Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
A. Apply calamine lotion to itching areas.
Applying calamine lotion can provide relief from itching but does not address potential complications such as swelling or allergic reactions.
B. Apply ice packs to both hands.
Applying ice packs can help reduce swelling and pain, but it is not the priority action in this scenario.
C. Attempt to remove the patient's stings.
Attempting to remove the patient's rings is crucial to prevent complications such as restricted blood flow due to swelling, which can be exacerbated by bee stings. However, this should be done after administering diphenhydramine.
D. Give diphenhydramine (Benadryl) 50 mg PO.
The nurse should first administer diphenhydramine (Benadryl) 50 mg PO to counteract the effects of the bee venom and reduce the risk of anaphylaxis.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Advanced Med Surg Proctored Exam 4. Take the full exam now
Full Explanation
A. Applying calamine lotion can provide relief from itching but does not address potential complications such as swelling or allergic reactions.
B. Applying ice packs can help reduce swelling and pain, but it is not the priority action in this scenario.
C. Attempting to remove the patient's rings is crucial to prevent complications such as restricted blood flow due to swelling, which can be exacerbated by bee stings. However, this should be done after administering diphenhydramine.
D. The nurse should first administer diphenhydramine (Benadryl) 50 mg PO to counteract the effects of the bee venom and reduce the risk of anaphylaxis.
Similar Questions
A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care?
A. Check the IV site for bleeding every 8 hr
Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtain a rectal temperature every 8 hr.
Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Check the client for proteinuria.
Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limit, IM injections.
Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.
Full Explanation
A. Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.
A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?
A. Guarded
Guarded suggests uncertainty, which may understate the seriousness of stage IV disease.
B. Good
"Good" and "very good" prognoses suggest favorable outcomes, which are less likely with stage IV ovarian cancer.
C. Very good
"Poor" prognosis indicates a bleak outlook with limited treatment options and expected decline in health.
D. Poor
Stage IV ovarian cancer indicates advanced disease with metastasis to distant organs, such as the liver or lungs. Even with aggressive treatment (surgery, radiation, chemotherapy), the overall survival rate is low, and the prognosis is considered poor. Discussing a poor prognosis allows the client to make informed decisions about treatment options, advance care planning, and supportive care.
E. None
None
F. None
None
Full Explanation
A. Guarded suggests uncertainty, which may understate the seriousness of stage IV disease.
B. "Good" and "very good" prognoses suggest favorable outcomes, which are less likely with stage IV ovarian cancer.
C. "Poor" prognosis indicates a bleak outlook with limited treatment options and expected decline in health.
D. Stage IV ovarian cancer indicates advanced disease with metastasis to distant organs, such as the liver or lungs. Even with aggressive treatment (surgery, radiation, chemotherapy), the overall survival rate is low, and the prognosis is considered poor. Discussing a poor prognosis allows the client to make informed decisions about treatment options, advance care planning, and supportive care.
A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take?
A. Monitor the client's vital signs once every 8 hr.
Monitoring vital signs every 8 hours is not sufficient for a client undergoing a stem cell transplant, who requires frequent assessment due to potential complications.
B. Provide the client with 1,000 mL of water to drink every 12 hr
Providing the client with water is important, but specific fluid volumes and intervals depend on individual needs and should not be standardized.
C. Keep blood pressure equipment in the client's room.
Clients undergoing stem cell transplants are immunocompromised due to chemotherapy and conditioning regimens. To reduce the risk of infection, all equipment that comes into contact with the client, such as blood pressure cuffs, should be dedicated to that room only. This prevents cross-contamination from other patients.
D. Place the client in a negative airflow room.
Negative pressure rooms are for protecting others from airborne infections (e.g., TB). Stem cell transplant clients require positive pressure rooms to protect them from pathogens in the environment.
Full Explanation
A. Monitoring vital signs every 8 hours is not sufficient for a client undergoing a stem cell transplant, who requires frequent assessment due to potential complications.
B. Providing the client with water is important, but specific fluid volumes and intervals depend on individual needs and should not be standardized.
C. Clients undergoing stem cell transplants are immunocompromised due to chemotherapy and conditioning regimens. To reduce the risk of infection, all equipment that comes into contact with the client, such as blood pressure cuffs, should be dedicated to that room only. This prevents cross-contamination from other patients.
D. Negative pressure rooms are for protecting others from airborne infections (e.g., TB). Stem cell transplant clients require positive pressure rooms to protect them from pathogens in the environment.