Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Exhibit 1 Exhibit 2 Graphic Record Blood pressure 176/122 mm Hg Heart rate 136/min Respiratory rate 32/min Exhibit 3 O2 saturation 88%.
A nurse in the emergency department is caring for a client who was involved in an explosion.
Which of the following actions should the nurse plan to take first? (Click on the "Exhibit" button for additional information about the client.
A. Obtain an ECG.
Choice A is incorrect because while obtaining an ECG may be important, it is not the nurse’s first priority in this situation.
B. Calculate the extent of burns using the rule of nines.
Choice B is incorrect because while calculating the extent of burns using the rule of nines may be important, it is not the nurse’s first priority in this situation.
C. Notify the Rapid Response Team.
The nurse should plan to notify the Rapid Response Team first. The client’s blood pressure is elevated, heart rate is high, respiratory rate is high, and oxygen saturation is low. These are all signs of potential instability and the Rapid Response Team should be notified immediately.
D. Initiate peripheral IV access.
Choice D is incorrect because while initiating peripheral IV access may be important, it is not the nurse’s first priority in this situation.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
The nurse should plan to notify the Rapid Response Team first.
The client’s blood pressure is elevated, heart rate is high, respiratory rate is high, and oxygen saturation is low.
These are all signs of potential instability and the Rapid Response Team should be notified immediately.
Choice A is incorrect because while obtaining an ECG may be important, it is not the nurse’s first priority in this situation.
Choice B is incorrect because while calculating the extent of burns using the rule of nines may be important, it is not the nurse’s first priority in this situation.
Choice D is incorrect because while initiating peripheral IV access may be important, it is not the nurse’s first priority in this situation.
Similar Questions
A nurse is caring for a client who is receiving radiation.
The client reports nausea since the therapy was initiated.
Which of the following considerations should the nurse include when planning the client's meals?
A. Offer highly seasoned foods.
Choice A is incorrect because offering highly seasoned foods may not help with nausea.
B. Offer hot beverages with meals.
Choice B is incorrect because offering hot beverages with meals may not help with nausea.
C. Offer a snack prior to radiation therapy.
Choice C is incorrect because offering a snack prior to radiation therapy may not help with nausea.
D. Offer frequent, high-carbohydrate meals.
The nurse should plan to offer frequent, high-carbohydrate meals to the client who is receiving radiation and reports nausea since the therapy was initiated. Eating smaller, more frequent meals rather than three large meals a day can help decrease nausea.
Full Explanation
The nurse should plan to offer frequent, high-carbohydrate meals to the client who is receiving radiation and reports nausea since the therapy was initiated.
Eating smaller, more frequent meals rather than three large meals a day can help decrease nausea.
Choice A is incorrect because offering highly seasoned foods may not help with nausea.
Choice B is incorrect because offering hot beverages with meals may not help with nausea.
Choice C is incorrect because offering a snack prior to radiation therapy may not help with nausea.
A nurse is providing discharge teaching for a client who has asthma and a new prescription for a metered-dose inhaler.
Which of the following client statements indicates an understanding of the teaching?
A. "I should clean the cap of the inhaler once per week.".
Choice A is incorrect because it is not necessary to clean the cap of the inhaler once per week. Instead, it is important to clean the inhaler at least once a week or as directed.
B. "I should inhale the medication quickly".
Choice B is incorrect because one should inhale the medication slowly, not quickly.
C. "I should shake the inhaler before I use it.".
This statement indicates an understanding of the teaching because shaking the inhaler helps to mix the medicine inside the canister.
D. "I should wait 15 seconds between puffs.".
Choice D is incorrect because one should wait 1 minute between puffs, not 15 seconds.
Full Explanation
This statement indicates an understanding of the teaching because shaking the inhaler helps to mix the medicine inside the canister.
Choice A is incorrect because it is not necessary to clean the cap of the inhaler once per week.
Instead, it is important to clean the inhaler at least once a week or as directed.
Choice B is incorrect because one should inhale the medication slowly, not quickly.
Choice D is incorrect because one should wait 1 minute between puffs, not 15 seconds.
A nurse is caring for a client who has advanced liver disease.
Which of the following laboratory results should the nurse monitor when assessing this client?
A. Glucose level.
Choice A is incorrect because glucose levels are not typically used to monitor liver disease.
B. Serum ammonia.
This statement indicates an understanding of the teaching because serum ammonia levels can be elevated in liver disease and are used to monitor the progression of liver disease.
C. Serum troponin.
Choice C is incorrect because serum troponin levels are used to diagnose heart attacks, not liver disease.
D. Phosphate level.
Choice D is incorrect because phosphate levels are not typically used to monitor liver disease.
Full Explanation
This statement indicates an understanding of the teaching because serum ammonia levels can be elevated in liver disease and are used to monitor the progression of liver disease.
Choice A is incorrect because glucose levels are not typically used to monitor liver disease.
Choice C is incorrect because serum troponin levels are used to diagnose heart attacks, not liver disease.
Choice D is incorrect because phosphate levels are not typically used to monitor liver disease.