Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse manager include?
A. Document the client’s condition every 15 min
Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:
B. Request a PRN restraint prescription for clients who are aggressive
Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.
C. Attach the restraint to the bed’s side rails
Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.
D. Remove the client’s restraint every
Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
When updating protocols for the use of belt restraints, the nurse manager should include the following guideline:
A) Document the client’s condition every 15 min
Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:
B) Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.
C) Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.
D) Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.
Similar Questions
A nurse is assessing a child who has bacterial pneumonia.
Which of the following manifestations should the nurse expect?
A. Drooling
drooling, is wrong because it is not a typical symptom of bacterial pneumonia. Drooling can be caused by other conditions, such as sore throat, dental problems, or neurological disorders.
B. Tinnitus
, tinnitus, is wrong because it is not a symptom of bacterial pneumonia either. Tinnitus is a ringing or buzzing sound in the ears that can be caused by exposure to loud noise, ear infections, or other ear problems.
C. Malaise
Malaise is a general feeling of discomfort, weakness, or illness that can be a sign of infection. According to the health search result from Focus Medica , bacterial pneumonia is an infection of the air sacs in one or both lungs that causes symptoms such as cough with phlegm, fever, chills, and difficulty breathing. Malaise is one of the symptoms that may follow these signs of infection.
D. Rhinorrhea
rhinorrhea, is wrong because it is not specific to bacterial pneumonia. Rhinorrhea is a runny nose that can be caused by many factors, such as allergies, colds, or sinus infections.
Full Explanation
The correct answer is choice C, malaise.
Malaise is a general feeling of discomfort, weakness, or illness that can be a sign of infection. According to the health search result from Focus Medica , bacterial pneumonia is an infection of the air sacs in one or both lungs that causes symptoms such as cough with phlegm, fever, chills, and difficulty breathing.
Malaise is one of the symptoms that may follow these signs of infection.
Choice A, drooling, is wrong because it is not a typical symptom of bacterial pneumonia.
Drooling can be caused by other conditions, such as sore throat, dental problems, or neurological disorders.
Choice B, tinnitus, is wrong because it is not a symptom of bacterial pneumonia either.
Tinnitus is a ringing or buzzing sound in the ears that can be caused by exposure to loud noise, ear infections, or other ear problems.
Choice D, rhinorrhea, is wrong because it is not specific to bacterial pneumonia.
Rhinorrhea is a runny nose that can be caused by many factors, such as allergies, colds, or sinus infections.
Rhinorrhea can sometimes occur with viral pneumonia, but not usually with bacterial pneumonia.
Question 26.
A nurse is caring for a 2-year-old toddler.
Which of the following food choices should the nurse recommend to promote independence in eating?
A. Popcorn
wrong because popcorn is a choking hazard for toddlers. It is hard, crunchy, and can get stuck in the airway. The NHS advises not to give whole nuts and peanuts to children under 5 years old.
B. Grapes
wrong because grapes are also a choking hazard for toddlers. They are round, slippery, and can block the airway. The NHS recommends cutting grapes into quarters before giving them to young children.
C. C. Banana slices
Banana slices are soft, easy to chew, and can be picked up by the toddler’s fingers, which promotes independence in eating. According to the CDC, foods that toddlers should avoid include: Added sugars and no-calorie sweeteners, such as sugar-sweetened and diet drinks High-salt foods, such as canned foods, processed meats, frozen dinners, fast food, and junk food Unpasteurized juice, milk, yogurt, or cheese Foods that may cause choking, such as hard or crunchy foods, sticky foods, stringy cheese, and foods that are not cut up into small pieces
D. D. Hot dog
is wrong because hot dogs are high in salt and can cause choking if not cut up into small pieces. The Extension warns against giving hot dogs to young toddlers.
Full Explanation
Banana slices are soft, easy to chew, and can be picked up by the toddler’s fingers, which promotes independence in eating. According to the CDC, foods that toddlers should avoid include:
- Added sugars and no-calorie sweeteners, such as sugar-sweetened and diet drinks
- High-salt foods, such as canned foods, processed meats, frozen dinners, fast food, and junk food
- Unpasteurized juice, milk, yogurt, or cheese
- Foods that may cause choking, such as hard or crunchy foods, sticky foods, stringy cheese, and foods that are not cut up into small pieces
Choice A is wrong because popcorn is a choking hazard for toddlers.
It is hard, crunchy, and can get stuck in the airway. The NHS advises not to give whole nuts and peanuts to children under 5 years old.
Choice B is wrong because grapes are also a choking hazard for toddlers.
They are round, slippery, and can block the airway. The NHS recommends cutting grapes into quarters before giving them to young children.
Choice D is wrong because hot dogs are high in salt and can cause choking if not cut up into small pieces. The Extension warns against giving hot dogs to young toddlers.
A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter.
Which of the following instructions should the nurse include in the teaching?
A. Maintain a semi-Fowler’s position during testing
is wrong because maintaining a semi-Fowler’s position during testing is not necessary. You can sit or stand up straight, but make sure you do it the same way each time.
B. Place tongue on the mouthpiece of the meter
is wrong because placing tongue on the mouthpiece of the meter can block the air flow and affect the accuracy of the measurement. You should close your lips tightly on the mouthpiece instead.
C. Blow into the meter as hard and quickly as possible
. Blow into the meter as hard and quickly as possible. This is because a peak flow meter measures how fast you can push air out of your lungs when you blow out as hard and as fast as you can. This is called peak expiratory flow rate (PEFR) or peak expiratory flow (PEF). It shows how open the airways are in the lungs and can help detect early signs of worsening asthma.
D. Record the average of the readings
because recording the average of the readings is not recommended. You should record the highest of the three readings on a sheet of paper, calendar or in your asthma diary. This is your daily peak flow.
Full Explanation
The correct answer is choice C. Blow into the meter as hard and quickly as possible.
This is because a peak flow meter measures how fast you can push air out of your lungs when you blow out as hard and as fast as you can.
This is called peak expiratory flow rate (PEFR) or peak expiratory flow (PEF). It shows how open the airways are in the lungs and can help detect early signs of worsening asthma.
Choice A is wrong because maintaining a semi-Fowler’s position during testing is not necessary. You can sit or stand up straight, but make sure you do it the same way each time.
Choice B is wrong because placing tongue on the mouthpiece of the meter can block the air flow and affect the accuracy of the measurement. You should close your lips tightly on the mouthpiece instead.
Choice D is wrong because recording the average of the readings is not recommended.
You should record the highest of the three readings on a sheet of paper, calendar or in your asthma diary. This is your daily peak flow.
Normal ranges for peak flow vary depending on age, height, gender and race. You can use a chart or calculator to find out your predicted normal peak flow based on these factors. However, it is more important to find out your personal best peak flow by performing peak flow testing twice a day for two weeks when your asthma is under good control. Your personal best peak flow will be used to create your asthma action plan with your healthcare provider.