Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?
A. Patient will exhibit O2 saturation > 92% by discharge.
Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge. The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.
B. Teach pursed-lip breathing prior to discharge.
Choice B is wrong because it is not a goal statement, but an intervention. A goal statement should describe the expected outcome of the intervention, not the intervention itself.
C. Patient will state 2 ways to decrease chance of reinfection by the end of shift.
This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.
D. Patient will demonstrate pursed-lip breathing.
Choice D is wrong because it is not measurable or time-bound. A goal statement should have a clear indicator of how and when the outcome will be achieved.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Sp23 N144 FINAL Proctored Exam. Take the full exam now
Full Explanation
This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.
Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.
The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.
Choice B is wrong because it is not a goal statement, but an intervention.
A goal statement should describe the expected outcome of the intervention, not the intervention itself.
Choice D is wrong because it is not measurable or time-bound.
A goal statement should have a clear indicator of how and when the outcome will be achieved.
Similar Questions
The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?
A. Provide a walker.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
B. Place a chair on either side of the bed.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
C. Provide a cane.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
D. Place a fall risk wrist band on the client.
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Full Explanation
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?
A. Instruct the client to use pursed-lip breathing.
Pursed-lip breathing is a technique that helps to slow down the breathing rate and keep the airways open longer. This improves gas exchange and reduces the work of breathing. Pursed-lip breathing also helps to prevent air trapping and hyperinflation of the lungs, which are common complications of COPD.
B. Plan to have the client lay down for 1 hr after meals.
Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.
C. Restrict the client’s fluid intake to less than 1 L/day.
Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.
D. Encourage the client to use the upper chest for respiration.
Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress. It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing. Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.
Full Explanation
Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.
Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.
Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.
It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.
Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.
A nurse is cheering on participants in a marathon and one runner collapses nearby. He begins to vomit and complain of a throbbing headache. The nurse notes that he is not sweating, yet his skin is red and very hot to touch, and his pulse is 170 bpm and strong. The nurse knows that:
A. The runner may lose consciousness due to heat stroke.
Heat stroke is a serious condition caused by overheating of the body, usually as a result of prolonged exposure to or physical exertion in high temperatures. It can damage the brain and other internal organs, and can be fatal if not treated promptly. Some of the symptoms of heat stroke are: • High body temperature of 104 F (40 C) or higher • Altered mental state or behavior, such as confusion, agitation, slurred speech, seizures or coma • Lack of sweating despite the heat • Red, hot and dry skin • Rapid and strong pulse • Throbbing headach • Nausea and vomiting
B. It is not necessary to call 911.
Choice B is wrong because it is necessary to call 911 if someone has heat stroke. Heat stroke is a medical emergency that requires immediate attention and cooling of the body.
C. It is normal to vomit and not sweat during a marathon.
Choice C is wrong because it is not normal to vomit and not sweat during a marathon. Vomiting and lack of sweating are signs of dehydration and heat stroke, which indicate that the body is unable to regulate its temperature properly.
D. Getting the patient to a cooler, air-conditioned place will reverse the heat exhaustion.
Choice D is wrong because getting the patient to a cooler, air-conditioned place will not reverse the heat exhaustion. Heat exhaustion is a milder form of heat-related illness that can lead to heat stroke if not treated. Heat exhaustion symptoms include heavy sweating, weakness, dizziness, nausea and muscle cramps. Getting the patient to a cooler place may help with heat exhaustion, but heat stroke requires more aggressive cooling measures such as immersing the patient in cold water or applying ice packs to the body.
Full Explanation
Some of the symptoms of heat stroke are:
• High body temperature of 104 F (40 C) or higher
• Altered mental state or behavior, such as confusion, agitation, slurred speech, seizures or coma
• Lack of sweating despite the heat
• Red, hot and dry skin
• Rapid and strong pulse
• Throbbing headach
• Nausea and vomiting
Choice B is wrong because it is necessary to call 911 if someone has heat stroke. Heat stroke is a medical emergency that requires immediate attention and cooling of the body.
Choice C is wrong because it is not normal to vomit and not sweat during a marathon. Vomiting and lack of sweating are signs of dehydration and heat stroke, which indicate that the body is unable to regulate its temperature properly.
Choice D is wrong because getting the patient to a cooler, air-conditioned place will not reverse the heat exhaustion.
Heat exhaustion is a milder form of heat-related illness that can lead to heat stroke if not treated. Heat exhaustion symptoms include heavy sweating, weakness, dizziness, nausea and muscle cramps. Getting the patient to a cooler place may help with heat exhaustion, but heat stroke requires more aggressive cooling measures such as immersing the patient in cold water or applying ice packs to the body.