the facility policy3. This is to assess for signs of nerve damage, compartment syndrome, or impaired circulation, which can result from the injury or the device.
Choice C rationale: Administering pain medication 30 min prior to pin care is a correct intervention, as it can help reduce the discomfort and anxiety associated with the procedure. Pin care involves cleaning the pin sites with an antiseptic solution and applying sterile dressings to prevent infection and promote healing. The frequency and technique of pin care may vary depending on the type of device, the condition of the wound, and the facility protocol.
Choice D rationale: Adjusting the clamps on the device’s frame daily is not a nursing intervention, as it can alter the alignment and stability of the fracture. The clamps should be tightened only by the orthopedic surgeon or a trained technician, and only when necessary. The nurse should inspect the device for any loose or broken parts and report any problems to the surgeon.
So, the correct answer is Choice C, after analysing all choices.
A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?
A. Have an assistive personnel feed the client.
Having an assistive personnel feed the client may decrease the client's autonomy.
B. Apply foam handles to the client's eating utensils.
Apply foam handles to the client's eating utensils. This intervention can help the client grip the utensils better and improve their ability to eat.
C. Obtain a referral for physical therapy.
Obtaining a referral for physical therapy may be helpful but does not address the immediate issue of difficulty with eating.
D. Ask the provider for a prescription for a pureed diet.
Asking the provider for a prescription for a pureed diet may not be necessary or desirable at this time.
Full Explanation
Apply foam handles to the client's eating utensils. This intervention can help the client grip the utensils better and improve their ability to eat.
Reasons why the other options are not answers:
Option A: Having an assistive personnel feed the client may decrease the client's autonomy.
Option C: Obtaining a referral for physical therapy may be helpful but does not address the immediate issue of difficulty with eating.
Option D: Asking the provider for a prescription for a pureed diet may not be necessary or desirable at this time.