Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient has returned to the unit following a peripheral artery angiogram with a stent insertion.
Four hours post-procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cold and dusky. What should be the nurse’s immediate action?
A. Reposition the limb and reassess.
While repositioning the limb and reassessing might be a part of the overall evaluation, it should not be the immediate action. The symptoms described are indicative of a serious issue that requires immediate medical attention.
B. Apply a warm blanket.
Applying a warm blanket will not address the underlying issue. The symptoms described suggest a problem with circulation that needs immediate medical attention.
C. Notify the healthcare provider.
Notifying the healthcare provider is the correct immediate action. The symptoms described suggest that the patient may be experiencing a complication such as occlusion of the stent. This is a medical emergency that requires immediate intervention.
D. Elevate the extremity on a pillow.
Elevating the extremity on a pillow is not the immediate action to take. While elevation can help with conditions like edema, it does not address the serious symptoms the patient is experiencing.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Nurs 200 Proctored Exam Roxoborouh Memorial College. Take the full exam now
Full Explanation
Choice A rationale
While repositioning the limb and reassessing might be a part of the overall evaluation, it should not be the immediate action. The symptoms described are indicative of a serious issue that requires immediate medical attention.
Choice B rationale
Applying a warm blanket will not address the underlying issue. The symptoms described suggest a problem with circulation that needs immediate medical attention.
Choice C rationale
Notifying the healthcare provider is the correct immediate action. The symptoms described suggest that the patient may be experiencing a complication such as occlusion of the stent. This is a medical emergency that requires immediate intervention.
Choice D rationale
Elevating the extremity on a pillow is not the immediate action to take. While elevation can help with conditions like edema, it does not address the serious symptoms the patient is experiencing.
Similar Questions
A patient is recovering from an episode of diabetic ketoacidosis and reports feeling “anxious, shaky, and sweaty.”. What should be the nurse’s initial action?
A. Obtain a full set of vital signs.
While obtaining a full set of vital signs is an important part of assessing a patient’s condition, it should not be the initial action in this case. The symptoms described by the patient suggest hypoglycemia, which requires immediate confirmation and treatment.
B. Administer 1 mg glucagon subcutaneously.
Administering 1 mg glucagon subcutaneously is not the initial action. Glucagon is used to treat severe hypoglycemia when the patient is unable to take glucose orally. However, the patient’s blood glucose level should be checked first.
C. Administer 25 mL of 50% dextrose.
Administering 25 mL of 50% dextrose is not the initial action. This treatment is used for severe hypoglycemia, but the patient’s blood glucose level should be checked first to confirm hypoglycemia.
D. Obtain a blood glucose reading.
Obtaining a blood glucose reading is the correct initial action. The symptoms described by the patient suggest hypoglycemia. Checking the blood glucose level will confirm whether the patient is hypoglycemic and needs treatment.
Full Explanation
Choice A rationale
While obtaining a full set of vital signs is an important part of assessing a patient’s condition, it should not be the initial action in this case. The symptoms described by the patient suggest hypoglycemia, which requires immediate confirmation and treatment.
Choice B rationale
Administering 1 mg glucagon subcutaneously is not the initial action. Glucagon is used to treat severe hypoglycemia when the patient is unable to take glucose orally. However, the patient’s blood glucose level should be checked first.
Choice C rationale
Administering 25 mL of 50% dextrose is not the initial action. This treatment is used for severe hypoglycemia, but the patient’s blood glucose level should be checked first to confirm hypoglycemia.
Choice D rationale
Obtaining a blood glucose reading is the correct initial action. The symptoms described by the patient suggest hypoglycemia. Checking the blood glucose level will confirm whether the patient is hypoglycemic and needs treatment.
The nurse is teaching a patient to wash their hands after using the bathroom as an attempt to break the chain of infection.
Between which two links in the chain of infection does this action intervene?
A. Infectious agent and reservoir.
The infectious agent is the pathogen that causes the disease, and the reservoir is where the infectious agent lives and multiplies. Hand washing does not directly intervene between these two links.
B. Mode of transmission and portal of entry.
The mode of transmission is how the infectious agent travels to other people and places, and the portal of entry is the route by which an infectious agent enters a new host. Hand washing does not directly intervene between these two links.
C. Susceptible host and infectious agent.
The susceptible host is a person who is vulnerable to the disease, and the infectious agent is the pathogen that causes the disease. Hand washing does not directly intervene between these two links.
D. Portal of exit and mode of transmission.
The portal of exit is the route by which an infectious agent escapes or leaves the reservoir, and the mode of transmission is how the infectious agent travels to other people and places. Hand washing directly intervenes between these two links by removing the infectious agent from the hands (portal of exit) and preventing its transmission to other people or surfaces.
Full Explanation
Choice A rationale
The infectious agent is the pathogen that causes the disease, and the reservoir is where the infectious agent lives and multiplies. Hand washing does not directly intervene between these two links.
Choice B rationale
The mode of transmission is how the infectious agent travels to other people and places, and the portal of entry is the route by which an infectious agent enters a new host. Hand washing does not directly intervene between these two links.
Choice C rationale
The susceptible host is a person who is vulnerable to the disease, and the infectious agent is the pathogen that causes the disease. Hand washing does not directly intervene between these two links.
Choice D rationale
The portal of exit is the route by which an infectious agent escapes or leaves the reservoir, and the mode of transmission is how the infectious agent travels to other people and places. Hand washing directly intervenes between these two links by removing the infectious agent from the hands (portal of exit) and preventing its transmission to other people or surfaces.
A nurse is preparing to administer a heparin infusion of 25,000 units in 250 mL of normal saline at a rate of 1000 units per hour for a client diagnosed with a Deep Vein Thrombosis (DVT). The client’s initial activated partial thromboplastin time (aPTT) value is 35 seconds.
Which laboratory result would indicate that the aPTT is at a therapeutic level?
A. 30 seconds
None
B. 45 seconds
None
C. 60 seconds
None
D. 75 seconds
Step 1 is to understand the therapeutic range for aPTT when a patient is on heparin therapy. The therapeutic range for aPTT is 1.5 to 2.5 times the normal value. Given that the normal aPTT value is around 30-40 seconds, the therapeutic range would be approximately 45-100 seconds. Therefore, an aPTT value of 75 seconds falls within this therapeutic range, indicating that the heparin therapy is effective.
Full Explanation
Step 1 is to understand the therapeutic range for aPTT when a patient is on heparin therapy. The therapeutic range for aPTT is 1.5 to 2.5 times the normal value. Given that the normal aPTT value is around 30-40 seconds, the therapeutic range would be approximately 45-100 seconds. Therefore, an aPTT value of 75 seconds falls within this therapeutic range, indicating that the heparin therapy is effective.