Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching?
A. "I will put beverages in large containers to give the appearance of drinking a lot.”.
Stating that they will put beverages in large containers to give the appearance of drinking a lot demonstrates a lack of understanding of fluid restriction guidelines. It focuses on the appearance rather than the actual fluid intake limitation. This statement does not reflect an understanding of the need to limit fluids in acute kidney disease.
B. "I should consume most of the fluid during the evening.”.
Consuming most fluids during the evening is not recommended for clients with acute kidney disease as it may lead to discomfort, nighttime urination, and fluid overload. This statement does not demonstrate an understanding of the importance of spreading fluid intake throughout the day.
C. "I will make a list of my favorite beverages.”.
Making a list of favorite beverages indicates the client's understanding of fluid restrictions. This approach can help the client prioritize their preferred beverages while staying within their prescribed fluid allowance. It shows that the client is aware of the need to be selective in their fluid intake.
D. "I will not add ice cream to the amount of fluid intake.”.
Although avoiding ice cream is an appropriate action due to its contribution to fluid intake, this statement alone does not necessarily indicate a comprehensive understanding of fluid restrictions. The client must also be aware of the importance of monitoring all sources of fluid intake, including other foods and beverages.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Custom NURSING 221 Proctored Exam 3. Take the full exam now
Full Explanation
The correct answer is Choice C: "I will make a list of my favorite beverages."
Choice A rationale: Stating that they will put beverages in large containers to give the appearance of drinking a lot demonstrates a lack of understanding of fluid restriction guidelines. It focuses on the appearance rather than the actual fluid intake limitation. This statement does not reflect an understanding of the need to limit fluids in acute kidney disease.
Choice B rationale: Consuming most fluids during the evening is not recommended for clients with acute kidney disease as it may lead to discomfort, nighttime urination, and fluid overload. This statement does not demonstrate an understanding of the importance of spreading fluid intake throughout the day.
Choice C rationale: Making a list of favorite beverages indicates the client's understanding of fluid restrictions. This approach can help the client prioritize their preferred beverages while staying within their prescribed fluid allowance. It shows that the client is aware of the need to be selective in their fluid intake.
Choice D rationale: Although avoiding ice cream is an appropriate action due to its contribution to fluid intake, this statement alone does not necessarily indicate a comprehensive understanding of fluid restrictions. The client must also be aware of the importance of monitoring all sources of fluid intake, including other foods and beverages.
Similar Questions
A nurse enters a client's room and finds the client on the floor having a seizure.
Which of the following actions should the nurse take?
A. Place the client back in bed.
Placing the client back in bed during a seizure could lead to injury.
B. Place the client on his side.
Placing the client on his side, specifically the left side, allows for the tongue to fall forward, preventing aspiration.
C. Hold the client's arms and legs from moving.
Holding the client’s arms and legs from moving could cause harm to the client or nurse.
D. Insert a tongue blade in the client's mouth.
Inserting a tongue blade in the client’s mouth could cause injury to the client’s oral cavity.
Full Explanation
Choice A rationale:
Placing the client back in bed during a seizure could lead to injury.
Choice B rationale:
Placing the client on his side, specifically the left side, allows for the tongue to fall forward, preventing aspiration.
Choice C rationale:
Holding the client’s arms and legs from moving could cause harm to the client or nurse.
Choice D rationale:
Inserting a tongue blade in the client’s mouth could cause injury to the client’s oral cavity.
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
A. "The bright light in this room is really bothering me.”.
Sensitivity to light is common after cataract surgery and does not need to be reported.
B. "I need something for the pain in my eye. I can't stand it.”.
Severe pain could indicate complications such as increased intraocular pressure or infection.
C. "My eye really itches, but I'm trying not to rub it.”.
Itching is common after surgery due to healing and does not need to be reported.
D. "It's hard to see with a patch on one eye. I'm afraid of falling.”.
Difficulty with vision is expected due to the eye patch, but fear of falling should be addressed through safety measures, not necessarily reported to the provider.
Full Explanation
Choice A rationale:
Sensitivity to light is common after cataract surgery and does not need to be reported.
Choice B rationale:
Severe pain could indicate complications such as increased intraocular pressure or infection.
Choice C rationale:
Itching is common after surgery due to healing and does not need to be reported.
Choice D rationale:
Difficulty with vision is expected due to the eye patch, but fear of falling should be addressed through safety measures, not necessarily reported to the provider.
A nurse is caring for a client who has HIV.
Which of the following laboratory values is the nurse's priority?
A. WBC 5,000/mm³.
A WBC count of 5,000/mm³ is within the normal range (4,500 to 11,000 cells/mm³) and is not a priority.
B. Platelets 150,000/mm³.
A platelet count of 150,000/mm³ is within the normal range (150,000 to 450,000/mm³) and is not a priority.
C. O Positive Western blot test.
A positive Western blot test confirms HIV infection, but it is not a priority in this case.
D. CD4-T-cell count 180 cells/mm.
A CD4-T-cell count of 180 cells/mm³ is below the normal range (500 to 1,500 cells/mm³), indicating severe immune system damage in a client with HIV. This is the nurse’s priority.
Full Explanation
Choice A rationale:
A WBC count of 5,000/mm³ is within the normal range (4,500 to 11,000 cells/mm³) and is not a priority.
Choice B rationale:
A platelet count of 150,000/mm³ is within the normal range (150,000 to 450,000/mm³) and is not a priority.
Choice C rationale:
A positive Western blot test confirms HIV infection, but it is not a priority in this case.
Choice D rationale:
A CD4-T-cell count of 180 cells/mm³ is below the normal range (500 to 1,500 cells/mm³), indicating severe immune system damage in a client with HIV. This is the nurse’s priority.