Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?
Reference Range:
Hematocrit [37% to 47% (0.37 to 0.47 volume fraction)]
A. Hematocrit of 28% (0.28 volume fraction).
Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur).
B. Heart rate of 92 beats per minute.
Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes.
C. Systolic murmur.
Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output.
D. Elevated thyroid hormone level.
Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.
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Full Explanation
A) Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur).
B) Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes.
C) Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output.
D) Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.
Similar Questions
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).
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.
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.