Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a client who has sickle cell disease about preventing a sickle cell crisis. Which of the following statements should the nurse make?
A. "You should avoid temperature extremes."
Avoiding temperature extremes can help prevent triggering a sickle cell crisis. Cold temperatures can cause blood vessels to constrict, leading to poor blood flow and increased risk of cell sickling.
B. "You should engage in high-impact exercise twice per week."
Engaging in high-impact exercise might not be recommended, as vigorous exercise can increase the risk of dehydration and oxygen deprivation, potentially triggering a crisis.
C. "You should drink at least 2 liters of fluids each day."
Staying well-hydrated by drinking fluids is important, but temperature regulation is a key factor in preventing sickle cell crises.
D. "You should not receive the influenza vaccine."
Receiving the influenza vaccine is recommended for individuals with sickle cell disease to reduce the risk of infections that could trigger a crisis. This statement is incorrect; the client should receive the influenza vaccine unless contraindicated.
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:
Avoiding temperature extremes can help prevent triggering a sickle cell crisis. Cold temperatures can cause blood vessels to constrict, leading to poor blood flow and increased risk of cell sickling.
Choice B rationale:
Engaging in high-impact exercise might not be recommended, as vigorous exercise can increase the risk of dehydration and oxygen deprivation, potentially triggering a crisis.
Choice C rationale:
Staying well-hydrated by drinking fluids is important, but temperature regulation is a key factor in preventing sickle cell crises.
Choice D rationale:
Receiving the influenza vaccine is recommended for individuals with sickle cell disease to reduce the risk of infections that could trigger a crisis. This statement is incorrect; the client should receive the influenza vaccine unless contraindicated.
Similar Questions
A nurse is developing a plan of care while admitting a client who has anorexia nervosa.
Which of the following interventions should the nurse include?
A. Observe the client for 1 hr following meals.
Monitoring the client for a period of time after meals helps prevent behaviors such as purging or excessive exercise, which individuals with anorexia nervosa might engage in to compensate for food intake.
B. Encourage the client to gain 2.27 kg (5 lb) per week.
Encouraging a specific weight gain is not the initial priority. Weight restoration should be approached carefully and gradually to avoid refeeding syndrome.
C. Allow the client to exercise for less than 1 hr per day.
Allowing the client to exercise for less than 1 hr per day is a potential intervention, but the priority is to observe the client after meals to prevent harmful behaviors.
D. weigh the client in the morning every other day.
Weighing the client in the morning every other day is an important monitoring step, but it is not the initial intervention during admission.
E. weigh the client in the morning every other day.
Full Explanation
Choice A rationale:
Monitoring the client for a period of time after meals helps prevent behaviors such as purging or excessive exercise, which individuals with anorexia nervosa might engage in to compensate for food intake.
Choice B rationale:
Encouraging a specific weight gain is not the initial priority. Weight restoration should be approached carefully and gradually to avoid refeeding syndrome.
Choice C rationale:
Allowing the client to exercise for less than 1 hr per day is a potential intervention, but the priority is to observe the client after meals to prevent harmful behaviors.
Choice D rationale:
Weighing the client in the morning every other day is an important monitoring step, but it is not the initial intervention during admission.
A nurse is teaching a client who has genital herpes. Which of the following statements by the client indicates an understanding of the teaching?
A. "I can pour warm water over the lesions to decrease painful urination."
Warm water can help soothe the lesions and decrease painful urination, providing relief to the client.
B. "I am not contagious when I don't have lesions."
The client with genital herpes can still shed the virus and potentially transmit it to others even when there are no visible lesions, so this statement is incorrect.
C. "I will finish my antibiotics so that my infection will not return."
Genital herpes is a viral infection, and antibiotics are not effective in treating viral infections. Antiviral medications are used to manage genital herpes outbreaks.
D. "I can soak in a bubble bath to reduce discomfort."
Soaking in a bubble bath can potentially irritate the lesions and worsen discomfort. It is not recommended for individuals with genital herpes.
Full Explanation
Choice A rationale:
Warm water can help soothe the lesions and decrease painful urination, providing relief to the client.
Choice B rationale:
The client with genital herpes can still shed the virus and potentially transmit it to others even when there are no visible lesions, so this statement is incorrect.
Choice C rationale:
Genital herpes is a viral infection, and antibiotics are not effective in treating viral infections. Antiviral medications are used to manage genital herpes outbreaks.
Choice D rationale:
Soaking in a bubble bath can potentially irritate the lesions and worsen discomfort. It is not recommended for individuals with genital herpes.
A nurse is preparing to administer the influenza vaccine to a group of clients. For which of the following clients should the nurse withhold the vaccine?
A. A client who developed influenza after receiving the vaccine last year
Developing influenza after receiving the vaccine the previous year is not a contraindication for receiving the vaccine this year. In fact, the vaccine is recommended annually.
B. A client who has hypertension
Hypertension is not a contraindication for receiving the influenza vaccine.
C. A client who has a history of Guillain-Barré syndrome
Clients with a history of Guillain-Barré syndrome should generally avoid receiving the influenza vaccine due to a potential increased risk of recurrence of the syndrome.
D. A client who has an allergy to dairy products.
Allergies to dairy products are not a contraindication for receiving the influenza vaccine.
Full Explanation
Choice A rationale:
Developing influenza after receiving the vaccine the previous year is not a contraindication for receiving the vaccine this year. In fact, the vaccine is recommended annually.
Choice B rationale:
Hypertension is not a contraindication for receiving the influenza vaccine.
Choice C rationale:
Clients with a history of Guillain-Barré syndrome should generally avoid receiving the influenza vaccine due to a potential increased risk of recurrence of the syndrome.
Choice D rationale:
Allergies to dairy products are not a contraindication for receiving the influenza vaccine.