Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)
A. Red blood cell count (RBC).
Incorrect - Red blood cell count (RBC) is not directly relevant to the assessment of infection and its spread.
B. Core body temperature.
Correct- Core body temperature can be an indicator of systemic infection and needs to be reported to the healthcare provider for assessment and intervention.
C. Swollen lymph nodes in the groin.
Correct- Swollen lymph nodes in the groin suggest local and regional lymphatic involvement, indicating possible spread of infection. This finding needs further assessment and intervention.
D. Location of the initial intravenous (IV) site.
Incorrect - The location of the initial intravenous (IV) site is not directly relevant to the assessment of infection and its spread.
E. White blood cell count (WBC).
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Full Explanation
A) Incorrect - Red blood cell count (RBC) is not directly relevant to the assessment of infection and its spread.
B) Correct- Core body temperature can be an indicator of systemic infection and needs to be reported to the healthcare provider for assessment and intervention.
C) Correct- Swollen lymph nodes in the groin suggest local and regional lymphatic involvement, indicating possible spread of infection. This finding needs further assessment and intervention.
D) Incorrect - The location of the initial intravenous (IV) site is not directly relevant to the assessment of infection and its spread.
E) Correct- An elevated white blood cell count (WBC) can indicate an inflammatory response to infection. This finding should be reported to the healthcare provider for further evaluation and treatment.
Similar Questions
The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?
A. Discuss that partners without similar symptoms may not be infected.
Incorrect - While discussing the potential for asymptomatic partners is important, addressing the client's concerns and providing accurate information is more immediate.
B. Answer questions directly and correct any misinformation.
Correct- Syphilis and other STIs are important public health concerns. The nurse should provide accurate information, answer questions, and correct any misconceptions the client might have. This approach supports the client's knowledge and understanding of their health condition and prevents the spread of misinformation.
C. Provide counseling that most contraceptives protect against infection.
Incorrect - While discussing contraceptives is relevant to sexual health education, it may not directly address the client's concerns about their prior infections.
D. Notify that persons with STIs are reported to local health departments.
Incorrect - Notifying local health departments is important for reporting communicable diseases, but it doesn't directly address the client's current situation and concerns.
Full Explanation
A) Incorrect - While discussing the potential for asymptomatic partners is important, addressing the client's concerns and providing accurate information is more immediate.
B) Correct- Syphilis and other STIs are important public health concerns. The nurse should provide accurate information, answer questions, and correct any misconceptions the client might have. This approach supports the client's knowledge and understanding of their health condition and prevents the spread of misinformation.
C) Incorrect - While discussing contraceptives is relevant to sexual health education, it may not directly address the client's concerns about their prior infections.
D) Incorrect - Notifying local health departments is important for reporting communicable diseases, but it doesn't directly address the client's current situation and concerns.
An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?
A. Have the client vocalize the instructions provided.
Having the client vocalize the instructions provided ensures that they have understood the information correctly. This method allows the nurse to confirm comprehension and clarify any misunderstandings.
B. Provide written instructions for eye drop administration.
Providing written instructions for eye drop administration is helpful but does not ensure that the client understands the instructions. It is a good supplementary measure but should not be the sole method of communication.
C. Speak clearly and face the client for lip reading.
Speaking clearly and facing the client for lip reading is important, especially for clients with hearing impairments. However, it does not guarantee that the client has understood the instructions.
D. Ensure that someone will stay with the client for 24 hours.
Ensuring that someone will stay with the client for 24 hours is a good safety measure but does not directly address the client’s understanding of the discharge instructions.
Full Explanation
The correct answer is choice A.
Choice A rationale:
Having the client vocalize the instructions provided ensures that they have understood the information correctly. This method allows the nurse to confirm comprehension and clarify any misunderstandings.
Choice B rationale:
Providing written instructions for eye drop administration is helpful but does not ensure that the client understands the instructions. It is a good supplementary measure but should not be the sole method of communication.
Choice C rationale:
Speaking clearly and facing the client for lip reading is important, especially for clients with hearing impairments. However, it does not guarantee that the client has understood the instructions.
Choice D rationale:
Ensuring that someone will stay with the client for 24 hours is a good safety measure but does not directly address the client’s understanding of the discharge instructions.
An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)
A. Place a bedside commode next to bed.
Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.
B. Measure neurological vital signs every 4 hours.
Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.
C. Suction oral cavity every 4 hours.
Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management. Routine suctioning can also cause discomfort and potential injury.
D. Encourage family to participate in the client's care.
Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process. Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.
E. Play classical music in room while client is
Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation. The effectiveness of music therapy can vary based on individual preferences.
Full Explanation
The correct answer is a. Place a bedside commode next to bed., b. Measure neurological vital signs every 4 hours., d. Encourage family to participate in the client’s care.
Choice A rationale:
Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.
Choice B rationale:
Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.
Choice C rationale:
Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management. Routine suctioning can also cause discomfort and potential injury.
Choice D rationale:
Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process. Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.
Choice E rationale:
Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation. The effectiveness of music therapy can vary based on individual preferences.