Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on the medical-surgical unit is caring for a client who has a seizure disorder.
Which of the following interventions should the nurse include in the plan of care?
A. Pad the upper two side rails of the client's bed.
Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B. Maintain peripheral IV access.
Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C. Teach assistive personnel how to apply restraints.
Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D. Keep a padded tongue blade at the client's bedside.
Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.
E. Keep a padded tongue blade at the client's bedside.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Med Surg 2023 Proctored Exam. Take the full exam now
Full Explanation
A) Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B) Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C) Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D) Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.
Similar Questions
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
A. Distended jugular veins
Distended jugular veins are associated with fluid overload, not dehydration.
B. Pitting, dependent edema
Pitting, dependent edema is also associated with fluid overload, not dehydration.
C. Decreased blood pressure
Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D. Increased blood pressure
Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.
Full Explanation
A) Distended jugular veins are associated with fluid overload, not dehydration.
B) Pitting, dependent edema is also associated with fluid overload, not dehydration.
C) Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D) Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.
A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessment should be the nurse's priority?
A. Morse Fall Risk scale
The Morse Fall Risk scale assesses the risk of falls in hospitalized patients but is not the priority for a postoperative client with an ORIF.
B. Braden scale
The Braden scale assesses the risk of pressure ulcers and is not the priority for a postoperative client with an ORIF.
C. Pain assessment
Pain assessment is important but may not be the priority compared to assessing neurovascular status, especially immediately postoperatively.
D. Neurovascular assessment
The neurovascular assessment, including circulation, sensation, and movement, is crucial for early detection of complications such as compartment syndrome or impaired blood flow.
Full Explanation
A) The Morse Fall Risk scale assesses the risk of falls in hospitalized patients but is not the priority for a postoperative client with an ORIF.
B) The Braden scale assesses the risk of pressure ulcers and is not the priority for a postoperative client with an ORIF.
C) Pain assessment is important but may not be the priority compared to assessing neurovascular status, especially immediately postoperatively.
D) The neurovascular assessment, including circulation, sensation, and movement, is crucial for early detection of complications such as compartment syndrome or impaired blood flow.
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
A. Decrease protein intake.
Decreasing protein intake is often recommended for clients with nephrotic syndrome to reduce proteinuria and slow the progression of kidney damage.
B. Decrease carbohydrate intake.
Decreasing carbohydrate intake is not typically a focus of dietary recommendations for nephrotic syndrome.
C. Increase potassium intake.
Increasing potassium intake may not be appropriate, as clients with nephrotic syndrome may be at risk of hyperkalemia due to impaired kidney function.
D. Increase phosphorus intake.
Increasing phosphorus intake is not typically indicated and may exacerbate complications associated with kidney dysfunction in nephrotic syndrome.
Full Explanation
A) Decreasing protein intake is often recommended for clients with nephrotic syndrome to reduce proteinuria and slow the progression of kidney damage.
B) Decreasing carbohydrate intake is not typically a focus of dietary recommendations for nephrotic syndrome.
C) Increasing potassium intake may not be appropriate, as clients with nephrotic syndrome may be at risk of hyperkalemia due to impaired kidney function.
D) Increasing phosphorus intake is not typically indicated and may exacerbate complications associated with kidney dysfunction in nephrotic syndrome.