Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness.
Which method should the nurse use to elicit a response from a painful stimulus?
A. Press down on the orbital area of the eye.
Pressing down on the orbital area of the eye is not typically used as it can cause injury to the eye.
B. Pinch the trapezius muscle.
Pinching the trapezius muscle is a common method used to elicit a response from a painful stimulus in an unresponsive patient. It is considered safe and effective.
C. Use a 25 gauge needle.
Using a 25 gauge needle to elicit a response is not typically recommended as it can cause unnecessary harm to the patient.
D. Elicit a reflex with a reflex hammer.
Eliciting a reflex with a reflex hammer is not typically used to assess responsiveness to painful stimuli. Reflex hammers are primarily used to test reflexes, not responsiveness.
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Full Explanation
Choice A rationale
Pressing down on the orbital area of the eye is not typically used as it can cause injury to the eye.
Choice B rationale
Pinching the trapezius muscle is a common method used to elicit a response from a painful stimulus in an unresponsive patient. It is considered safe and effective.
Choice C rationale
Using a 25 gauge needle to elicit a response is not typically recommended as it can cause unnecessary harm to the patient.
Choice D rationale
Eliciting a reflex with a reflex hammer is not typically used to assess responsiveness to painful stimuli. Reflex hammers are primarily used to test reflexes, not responsiveness.
Similar Questions
A nurse is preparing to administer heparin subcutaneously to a client.
Which action by the nurse is appropriate?
A. Inject the medication into the abdomen above the level of the iliac crest.
The abdomen is a common site for subcutaneous injections because it allows for consistent absorption. The area above the iliac crest is often used because it is easy to access and usually has enough subcutaneous tissue for the injection.
B. Use a 1-inch needle to inject the medication.
A 1-inch needle is typically too long for a subcutaneous injection. A shorter needle (usually 1/2 to 5/8 inch) is usually used to ensure the medication is delivered to the subcutaneous tissue.
C. Use a 22-gauge needle to inject the medication.
A 22-gauge needle is typically too large for a subcutaneous injection. Smaller gauge needles (usually 25-27 gauge) are usually used for subcutaneous injections.
D. Massage the injection site after administration of the medication.
Massaging the injection site after administration of heparin is not recommended. It can cause the medication to be absorbed too quickly and can also lead to bruising.
Full Explanation
Choice A rationale
The abdomen is a common site for subcutaneous injections because it allows for consistent absorption. The area above the iliac crest is often used because it is easy to access and usually has enough subcutaneous tissue for the injection.
Choice B rationale
A 1-inch needle is typically too long for a subcutaneous injection. A shorter needle (usually 1/2 to 5/8 inch) is usually used to ensure the medication is delivered to the subcutaneous tissue.
Choice C rationale
A 22-gauge needle is typically too large for a subcutaneous injection. Smaller gauge needles (usually 25-27 gauge) are usually used for subcutaneous injections.
Choice D rationale
Massaging the injection site after administration of heparin is not recommended. It can cause the medication to be absorbed too quickly and can also lead to bruising.
The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain.
Which is the correct instruction?
A. Take two tablets PO every 15 minutes.
Taking two tablets every 15 minutes is not the recommended dosing for nitroglycerin. Overdosing can lead to hypotension and other side effects.
B. Take one tablet SL every 15 minutes, up to 5 times.
While the client should take the nitroglycerin sublingually, taking one tablet every 15 minutes up to 5 times is not the recommended dosing. This could lead to an overdose.
C. Take one tablet PO every hour, up to 5 times.
Nitroglycerin should be taken sublingually, not orally, for rapid absorption. Taking one tablet orally every hour up to 5 times is not the recommended dosing.
D. Take one tablet SL every 5 minutes, up to 3 times.
This is the correct dosing for nitroglycerin. If chest pain persists after the third dose, the client should seek immediate medical attention.
Full Explanation
Choice A rationale
Taking two tablets every 15 minutes is not the recommended dosing for nitroglycerin. Overdosing can lead to hypotension and other side effects.
Choice B rationale
While the client should take the nitroglycerin sublingually, taking one tablet every 15 minutes up to 5 times is not the recommended dosing. This could lead to an overdose.
Choice C rationale
Nitroglycerin should be taken sublingually, not orally, for rapid absorption. Taking one tablet orally every hour up to 5 times is not the recommended dosing.
Choice D rationale
This is the correct dosing for nitroglycerin. If chest pain persists after the third dose, the client should seek immediate medical attention.
A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia.
Which of the following manifestations should the nurse carefully monitor the client for?
A. Severe, throbbing headache.
A severe, throbbing headache is a common symptom of autonomic dysreflexia. It is caused by a sudden and severe rise in blood pressure.
B. Hypotension.
Hypotension is not typically associated with autonomic dysreflexia. The condition is more commonly associated with hypertension.
C. Fever.
Fever is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure.
D. Cyanosis of the head and neck.
Cyanosis of the head and neck is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure. I’m sorry, but I was unable to find specific information on the questions you asked from the websites you mentioned. However, I can provide some general guidance based on my knowledge.
Full Explanation
Choice A rationale
A severe, throbbing headache is a common symptom of autonomic dysreflexia. It is caused by a sudden and severe rise in blood pressure.
Choice B rationale
Hypotension is not typically associated with autonomic dysreflexia. The condition is more commonly associated with hypertension.
Choice C rationale
Fever is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure.
Choice D rationale
Cyanosis of the head and neck is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure. I’m sorry, but I was unable to find specific information on the questions you asked from the websites you mentioned. However, I can provide some general guidance based on my knowledge.