Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for a client diagnosed with deep vein thrombosis who suddenly becomes short of breath, anxious, and restless.
The vital signs are: heart rate 130 beats/minute, respirations 42/minute, blood pressure 90/50, and pulse oximetry is 90%. An intravenous infusion of normal saline is running at 75ml/hr. The nurse elevates the head of the bed and applies nasal oxygen at 2L/min.
What action should the nurse take next?
A. Administer the PRN antianxiety medication.
Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.
B. Call the rapid response team.
Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.
C. Increase the intravenous infusion rate.
Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.
D. Prepare for mechanical ventilation.
Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Nurs 200 Proctored Exam Roxoborouh Memorial College. Take the full exam now
Full Explanation
Choice A rationale
Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.
Choice B rationale
Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.
Choice C rationale
Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.
Choice D rationale
Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.
Similar Questions
The nurse is aware that the diagnostic level of a fasting blood glucose for a client with diabetes is:
A. 135 mg/dL of glucose.
A fasting blood glucose level of 135 mg/dL is above the diagnostic threshold for diabetes. However, it is not the exact threshold value.
B. 140 mg/dL of glucose.
A fasting blood glucose level of 140 mg/dL is significantly above the diagnostic threshold for diabetes.
C. 126 mg/dL of glucose.
A fasting blood glucose level of 126 mg/dL or higher on two separate tests indicates diabetes.
D. 145 mg/dL of glucose.
A fasting blood glucose level of 145 mg/dL is significantly above the diagnostic threshold for diabetes.
Full Explanation
Choice A rationale
A fasting blood glucose level of 135 mg/dL is above the diagnostic threshold for diabetes. However, it is not the exact threshold value.
Choice B rationale
A fasting blood glucose level of 140 mg/dL is significantly above the diagnostic threshold for diabetes.
Choice C rationale
A fasting blood glucose level of 126 mg/dL or higher on two separate tests indicates diabetes.
Choice D rationale
A fasting blood glucose level of 145 mg/dL is significantly above the diagnostic threshold for diabetes.
The client newly diagnosed with Type 1 diabetes is to be discharged in the morning and has received no instruction on diabetes.
What should be the nurse’s teaching priority?
A. The recommended diabetic diet.
While understanding the recommended diabetic diet is important for managing type 1 diabetes, it is not the immediate priority for a client who has received no instruction on diabetes management. Without insulin, a person with type 1 diabetes can develop life- threatening diabetic ketoacidosis, regardless of their diet.
B. Administration of insulin.
Administration of insulin is the immediate priority for a client newly diagnosed with type 1 diabetes. In type 1 diabetes, the body does not produce insulin, a hormone that regulates blood sugar levels. Without insulin, blood sugar levels can become dangerously high, leading to diabetic ketoacidosis, a serious condition that requires emergency medical treatment.
C. Importance of exercise.
While exercise is an important part of managing diabetes, it is not the immediate priority for a client newly diagnosed with type 1 diabetes who has received no instruction on diabetes management. Exercise can help regulate blood sugar levels, but without insulin, exercise alone is not sufficient to prevent diabetic ketoacidosis.
D. Urine testing for ketones.
Urine testing for ketones is an important part of managing type 1 diabetes, especially during illness or stress, when ketone levels can rise quickly. However, it is not the immediate priority for a client newly diagnosed with type 1 diabetes who has received no instruction on diabetes management.
Full Explanation
Choice A rationale
While understanding the recommended diabetic diet is important for managing type 1 diabetes, it is not the immediate priority for a client who has received no instruction on diabetes management. Without insulin, a person with type 1 diabetes can develop life- threatening diabetic ketoacidosis, regardless of their diet.
Choice B rationale
Administration of insulin is the immediate priority for a client newly diagnosed with type 1 diabetes. In type 1 diabetes, the body does not produce insulin, a hormone that regulates blood sugar levels. Without insulin, blood sugar levels can become dangerously high, leading to diabetic ketoacidosis, a serious condition that requires emergency medical treatment.
Choice C rationale
While exercise is an important part of managing diabetes, it is not the immediate priority for a client newly diagnosed with type 1 diabetes who has received no instruction on diabetes management. Exercise can help regulate blood sugar levels, but without insulin, exercise alone is not sufficient to prevent diabetic ketoacidosis.
Choice D rationale
Urine testing for ketones is an important part of managing type 1 diabetes, especially during illness or stress, when ketone levels can rise quickly. However, it is not the immediate priority for a client newly diagnosed with type 1 diabetes who has received no instruction on diabetes management.
The client, on an intensified insulin regimen, consistently has a fasting blood glucose between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. What is the nurse’s interpretation of these findings?
A. The client is at increased risk for developing hypoglycemia.
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is not at an increased risk for developing hypoglycemia.
B. The client is demonstrating signs of insulin resistance.
Insulin resistance is a characteristic of type 2 diabetes, not type 1 diabetes. The client’s blood glucose levels are well controlled, which suggests that the client’s insulin regimen is effective, not that the client is demonstrating signs of insulin resistance.
C. The client is demonstrating good control of blood glucose.
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is demonstrating good control of blood glucose.
D. The client is at increased risk for developing hyperglycemia.
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is not at an increased risk for developing hyperglycemia.
Full Explanation
Choice A rationale
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is not at an increased risk for developing hypoglycemia.
Choice B rationale
Insulin resistance is a characteristic of type 2 diabetes, not type 1 diabetes. The client’s blood glucose levels are well controlled, which suggests that the client’s insulin regimen is effective, not that the client is demonstrating signs of insulin resistance.
Choice C rationale
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is demonstrating good control of blood glucose.
Choice D rationale
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is not at an increased risk for developing hyperglycemia.