Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
A. Increase the room temperature.
Increasing the room temperature is not a priority intervention for a client with a burn injury, especially immediately after securing the airway.
B. Cleanse the client's wounds.
While wound care is essential in the management of burn injuries, it is not the first intervention to prioritize after securing the airway.
C. Administer analgesic medication.
Burn injuries can be extremely painful, and providing analgesic medication is important but not a priority intervention
D. Start an IV with a large-bore needle.
Start an IV with a large-bore needle. Establishing intravenous access is crucial for fluid resuscitation and administering medications. It allows for timely administration of fluids and other necessary treatments to stabilize the client’s condition.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
D. Start an IV with a large-bore needle. Establishing intravenous access is crucial for fluid resuscitation and administering medications. It allows for timely administration of fluids and other necessary treatments to stabilize the client’s condition.
A. Increasing the room temperature is not a priority intervention for a client with a burn injury, especially immediately after securing the airway.
B. While wound care is essential in the management of burn injuries, it is not the first intervention to prioritize after securing the airway.
C. Burn injuries can be extremely painful, and providing analgesic medication is important but not a priority intervention
Similar Questions
A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will take this medication with fiber to prevent constipation."
While constipation is a potential side effect of digoxin, taking it with fiber is not a recommended method for preventing constipation.
B. "I will notify my provider if I experience muscle weakness."
Muscle weakness can be a sign of digoxin toxicity, and it is essential for the client to notify their healthcare provider if they experience this symptom. Muscle weakness is a potential adverse effect of digoxin, especially if the medication level in the blood becomes too high.
C. "I will increase my dose if my vision becomes blurred."
Blurred vision can be a sign of digoxin toxicity, and the client should not increase their dose if they experience this symptom. Instead, they should promptly notify their healthcare provider to assess for toxicity and adjust the medication regimen as needed.
D. "I will take my digoxin if my pulse is less than 50 beats per minute."
Digoxin is a medication that can slow the heart rate, and a pulse rate less than 60 beats per minute is considered bradycardia. If the client's pulse is less than 60 beats per minute, they should hold the digoxin and promptly notify their healthcare provider.
Full Explanation
B. Muscle weakness can be a sign of digoxin toxicity, and it is essential for the client to notify their healthcare provider if they experience this symptom. Muscle weakness is a potential adverse effect of digoxin, especially if the medication level in the blood becomes too high.
A. While constipation is a potential side effect of digoxin, taking it with fiber is not a recommended method for preventing constipation.
C. Blurred vision can be a sign of digoxin toxicity, and the client should not increase their dose if they experience this symptom. Instead, they should promptly notify their healthcare provider to assess for toxicity and adjust the medication regimen as needed.
D. Digoxin is a medication that can slow the heart rate, and a pulse rate less than 60 beats per minute is considered bradycardia. If the client's pulse is less than 60 beats per minute, they should hold the digoxin and promptly notify their healthcare provider.
A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?
A. Hypertension
Typically, bleeding would cause a decrease in blood pressure rather than hypertension. High blood pressure could indicate other issues like pain or anxiety
B. 2+ edema
Edema is not typically a direct manifestation of bleeding. It could indicate fluid overload, a common complication post-surgery, but not necessarily indicative of bleeding.
C. Crackles in lungs
Crackles in lungs could suggest fluid overload or pulmonary edema but not related to bleeding.
D. Tachycardia
Increased heart rate (tachycardia) is a common manifestation of bleeding. The body compensates for blood loss by increasing the heart rate to maintain blood flow to vital organs
Full Explanation
D. Increased heart rate (tachycardia) is a common manifestation of bleeding. The body compensates for blood loss by increasing the heart rate to maintain blood flow to vital organs
A. Typically, bleeding would cause a decrease in blood pressure rather than hypertension. High blood pressure could indicate other issues like pain or anxiety
B. Edema is not typically a direct manifestation of bleeding. It could indicate fluid overload, a common complication post-surgery, but not necessarily indicative of bleeding.
C. Crackles in lungs could suggest fluid overload or pulmonary edema but not related to bleeding.
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
A. "These discomforts should decrease with time."
This response dismisses the client's symptoms without addressing the underlying cause or providing potential solutions.
B. "Women your age experience thickening of the vaginal tissue."
The opposite tends to occur with age – vaginal tissue can become thinner and drier due to decreasing estrogen levels, leading to symptoms like vaginal dryness and itching.
C. "Your symptoms are likely due to decreasing estrogen levels."
It acknowledges the client's symptoms and provides a likely explanation related to hormonal changes associated with aging. It opens the door for further discussion and potential interventions to address the underlying cause.
D. "You should avoid intercourse to prevent injury to your vagina."
While avoiding intercourse may be recommended in certain situations, such as if there is discomfort or pain, it does not address the underlying cause of the symptoms. Additionally, it may not be necessary if appropriate treatments are pursued to alleviate vaginal dryness and itching.
Full Explanation
C. It acknowledges the client's symptoms and provides a likely explanation related to hormonal changes associated with aging. It opens the door for further discussion and potential interventions to address the underlying cause.
A. This response dismisses the client's symptoms without addressing the underlying cause or providing potential solutions.
B. The opposite tends to occur with age – vaginal tissue can become thinner and drier due to decreasing estrogen levels, leading to symptoms like vaginal dryness and itching.
D. While avoiding intercourse may be recommended in certain situations, such as if there is discomfort or pain, it does not address the underlying cause of the symptoms. Additionally, it may not be necessary if appropriate treatments are pursued to alleviate vaginal dryness and itching.