Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?
A. Ensuring that creases in the stockings are on the front of the client's legs
This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.
B. Applying the stockings before the client gets out of bed
Applying the stockings before the client gets out of bed is correct. Antiembolic stockings should be applied before the client gets out of bed to prevent blood from pooling in the legs, which can help reduce the risk of deep vein thrombosis (DVT).
C. Asking the client to point their toes before applying the stockings
Asking the client to point their toes before applying the stockings is a correct action. This helps in the proper fitting of the stockings and ensures they are applied smoothly without causing discomfort.
D. Turning the stockings inside out before applying them
Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.
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Full Explanation
Choice A rationale:
This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.
Choice B rationale:
Applying the stockings before the client gets out of bed is correct. Antiembolic stockings should be applied before the client gets out of bed to prevent blood from pooling in the legs, which can help reduce the risk of deep vein thrombosis (DVT).
Choice C rationale:
Asking the client to point their toes before applying the stockings is a correct action. This helps in the proper fitting of the stockings and ensures they are applied smoothly without causing discomfort.
Choice D rationale:
Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.
Similar Questions
A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?
A. Tape the tube to the child's cheek.
Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
B. Apply water-soluble lubricant to the site.
Applying water-soluble lubricant to the gastrostomy site routinely is not recommended because it can trap moisture, leading to maceration or infection.
C. Attach an extension tube to the site's opening prior to use.
Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
D. Secure the tubing to the child's abdomen.
Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
Full Explanation
A. Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
B. Applying water-soluble lubricant to the gastrostomy site routinely is not recommended because it can trap moisture, leading to maceration or infection.
C. Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
D. Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?
A. Decreased BUN level
B. Decreased hemoglobin level
C. Increased urinary output
The increased urinary output indicates that furosemide, a loop diuretic, is effective in reducing fluid retention and edema in clients with heart failure. The other findings are not indicative of furosemide effectiveness and may suggest adverse effects or complications. Decreased BUN level may indicate overhydration or liver dysfunction. Decreased hemoglobin levelmay indicate anemia or bleeding.Increased weight of 0.91 kg (2 lb) may indicate fluid overload or worsening heart failure.
D. Increased weight of 0.91 kg (2 lb)
Full Explanation
The correct answer is C. Increased urinary output indicates that furosemide, a loop diuretic, is effective in reducing fluid retention and edema in clients with heart failure. The other findings are not indicative of furosemide effectiveness and may suggest adverse effects or complications. Decreased BUN level may indicate overhydration or liver dysfunction. Decreased hemoglobin level may indicate anemia or bleeding. Increased weight of 0.91 kg (2 lb) may indicate fluid overload or worsening heart failure.
A nurse is collecting data from a client who has pernicious anemia. The nurse should identify that which of the following findings increases the client's risk for injury?
A. Uses a firm-bristled toothbrush
Pernicious anemia is caused by a deficiency of vitamin B12, which is essential for red blood cell production and neurological function. Clients with this condition often experience glossitis (inflammation of the tongue) and oral mucosal atrophy, making the oral tissues fragile and more prone to injury. Using a firm-bristled toothbrush can cause gum trauma, leading to bleeding, ulcers, and discomfort. A soft-bristled toothbrush is recommended to minimize the risk of injury.
B. Increased intake of green, leafy vegetables
Green, leafy vegetables are rich in folic acid, which supports red blood cell production. However, pernicious anemia is specifically caused by vitamin B12 deficiency, not folate deficiency.
C. Drinks 2,500 mL of fluid per day
Adequate hydration does not contribute to injury risk in pernicious anemia. In fact, maintaining proper fluid intake helps prevent dehydration and supports overall circulation.
D. Wears a face mask around others
Wearing a face mask does not increase the risk of injury. It may actually help protect the client from infections if they have weakened immunity due to anemia.
E. None
None
F. None
None
Full Explanation
Pernicious anemia is caused by a deficiency of vitamin B12, which is essential for red blood cell production and neurological function. Clients with this condition often experience glossitis (inflammation of the tongue) and oral mucosal atrophy, making the oral tissues fragile and more prone to injury. Using a firm-bristled toothbrush can cause gum trauma, leading to bleeding, ulcers, and discomfort. A soft-bristled toothbrush is recommended to minimize the risk of injury.