Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is continuing to care for the adolescent.
Provider Prescriptions 1415:
X-ray of right leg shows open fracture of the right proximal tibia
Surgery consult
Morphine 4 mg IV every 2 hr as needed for pain.
The nurse is preparing the adolescent for the fasciotomy.
Which of the following findings should the nurse report to the provider prior to surgery?
A. The adolescent's parents have concerns regarding the surgery
The nurse should not address the parents' concerns and provide education and support, but refer the concerns to the provider to address the concerns about the surgical procedure.
B. The adolescent's blood pressure is 131/89 mm Hg
This is not a correct answer because this blood pressure is within the normal range for an adolescent and does not indicate any complications or adverse effects from the injury or medication.
C. The adolescent reports severe pain
This is not a correct answer because the nurse should administer morphine as prescribed for pain relief, but this is not a priority finding that requires immediate intervention or reporting to the provider. The nurse should also monitor the adolescent's pain level and response to medication, and use nonpharmacological methods to reduce pain and anxiety.
D. The adolescent has not voided in 4 hr
Although this may raise concerns about renal injury, it is no a contraindication or cause for delay for the emergency surgical procedure.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
The adolescent has not voided in 4 hr.
Rationale:
- A. The nurse should not address the parents' concerns and provide education and support, but refer the concerns to the provider to address the concerns about the surgical procedure.
- B. The adolescent's blood pressure is 131/89 mm Hg. This is not a correct answer because this blood pressure is within the normal range for an adolescent and does not indicate any complications or adverse effects from the injury or medication.
- C. The adolescent reports severe pain. This is not a correct answer because the nurse should administer morphine as prescribed for pain relief, but this is not a priority finding that requires immediate intervention or reporting to the provider. The nurse should also monitor the adolescent's pain level and response to medication, and use nonpharmacological methods to reduce pain and anxiety.
- D. Although this may raise concerns about renal injury, it is no a contraindication or cause for delay for the emergency surgical procedure.
Similar Questions
8-year-old male admitted with cystic fibrosis reports the following symptoms:
- Shortness of breath
- Wheezing throughout lung fields
- Productive cough with thick sputum
A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan?
A. Initiate droplet isolation precautions
Initiate droplet isolation precautions is incorrect because cystic fibrosis is not transmitted by droplets, but by autosomal recessive inheritance.
B. Keep the child on NPO status for 12 hr
Keep the child on NPO status for 12 hr is incorrect because there is no indication for withholding oral intake in this child. The child needs adequate hydration and nutrition to prevent dehydration and malnutrition due to increased metabolic demands and mucus production.
C. Maintain the child on bed rest for 24 hr
Maintain the child on bed rest for 24 hr is incorrect because bed rest can worsen the child's respiratory status by decreasing lung expansion and increasing mucus retention. The child needs to be encouraged to ambulate and participate in activities as tolerated to promote airway clearance and prevent atelectasis and infection.
D. Administer high-dose antibiotic therapy
Administer high-dose antibiotic therapy is correct because the child has signs of a pulmonary infection, such as wheezing, productive cough, and thick sputum. Antibiotics are indicated to treat the infection and prevent complications such as pneumonia and bronchiectasis.
Full Explanation
Administer high-dose antibiotic therapy.
Rationale:
- A. Initiate droplet isolation precautions is incorrect because cystic fibrosis is not transmitted by droplets, but by autosomal recessive inheritance.
- B. Keep the child on NPO status for 12 hr is incorrect because there is no indication for withholding oral intake in this child. The child needs adequate hydration and nutrition to prevent dehydration and malnutrition due to increased metabolic demands and mucus production.
- C. Maintain the child on bed rest for 24 hr is incorrect because bed rest can worsen the child's respiratory status by decreasing lung expansion and increasing mucus retention. The child needs to be encouraged to ambulate and participate in activities as tolerated to promote airway clearance and prevent atelectasis and infection.
- D. Administer high-dose antibiotic therapy is correct because the child has signs of a pulmonary infection, such as wheezing, productive cough, and thick sputum. Antibiotics are indicated to treat the infection and prevent complications such as pneumonia and bronchiectasis.
A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.
A. Weight
Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
B. Neuro status
Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
C. Auditory hallucinations
Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
D. Speech
Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
E. Restlessness
Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.
Full Explanation
The correct answer is B, C, and E.
- A. Weight is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition.
- B. Neuro status is a correct choice because it reflects the client's level of consciousness, orientation, memory, and cognitive function. Any alteration in neuro status could indicate a serious problem such as infection, stroke, or medication toxicity.
- C. Auditory hallucinations are a correct choice because they are a symptom of psychosis and could indicate a relapse or worsening of the client's mental illness. Auditory hallucinations could also impair the client's ability to cope, communicate, and function effectively.
- D. Speech is not a correct choice because it is not a vital sign and it does not indicate an acute change in the client's condition. Speech could be affected by various factors such as mood, anxiety, or medication side effects.
- E. Restlessness is a correct choice because it is a sign of agitation, anxiety, or discomfort. Restlessness could also indicate an underlying physical or psychological problem such as pain, infection, or psychosis.
A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG) and a prescription for neostigmine. Which of the following information should the nurse include about the action of the medication?
A. Improves muscle strength.
Neostigmine is a medication used in the treatment of myasthenia gravis (MG). It belongs to a class of drugs called cholinesterase inhibitors. Neostigmine works by inhibiting the breakdown of acetylcholine, a neurotransmiter involved in muscle contraction. In MG, there is a decrease in the amount of acetylcholine available at the neuromuscular junction, leading to muscle weakness and fatigue. By inhibiting the breakdown of acetylcholine, neostigmine helps to increase the concentration of acetylcholine at the neuromuscular junction. This, in turn, improves muscle strength and can alleviate the symptoms of weakness and fatigue associated with MG.
B. Destroys the antibodies that cause MG
Destroying the antibodies that cause MG, is not accurate. Myasthenia gravis is an autoimmune disorder characterized by the presence of antibodies that interfere with neuromuscular transmission. Neostigmine does not directly target or eliminate these antibodies.
C. Enhances immune system function
Enhancing immune system function, is not accurate either. Neostigmine primarily acts on the neuromuscular junction to improve muscle strength and does not have a direct effect on immune system function.
D. Prevents excessive coughing
Preventing excessive coughing, is not the primary action of neostigmine. While increased muscle strength may indirectly improve respiratory function and reduce coughing in individuals with myasthenia gravis, it is not the primary indication or action of neostigmine.
Full Explanation
a. Improves muscle strength.
Explanation:
Neostigmine is a medication used in the treatment of myasthenia gravis (MG). It belongs to a class of drugs called cholinesterase inhibitors. Neostigmine works by inhibiting the breakdown of acetylcholine, a neurotransmiter involved in muscle contraction. In MG, there is a decrease in the amount of acetylcholine available at the neuromuscular junction, leading to muscle weakness and fatigue.
By inhibiting the breakdown of acetylcholine, neostigmine helps to increase the concentration of acetylcholine at the neuromuscular junction. This, in turn, improves muscle strength and can alleviate the symptoms of weakness and fatigue associated with MG.
Option b, destroying the antibodies that cause MG, is not accurate. Myasthenia gravis is an autoimmune disorder characterized by the presence of antibodies that interfere with neuromuscular transmission.
Neostigmine does not directly target or eliminate these antibodies.
Option c, enhancing immune system function, is not accurate either. Neostigmine primarily acts on the neuromuscular junction to improve muscle strength and does not have a direct effect on immune system function.
Option d, preventing excessive coughing, is not the primary action of neostigmine. While increased muscle strength may indirectly improve respiratory function and reduce coughing in individuals with myasthenia gravis, it is not the primary indication or action of neostigmine.
Therefore, the most accurate information to include in teaching about neostigmine for a client with myasthenia gravis is that it improves muscle strength.