Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for a client who has a fractured tibia and is in a cast. Which of the following findings is a manifestation of compartment syndrome?
A. Redness and warmth of affected extremity
Reason: Redness and warmth of affected extremity are not signs of compartment syndrome, but they may indicate other conditions such as infection or inflammation.
B. Slow capillary refill
Reason: Slow capillary refill is a sign of compartment syndrome, as it indicates that there is impaired blood flow to the tissues due to increased pressure within the fascial compartment.
C. Reduced level of consciousness
Reason: Reduced level of consciousness is not a sign of compartment syndrome, but it may indicate other serious conditions such as head injury, stroke, or hypoxia.
D. Pain and bleeding
Reason: Pain and bleeding are not specific signs of compartment syndrome, but they may occur due to the fracture or other causes.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 3. Take the full exam now
Full Explanation
Choice A Reason: Redness and warmth of affected extremity are not signs of compartment syndrome, but they may indicate other conditions such as infection or inflammation.
Choice B Reason: Slow capillary refill is a sign of compartment syndrome, as it indicates that there is impaired blood flow to the tissues due to increased pressure within the fascial compartment.
Choice C Reason: Reduced level of consciousness is not a sign of compartment syndrome, but it may indicate other serious conditions such as head injury, stroke, or hypoxia.
Choice D Reason: Pain and bleeding are not specific signs of compartment syndrome, but they may occur due to the fracture or other causes.
Similar Questions
A nurse is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect? Select all that apply.
A. Cloudy urine
Choice A Reason: Cloudy urine is a finding that indicates a urinary tract infection, as it shows that there are bacteria, pus, or blood in the urine.
B. Muscle tetany
Choice B Reason: Muscle tetany is not a finding that indicates a urinary tract infection, but it may indicate other conditions such as hypocalcemia or alkalosis.
C. Presence of calculi
Choice C Reason: Presence of calculi is not a finding that indicates a urinary tract infection, but it may cause or complicate a urinary tract infection by obstructing the urine flow and creating a nidus for bacterial growth.
D. Urinary frequency
Choice D Reason: Urinary frequency is a finding that indicates a urinary tract infection, as it shows that there is irritation and inflammation of the bladder and urethra.
E. Dysuria
Choice E Reason: Dysuria is a finding that indicates a urinary tract infection, as it shows that there is pain or burning sensation during urination.
Full Explanation
Choice A Reason: Cloudy urine is a finding that indicates a urinary tract infection, as it shows that there are bacteria, pus, or blood in the urine.
Choice B Reason: Muscle tetany is not a finding that indicates a urinary tract infection, but it may indicate other conditions such as hypocalcemia or alkalosis.
Choice C Reason: Presence of calculi is not a finding that indicates a urinary tract infection, but it may cause or complicate a urinary tract infection by obstructing the urine flow and creating a nidus for bacterial growth.
Choice D Reason: Urinary frequency is a finding that indicates a urinary tract infection, as it shows that there is irritation and inflammation of the bladder and urethra.
Choice E Reason: Dysuria is a finding that indicates a urinary tract infection, as it shows that there is pain or burning sensation during urination.
Which of the following would be the most appropriate nursing diagnosis for a client admitted with Addison's disease?
A. Impaired skin integrity
Reason: Impaired skin integrity is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and cortisol deficiency.
B. Fluid volume overload
Reason: Fluid volume overload is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and aldosterone deficiency.
C. Imbalanced nutrition: more than body requirements
Reason: Imbalanced nutrition: more than body requirements is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and weight loss.
D. Risk for injury
Reason: Risk for injury is the most appropriate nursing diagnosis for a client with Addison's disease, as it reflects the main problem of adrenal insufficiency and hypotension, which can cause falls, fainting, or shock.
Full Explanation
Choice A Reason: Impaired skin integrity is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and cortisol deficiency.
Choice B Reason: Fluid volume overload is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and aldosterone deficiency.
Choice C Reason: Imbalanced nutrition: more than body requirements is not the most appropriate nursing diagnosis for a client with Addison's disease, as it does not reflect the main problem of adrenal insufficiency and weight loss.
Choice D Reason: Risk for injury is the most appropriate nursing diagnosis for a client with Addison's disease, as it reflects the main problem of adrenal insufficiency and hypotension, which can cause falls, fainting, or shock.
A home health nurse reinforces instructions to a client who is taking allopurinol for the treatment of gout. The nurse provides which client instructions?
A. Place an ice pack on the lips if they swell.
Reason: Placing an ice pack on the lips if they swell is not an appropriate instruction for a client who is taking allopurinol, as it may indicate an allergic reaction or angioedema, which requires immediate medical attention.
B. Use an over-the-counter (OTC) antihistamine lotion if a rash develops.
Reason: Using an OTC antihistamine lotion if a rash develops is not an appropriate instruction for a client who is taking allopurinol, as it may indicate a serious skin reaction such as Stevens-Johnson syndrome or toxic epidermal necrolysis, which requires immediate medical attention.
C. Drink at least 8 glasses of fluid every day.
Reason: Drinking at least 8 glasses of fluid every day is an appropriate instruction for a client who is taking allopurinol, as it helps to prevent kidney stones and flush out uric acid from the body.
D. Take the medication on an empty stomach 2 hours before meals.
Reason: Taking the medication on an empty stomach 2 hours before meals is not an appropriate instruction for a client who is taking allopurinol, as it may cause stomach upset or nausea. The medication should be taken after meals with plenty of water.
Full Explanation
Choice A Reason: Placing an ice pack on the lips if they swell is not an appropriate instruction for a client who is taking allopurinol, as it may indicate an allergic reaction or angioedema, which requires immediate medical attention.
Choice B Reason: Using an OTC antihistamine lotion if a rash develops is not an appropriate instruction for a client who is taking allopurinol, as it may indicate a serious skin reaction such as Stevens-Johnson syndrome or toxic epidermal necrolysis, which requires immediate medical attention.
Choice C Reason: Drinking at least 8 glasses of fluid every day is an appropriate instruction for a client who is taking allopurinol, as it helps to prevent kidney stones and flush out uric acid from the body.
Choice D Reason: Taking the medication on an empty stomach 2 hours before meals is not an appropriate instruction for a client who is taking allopurinol, as it may cause stomach upset or nausea. The medication should be taken after meals with plenty of water.