Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes the abdomen is distended and bowel sounds are diminished.
Which is the most appropriate nursing intervention?
A. Administer the prescribed medication.
Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.
B. Reposition the client and apply a heating pad on the warm setting to the client’s abdomen.
Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.
C. Call the healthcare provider.
The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.
D. Call and ask the operating room team to perform surgery as soon as possible.
Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.
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
The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.
Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.
Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.
Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.
Similar Questions
A person with anemia is prescribed erythropoietin subcutaneously. The nurse knows that erythropoietin:
A. Stimulates bone marrow production of red blood cells.
This helps increase the oxygen-carrying capacity of the blood and corrects anemia.
B. Is given to all people with anemia.
Choice B is wrong because erythropoietin is not given to all people with anemia. It is only used for certain types of anemia, such as those caused by chronic kidney disease or chemotherapy.
C. Is given for iron deficiency anemia.
Choice C is wrong because erythropoietin is not given for iron deficiency anemia. Iron deficiency anemia is treated with iron supplements and dietary changes.
D. Stimulates bone marrow production of white blood cells.
Choice D is wrong because erythropoietin does not stimulate bone marrow production of white blood cells. White blood cells are involved in immune responses and are produced by different growth factors.
Full Explanation
This helps increase the oxygen-carrying capacity of the blood and corrects anemia.
Choice B is wrong because erythropoietin is not given to all people with anemia. It is only used for certain types of anemia, such as those caused by chronic kidney disease or chemotherapy.
Choice C is wrong because erythropoietin is not given for iron deficiency anemia. Iron deficiency anemia is treated with iron supplements and dietary changes.
Choice D is wrong because erythropoietin does not stimulate bone marrow production of white blood cells. White blood cells are involved in immune responses and are produced by different growth factors.
Question 22.
The nurse does not turn a client every two hours as ordered, and the client develops a pressure injury.
What legal concept applies?
A. Breach of duty.
This is because the nurse had a legal obligation to turn the client every two hours as ordered, and by failing to do so, they did not exercise reasonable care that could foreseeably prevent harm to the client. This is an example of negligence, which requires four elements: duty, breach, injury and causation.
B. Criminality.
Choice B is wrong because criminality refers to the violation of criminal laws, such as theft or assault, which are not applicable in this case.
C. Scope of practice.
Choice C is wrong because scope of practice refers to the range of activities that a health care professional is authorized to perform based on their education, training and certification. The nurse’s failure to turn the client does not relate to their scope of practice. Choice D is wrong because false imprisonment refers to the unlawful restraint of a person’s freedom of movement, such as locking them in a room or restraining them against their will. The nurse’s failure to turn the client does not involve any such restraint.
D. False imprisonment.
This is because the nurse had a legal obligation to turn the client every two hours as ordered, and by failing to do so, they did not exercise reasonable care that could foreseeably prevent harm to the client. This is an example of negligence, which requires four elements: duty, breach, injury and causation.
Full Explanation
This is because the nurse had a legal obligation to turn the client every two hours as ordered, and by failing to do so, they did not exercise reasonable care that could foreseeably prevent harm to the client. This is an example of negligence, which requires four elements: duty, breach, injury and causation.
Choice B is wrong because criminality refers to the violation of criminal laws, such as theft or assault, which are not applicable in this case.
Choice C is wrong because scope of practice refers to the range of activities that a health care professional is authorized to perform based on their education, training and certification.
The nurse’s failure to turn the client does not relate to their scope of practice. Choice D is wrong because false imprisonment refers to the unlawful restraint of a person’s freedom of movement, such as locking them in a room or restraining them against their will.
The nurse’s failure to turn the client does not involve any such restraint.
A nurse is reinforcing teaching with a client about healthful sleep habits.
Which of the following statements should the nurse identify as an indication that the client needs further instructions?
A. “I watch television until I fall asleep at night.”
Watching television until falling asleep at night is a poor sleep habit because it can interfere with the body’s natural sleep-wake cycle and make it harder to fall asleep and stay asleep. Television can also expose the eyes to bright light and stimulating or stressful content, which can affect the production of melatonin, a hormone that regulates sleep.
B. “I have a small snack and take a bath before going to bed each day.”
Choice B is wrong because having a small snack and taking a bath before going to bed each day are good sleep habits that can promote relaxation and sleep quality.
C. “I don’t take naps throughout the day.”
Choice C is wrong because not taking naps throughout the day is a good sleep habit that can help maintain a consistent sleep schedule and avoid disrupting the night-time sleep.
D. “I go to bed and get up at the same times each day.”.
Choice D is wrong because going to bed and getting up at the same times each day is a good sleep habit that can reinforce the body’s circadian rhythm and make it easier to fall asleep and wake up.
Full Explanation
Watching television until falling asleep at night is a poor sleep habit because it can interfere with the body’s natural sleep-wake cycle and make it harder to fall asleep and stay asleep. Television can also expose the eyes to bright light and stimulating or stressful content, which can affect the production of melatonin, a hormone that regulates sleep.
Choice B is wrong because having a small snack and taking a bath before going to bed each day are good sleep habits that can promote relaxation and sleep quality.
Choice C is wrong because not taking naps throughout the day is a good sleep habit that can help maintain a consistent sleep schedule and avoid disrupting the night-time sleep.
Choice D is wrong because going to bed and getting up at the same times each day is a good sleep habit that can reinforce the body’s circadian rhythm and make it easier to fall asleep and wake up.