Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea.
Vital Signs
Heart Rate-beats/minute- 110 Respirations - breathes/minute- 28 Blood Pressure – mmHG- 80/60
Arterial blood gases (ABGs)
Ph- 7.34
PaCO2- 34 mmHg
HCO3- 20 mmol/L
pO2- 90 mmHg
Electrolytes Results
Sodium
130 mEq/L(mmol/L) Potassium
2.5 mEq/L (mmol/L) Chloride
95 mEq/L (mmol/L)
Reference Range:
Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]
Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]
Chloride [98 to 106 mEq/L (98 to 106 mmol/L)]
PaCO2 [35 to 45 mm Hg]
HCO, [21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg)
The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the nurse implement first? (Please scroll and view each tab's information in the client's medical record before selecting the answer.)
A. Initiate continuous dopamine infusion at 2 mcg/kg/minute.
Incorrect - Initiating continuous dopamine infusion is not a priority in this situation. The client's low blood pressure and electrolyte imbalances require more immediate attention.
B. Administer promethazine 25 mg slow intravenous (IV) push every 4 hours.
Incorrect - Administering promethazine addresses symptoms like nausea and vomiting, but it doesn't address the primary issue of hypovolemia and low blood pressure.
C. Begin potassium chloride 10 mEq over 1 hour per secondary infusion.
Incorrect - Administering potassium chloride without addressing the fluid deficit can be dangerous and may lead to further electrolyte imbalances.
D. Give a bolus of 0.9% sodium chloride 1,000 ml over 30 minutes.
Correct- The client's vital signs and laboratory results indicate hypovolemia (low blood pressure, low sodium, and low potassium). The immediate priority is to address the fluid deficit and correct the electrolyte imbalances. Administering a bolus of 0.9% sodium chloride (normal saline) will help increase intravascular volume and improve blood pressure, as well as correct the electrolyte imbalances to some extent.
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Full Explanation
A) Incorrect - Initiating continuous dopamine infusion is not a priority in this situation. The client's low blood pressure and electrolyte imbalances require more immediate attention.
B) Incorrect - Administering promethazine addresses symptoms like nausea and vomiting, but it doesn't address the primary issue of hypovolemia and low blood pressure.
C) Incorrect - Administering potassium chloride without addressing the fluid deficit can be dangerous and may lead to further electrolyte imbalances.
D) Correct- The client's vital signs and laboratory results indicate hypovolemia (low blood pressure, low sodium, and low potassium). The immediate priority is to address the fluid deficit and correct the electrolyte imbalances. Administering a bolus of 0.9% sodium chloride (normal saline) will help increase intravascular volume and improve blood pressure, as well as correct the electrolyte imbalances to some extent.
Similar Questions
The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?
A. New screening protocols were developed, validated, and implemented.
Incorrect - Developing new screening protocols is important, but it doesn't directly indicate that the program has prevented diseases. Screening protocols might catch diseases but don't prevent them.
B. Clients who incurred disease complications promptly received rehabilitation.
Incorrect - Clients receiving rehabilitation indicates they already had disease complications, which is not a primary prevention outcome.
C. Average client scores improved on specific risk factor knowledge tests.
Correct- An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.
D. More than half at risk clients were diagnosed early in the disease process
Incorrect - Diagnosing clients early in their disease process is related to early detection (secondary prevention), not primary prevention.
Full Explanation
A) Incorrect - Developing new screening protocols is important, but it doesn't directly indicate that the program has prevented diseases. Screening protocols might catch diseases but don't prevent them.
B) Incorrect - Clients receiving rehabilitation indicates they already had disease complications, which is not a primary prevention outcome.
C) Correct- An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.
D) Incorrect - Diagnosing clients early in their disease process is related to early detection (secondary prevention), not primary prevention.
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?
A. A salad with three kinds of lettuce and fruit.
Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B. Vegetable soup, crackers, and milk.
Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C. A peanut butter sandwich with soda and cookies.
Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.
D. A tuna fish sandwich with chips and ice cream.
Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.
Full Explanation
A) Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B) Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C) Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.
D) Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.
A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast.
The nurse determines that the client's nipples are inverted. Which action should the nurse implement?
A. Encourage the use of ice on the areola.
Incorrect - Encouraging the use of ice on the areola is not a recommended intervention for addressing inverted nipples and promoting successful breastfeeding.
B. Teach about the use of a breast pump.
While a pump can help draw out a nipple or maintain supply, the immediate concern is the baby's inability to latch at the breast for a successful feeding session.
C. Offer supplemental formula feedings.
Incorrect - Offering supplemental formula feedings does not address the underlying issue of inverted nipples and breastfeeding difficulties.
D. Recommend using a breast shield.
A breast shield is a silicone device that fits over the nipple and areola, providing a firm, protruded surface for the infant to latch onto when nipples are flat.
E. None
None
F. None
None
Full Explanation
Choice A rationale: Applying ice can cause vasoconstriction and potentially inhibit the let-down reflex. While it might temporarily firm the tissue, it does not effectively address the anatomical challenge of inverted nipples.
Choice B rationale: While a pump can help draw out a nipple or maintain supply, the immediate concern is the baby's inability to latch at the breast for a successful feeding session.
Choice C rationale: Offering formula as a first-line intervention can undermine the mother's breastfeeding goals and interfere with the establishment of her milk supply and the infant's natural sucking reflex.
Choice D rationale: A breast shield is a silicone device that fits over the nipple and areola, providing a firm, protruded surface for the infant to latch onto when nipples are flat.