Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
In caring for a client who is receiving meropenem IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?
A. Yellow-tinged sputum
A: Yellow-tinged sputum is not a critical finding for the nurse to report, as this is a common sign of pneumonia and does not indicate an adverse reaction to meropenem. This is a distractor choice.
B. Nausea and headache
B: Nausea and headache are not urgent findings for the nurse to report, as these are mild side effects of meropenem and can be managed with supportive measures. This is another distractor choice.
C. Watery diarrhea
C: Watery diarrhea is an important finding for the nurse to report, as this can indicate a serious complication of meropenem, such as Clostridioides difficile infection, which can cause severe dehydration, electrolyte imbalance, and sepsis. Therefore, this is the correct choice.
D. Increased fatigue
D: Increased fatigue is not a significant finding for the nurse to report, as this can be related to the client's underlying condition and does not suggest a problem with meropenem. This is another distractor choice.
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Full Explanation
Choice A: Yellow-tinged sputum is not a critical finding for the nurse to report, as this is a common sign of pneumonia and does not indicate an adverse reaction to meropenem. This is a distractor choice.
Choice B: Nausea and headache are not urgent findings for the nurse to report, as these are mild side effects of meropenem and can be managed with supportive measures. This is another distractor choice.
Choice C: Watery diarrhea is an important finding for the nurse to report, as this can indicate a serious complication of meropenem, such as Clostridioides difficile infection, which can cause severe dehydration, electrolyte imbalance, and sepsis. Therefore, this is the correct choice.
Choice D: Increased fatigue is not a significant finding for the nurse to report, as this can be related to the client's underlying condition and does not suggest a problem with meropenem. This is another distractor choice.
Similar Questions
A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take?
A. Notify the emergency response team of the client's seizure.
A: Notifying the emergency response team of the client's seizure is not a necessary action for the nurse, as the seizure has already stopped and there is no immediate threat to the client's life. This is a distractor choice.
B. Keep orienting the client to time and place until he is less confused.
B: Keeping orienting the client to time and place until he is less confused is an appropriate action for the nurse, as this can help restore the client's cognitive function and reduce his anxiety after a seizure. Therefore, this is the correct choice.
C. Explain the postictal state that usually follows seizures.
C: Explaining the postictal state that usually follows seizures is not a priority action for the nurse, as this can be done later when the client is more alert and receptive. This is another distractor choice.
D. Ask the wife to wait outside the room until the nurse can talk with her.
D: Asking the wife to wait outside the room until the nurse can talk with her is not a considerate action for the nurse, as this can increase her stress and worry about her husband's condition. This is a contraindicated choice.
Full Explanation
Choice A: Notifying the emergency response team of the client's seizure is not a necessary action for the nurse, as the seizure has already stopped and there is no immediate threat to the client's life. This is a distractor choice.
Choice B: Keeping orienting the client to time and place until he is less confused is an appropriate action for the nurse, as this can help restore the client's cognitive function and reduce his anxiety after a seizure. Therefore, this is the correct choice.
Choice C: Explaining the postictal state that usually follows seizures is not a priority action for the nurse, as this can be done later when the client is more alert and receptive. This is another distractor choice.
Choice D: Asking the wife to wait outside the room until the nurse can talk with her is not a considerate action for the nurse, as this can increase her stress and worry about her husband's condition. This is a contraindicated choice.
When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?
A. Check for a distended bladder.
A is correct because a distended bladder can displace the uterus and prevent it from contracting properly, leading to increased bleeding and risk of infection. The nurse should check for a distended bladder and assist the client to empty it if needed.
B. Review the hemoglobin to determine hemorrhage.
B is incorrect because reviewing the hemoglobin is not a priority action. The hemoglobin may not reflect the current blood loss and may be done later.
C. Massage the uterus to decrease atony.
C is incorrect because massaging the uterus is not necessary if it is firm. Massaging a firm uterus can cause overstimulation and pain.
D. Increase intravenous infusion.
D is incorrect because increasing intravenous infusion is not a priority action. The client may not need additional fluids if the bleeding is moderate and the vital signs are stable.
Full Explanation
Choice A is correct because a distended bladder can displace the uterus and prevent it from contracting properly, leading to increased bleeding and risk of infection. The nurse should check for a distended bladder and assist the client to empty it if needed.
Choice B is incorrect because reviewing the hemoglobin is not a priority action. The hemoglobin may not reflect the current blood loss and may be done later.
Choice C is incorrect because massaging the uterus is not necessary if it is firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D is incorrect because increasing intravenous infusion is not a priority action. The client may not need additional fluids if the bleeding is moderate and the vital signs are stable.
A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?
A. Increase the intake of dark green leafy vegetables while taking warfarin.
A is incorrect because increasing the intake of dark green leafy vegetables while taking warfarin can decrease the effectiveness of warfarin and increase the risk of clotting.
B. Eat two servings of dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed.
B is incorrect because eating two servings of dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed can cause unpredictable changes in the blood levels of warfarin and increase the risk of bleeding or clotting.
C. Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.
C is correct because vitamin K can interfere with the anticoagulant effect of warfarin and increase the risk of clotting. The client should maintain a consistent intake of vitamin K from food sources, such as dark green leafy vegetables, to avoid fluctuations in the blood levels of warfarin.
D. Avoid eating any foods that contain any vitamin K because it is an antagonist of warfarin.
D is incorrect because avoiding any foods that contain any vitamin K while taking warfarin can increase the sensitivity to warfarin and increase the risk of bleeding.
Full Explanation
Choice C is correct because vitamin K can interfere with the anticoagulant effect of warfarin and increase the risk of clotting. The client should maintain a consistent intake of vitamin K from food sources, such as dark green leafy vegetables, to avoid fluctuations in the blood levels of warfarin.
Choice A is incorrect because increasing the intake of dark green leafy vegetables while taking warfarin can decrease the effectiveness of warfarin and increase the risk of clotting.
Choice B is incorrect because eating two servings of dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed can cause unpredictable changes in the blood levels of warfarin and increase the risk of bleeding or clotting.
Choice D is incorrect because avoiding any foods that contain any vitamin K while taking warfarin can increase the sensitivity to warfarin and increase the risk of bleeding.