Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
In assessing a client with an indwelling urinary catheter following the provision of care by an unlicensed assistive personnel (UAP), the practical nurse (PN) observes that the catheter drainage bag, which is half- full, is attached to the side rail and the tubing is looped on the bed.
Which action should the PN implement?
A. Apply gloves and empty the drainage bag
Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full.
B. Remove the looped tubing from the bed
Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag.
C. Measure the urinary output in the bag
Measuring the urinary output in the bag is a routine task but does not correct the improper placement of the drainage bag.
D. Attach the drainage bag to the bed frame
Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.
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Full Explanation
The correct answer is choice d. Attach the drainage bag to the bed frame.
Choice A rationale:
Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full.
Choice B rationale:
Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag.
Choice C rationale:
Measuring the urinary output in the bag is a routine task but does not correct the improper placement of the drainage bag.
Choice D rationale:
Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.
Similar Questions
The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.
Which action should the PN implement first?
A. Ask the client to describe what happened
This is the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Asking the client to describe what happened shows empathy, respect, and active listening, and allows the PN to gather more information and validate the client's feelings and concerns. The PN should also apologize for the delay, assess the client's pain level and needs, and provide appropriate interventions and support.
B. Inform the charge nurse of the situation
This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Informing the charge nurse of the situation may be necessary, but it should be done after addressing the client's immediate needs and concerns. The PN should not ignore or avoid the client, but should communicate with him and try to resolve the issue.
C. Complete a client adverse incident report
This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Completing a client adverse incident report may be required, but it should be done after addressing the client's immediate needs and concerns. The PN should not prioritize documentation over care, but should provide timely and effective pain management and support to the client.
D. Call the agency-based client advocate
This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Calling the agency-based client advocate may be helpful, but it should be done after addressing the client's immediate needs and concerns. The PN should not delegate or defer responsibility for care, but should communicate with the client and try to resolve the issue. The PN should also respect the client's right to choose whether or not to involve an advocate in his care.
Full Explanation
The correct answer and explanation are:
A - Ask the client to describe what happened. Correct
This is the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.
Asking the client to describe what happened shows empathy, respect, and active listening, and allows the PN to gather more information and validate the client's feelings and concerns. The PN should also apologize for the delay, assess the client's pain level and needs, and provide appropriate interventions and support.
B - Inform the charge nurse of the situation.
This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.
Informing the charge nurse of the situation may be necessary, but it should be done after addressing the client's immediate needs and concerns. The PN should not ignore or avoid the client, but should communicate with him and try to resolve the issue.
C - Complete a client adverse incident report.
This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.
Completing a client adverse incident report may be required, but it should be done after addressing the client's immediate needs and concerns. The PN should not prioritize documentation over care, but should provide timely and effective pain management and support to the client.
D - Call the agency-based client advocate.
This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Calling the agency-based client advocate may be helpful, but it should be done after addressing the client's immediate needs and concerns.
The PN should not delegate or defer responsibility for care, but should communicate with the client and try to resolve the issue. The PN should also respect the client's right to choose whether or not to involve an advocate in his care.
The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. The mother says the boy is in pain and needs medical help.
The nurse should assess the injury and decide the appropriate action to take.
Help the nurse reason out the best assessment.
A. The injury may require medical attention, as the mother mentioned that the boy is in pain
This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it. The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.
B. The abrasions on the boy's leg and hand have healed
This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The abrasions on the boy's leg and hand are not relevant to his current complaint of arm and shoulder pain, and do not indicate whether he needs medical attention or not. The nurse should focus on the boy's primary concern and not distract him with unrelated questions or comments.
C. The mother describes what she did after her child got injured
This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The mother's description of what she did after her child got injured may provide some useful information, such as how long ago the injury occurred, what first aid measures were applied, and whether there was any improvement or worsening of symptoms. However, it does not directly answer the question of whether the injury requires medical attention or not. The nurse should listen to the mother's account, but also perform a physical examination and ask relevant questions to assess the injury.
D. The boy lacks coordination when answering the nurse's questions
This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The boy's lack of coordination when answering the nurse's questions may indicate a possible head injury, concussion, or shock, which are serious complications that require immediate medical attention. However, it does not directly relate to his arm and shoulder pain, which is his main complaint. The nurse should assess the boy's mental status and neurological function, but also evaluate his arm and shoulder for any signs of damage or inflammation.
Full Explanation
A - The injury may require medical attention, as the mother mentioned that the boy is in pain. Correct
This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it.
The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.
B - The abrasions on the boy's leg and hand have healed.
This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The abrasions on the boy's leg and hand are not relevant to his current complaint of arm and shoulder pain, and do not indicate whether he needs medical attention or not. The nurse should focus on the boy's primary concern and not distract him with unrelated questions or comments.
C - The mother describes what she did after her child got injured.
This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The mother's description of what she did after her child got injured may provide some useful information, such as how long ago the injury occurred, what first aid measures were applied, and whether there was any improvement or worsening of symptoms. However, it does not directly answer the question of whether the injury requires medical attention or not. The nurse should listen to the mother's account, but also perform a physical examination and ask relevant questions to assess the injury.
D - The boy lacks coordination when answering the nurse's questions.
This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The boy's lack of coordination when answering the nurse's questions may indicate a possible head injury, concussion, or shock, which are serious complications that require immediate medical attention. However, it does not directly relate to his arm and shoulder pain, which is his main complaint.
The nurse should assess the boy's mental status and neurological function, but also evaluate his arm and shoulder for any signs of damage or inflammation.
Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?
A. Health care proxy documentation.
A terminally ill client is a client who has a progressive and incurable disease or condition that is expected to result in death within a short period of time, such as months or weeks. A terminally ill client may require palliative care, which is the care that focuses on relieving pain and suffering and improving the quality of life for the client and their family. - An admission assessment is the process of collecting information about a client's health status, needs, preferences, and goals when they are admited to a health care facility, such as a hospital, nursing home, or hospice. An admission assessment helps to establish a baseline for the client's condition, plan and implement appropriate interventions, and evaluate the outcomes of care. - A health care proxy is a legal document that allows a client to appoint another person, such as a family member or a friend, to make health care decisions for them if they become unable to do so themselves. A health care proxy may also include specific instructions or preferences about the type and extent of care that the client wishes to receive or refuse, such as life-sustaining treatments, resuscitation, or organ donation. - Health care proxy documentation is an important information that the practical nurse (PN) should collect during the admission assessment of a terminally ill client to an acute care facility, as it reflects the client's autonomy, dignity, and wishes regarding their end-of-life care. It also helps to ensure that the client's healthcare decisions are respected and followed by the healthcare team and the facility.
B. Name of funeral home to contact
The name of the funeral home to contact is not relevant or necessary for the admission assessment of a terminally ill client, as it does not affect their health status or care plan.
C. Client's wishes regarding organ donation
The client's wishes regarding organ donation may be included in their healthcare proxy documentation, but they are not required or essential for the admission assessment of a terminally ill client.
D. Contact information for the client's next of kin
The contact information for the client's next of kin may be useful for communication and support purposes, but it is not as important as the health care proxy documentation for the admission assessment of a terminally ill client.
Full Explanation
- A terminally ill client is a client who has a progressive and incurable disease or condition that is expected to result in death within a short period of time, such as months or weeks. A terminally ill client may require palliative care, which is the care that focuses on relieving pain and suffering and improving the quality of life for the client and their family.
- An admission assessment is the process of collecting information about a client's health status, needs, preferences, and goals when they are admited to a health care facility, such as a hospital, nursing home, or hospice. An admission assessment helps to establish a baseline for the client's condition, plan and implement appropriate interventions, and evaluate the outcomes of care.
- A health care proxy is a legal document that allows a client to appoint another person, such as a family member or a friend, to make health care decisions for them if they become unable to do so themselves. A health care proxy may also include specific instructions or preferences about the type and extent of care that the client wishes to receive or refuse, such as life-sustaining treatments, resuscitation, or organ donation.
- Health care proxy documentation is an important information that the practical nurse (PN) should collect during the admission assessment of a terminally ill client to an acute care facility, as it reflects the client's autonomy, dignity, and wishes regarding their end-of-life care. It also helps to ensure that the client's healthcare decisions are respected and followed by the healthcare team and the facility.
- Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because the name of the funeral home to contact is not relevant or necessary for the admission assessment of a terminally ill client, as it does not affect their health status or care plan.
Option C is incorrect because the client's wishes regarding organ donation may be included in their health care proxy documentation, but they are not required or essential for the admission assessment of a terminally ill client.
Option D is incorrect because the contact information for the client's next of kin may be useful for communication and support purposes, but it is not as important as the health care proxy documentation for the admission assessment of a terminally ill client.