Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a newly licensed nurse about incident reports.
The nurse should include that which of the following events requires an incident report?
A. An IV medication is administered via an oral route.
Administering IV medication via an oral route is a medication error and should be reported.
B. A client vomits their morning medications.
A client vomiting their morning medications is an adverse event, but not all adverse events require an incident report. The nurse should assess the situation and report if it poses a risk to the patient's health.
C. A lipid-lowering medication is administered to a client 1 hr after the scheduled time.
Administering a lipid-lowering medication to a client one hour after the scheduled time is a medication error, but again, the need for an incident report depends on the potential harm to the patient.
D. A client has an allergic reaction to an antibiotic.
An allergic reaction can occur in clients with no known drug allergies. Unless a drug was given in known allergies, it does not require an incident report.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom NSG 240 Final Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Administering IV medication via an oral route is a medication error and should be reported.
Choice B rationale:
A client vomiting their morning medications is an adverse event, but not all adverse events require an incident report. The nurse should assess the situation and report if it poses a risk to the patient's health.
Choice C rationale:
Administering a lipid-lowering medication to a client one hour after the scheduled time is a medication error, but again, the need for an incident report depends on the potential harm to the patient. In some cases, reporting this incident may be necessary.
Choice D rationale
An allergic reaction can occur in clients with no known drug allergies. Unless a drug was given in known allergies, it does not require an incident report.
Similar Questions
A nurse is caring for a client who has phantom limb pain.
The nurse should identify the client is experiencing which type of pain?
A. Neuropathic pain.
B. Acute pain.
Acute pain is typically associated with a sudden injury or condition, and it is usually short-term and self-limiting. Phantom limb pain is a chronic condition that is often neuropathic in nature.
C. Cancer pain.
Cancer pain is generally associated with the presence of a tumor or cancer-related treatment. Phantom limb pain is not directly related to cancer.
D. Chronic pain.
Chronic pain is a broad category that includes various types of long-lasting pain, but in the case of phantom limb pain, it is specifically neuropathic in nature. Neuropathic pain originates from damage or dysfunction of the nervous system and is a common characteristic of phantom limb pain. .
Full Explanation
Choice B rationale:
Acute pain is typically associated with a sudden injury or condition, and it is usually short-term and self-limiting. Phantom limb pain is a chronic condition that is often neuropathic in nature.
Choice C rationale:
Cancer pain is generally associated with the presence of a tumor or cancer-related treatment. Phantom limb pain is not directly related to cancer.
Choice D rationale:
Chronic pain is a broad category that includes various types of long-lasting pain, but in the case of phantom limb pain, it is specifically neuropathic in nature. Neuropathic pain originates from damage or dysfunction of the nervous system and is a common characteristic of phantom limb pain. .
A nurse is assessing a client who has impaired mobility.
The nurse should monitor the client for a pressure injury due to which of the following factors?
A. Increased collagen.
Increased collagen. Increased collagen is not a risk factor for pressure injuries. Collagen provides strength and support to the skin and tissues, which can be protective against pressure injuries by maintaining tissue integrity.
B. Decreased circulation.
Decreased circulation. Decreased circulation is a significant risk factor for pressure injuries. When blood flow to a specific area is reduced, it can lead to tissue ischemia, which makes the tissue more vulnerable to pressure damage. The lack of oxygen and nutrients from reduced circulation impairs the skin's ability to withstand pressure, increasing the risk of pressure injury development.
C. Increased muscle mass.
Increased muscle mass. While having increased muscle mass can offer some protection against pressure injuries due to the added support and padding, it is not a primary risk factor for developing pressure injuries. In fact, individuals with increased muscle mass may be less prone to pressure injuries because their muscle tissue helps distribute pressure more evenly.
D. Decreased serum calcium.
Decreased serum calcium. Decreased serum calcium levels can affect muscle function and bone health but are not a direct risk factor for pressure injuries. Pressure injuries primarily result from sustained pressure on the skin and underlying tissues, often due to immobility and other factors. Calcium levels are not directly related to the development of pressure injuries.
Full Explanation
Choice A rationale:
Increased collagen. Increased collagen is not a risk factor for pressure injuries. Collagen provides strength and support to the skin and tissues, which can be protective against pressure injuries by maintaining tissue integrity.
Choice B rationale:
Decreased circulation. Decreased circulation is a significant risk factor for pressure injuries. When blood flow to a specific area is reduced, it can lead to tissue ischemia, which makes the tissue more vulnerable to pressure damage. The lack of oxygen and nutrients from reduced circulation impairs the skin's ability to withstand pressure, increasing the risk of pressure injury development.
Choice C rationale:
Increased muscle mass. While having increased muscle mass can offer some protection against pressure injuries due to the added support and padding, it is not a primary risk factor for developing pressure injuries. In fact, individuals with increased muscle mass may be less prone to pressure injuries because their muscle tissue helps distribute pressure more evenly.
Choice D rationale:
Decreased serum calcium. Decreased serum calcium levels can affect muscle function and bone health but are not a direct risk factor for pressure injuries. Pressure injuries primarily result from sustained pressure on the skin and underlying tissues, often due to immobility and other factors. Calcium levels are not directly related to the development of pressure injuries.
A nurse is caring for a client who reports they are feeling stressed because they are unable to meet demands at work and care for a family member who is ill.
The nurse should identify that the client is experiencing which of the following self-concept stressors?
A. Role performance.
Role performance. Role performance is a self-concept stressor that occurs when individuals struggle to meet their responsibilities and expectations in various roles, such as work, family, or social roles. In this scenario, the client is feeling stressed due to the demands of work and caring for an ill family member, indicating a struggle with their roles and responsibilities.
B. Body image.
Body image. Body image relates to how individuals perceive and feel about their physical appearance. It is not the primary self-concept stressor described in this situation. While stressors related to body image can cause psychological distress, the client's stress is primarily linked to their roles and responsibilities.
C. Self-esteem.
Self-esteem. Self-esteem refers to an individual's overall self-worth and self-evaluation. While it can contribute to stress in various situations, the client's stress in this case is more directly related to their role performance and responsibilities.
D. Identity.
Identity. Identity concerns are related to an individual's sense of self and how they define themselves in terms of their values, beliefs, and personal characteristics. While identity can be a source of stress in some cases, the client's reported stress is primarily due to their inability to manage their roles effectively.
Full Explanation
Choice A rationale:
Role performance. Role performance is a self-concept stressor that occurs when individuals struggle to meet their responsibilities and expectations in various roles, such as work, family, or social roles. In this scenario, the client is feeling stressed due to the demands of work and caring for an ill family member, indicating a struggle with their roles and responsibilities.
Choice B rationale:
Body image. Body image relates to how individuals perceive and feel about their physical appearance. It is not the primary self-concept stressor described in this situation. While stressors related to body image can cause psychological distress, the client's stress is primarily linked to their roles and responsibilities.
Choice C rationale:
Self-esteem. Self-esteem refers to an individual's overall self-worth and self-evaluation. While it can contribute to stress in various situations, the client's stress in this case is more directly related to their role performance and responsibilities.
Choice D rationale:
Identity. Identity concerns are related to an individual's sense of self and how they define themselves in terms of their values, beliefs, and personal characteristics. While identity can be a source of stress in some cases, the client's reported stress is primarily due to their inability to manage their roles effectively.