Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis.
What is the priority nursing action?
A. Monitor the peak level of the antibiotic.
Monitoring the peak level of the antibiotic is important, but it is not the priority nursing action. Peak levels are typically drawn after the drug has been administered and are used to assess whether the dosage is sufficient.
B. Assess the client’s vital signs.
Assessing the client’s vital signs is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.
C. Obtain a serum trough level.
Obtaining a serum trough level is the priority nursing action. Trough levels are drawn just before the next dose of the drug is due and are used to assess whether the dosage is safe.
D. Ask the client about drug allergies.
Asking the client about drug allergies is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.
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
Monitoring the peak level of the antibiotic is important, but it is not the priority nursing action. Peak levels are typically drawn after the drug has been administered and are used to assess whether the dosage is sufficient.
Choice B rationale
Assessing the client’s vital signs is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.
Choice C rationale
Obtaining a serum trough level is the priority nursing action. Trough levels are drawn just before the next dose of the drug is due and are used to assess whether the dosage is safe.
Choice D rationale
Asking the client about drug allergies is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.
Similar Questions
A client is receiving trimethoprim-sulfamethoxazole.
What information should the nurse include in the teaching about this medication?
A. Increase fluid intake to 3 to 4 liters per 24 hours.
Trimethoprim-sulfamethoxazole is an antibiotic used to treat or prevent bacterial infections. One of the key instructions for patients taking this medication is to increase fluid intake to 3 to 4 liters per 24 hours. This is because the medication can crystallize in the urine, which can lead to kidney stones or damage if the patient is not adequately hydrated.
B. Spend some time in the sun to improve drug metabolism.
Spending time in the sun does not improve the metabolism of trimethoprim-sulfamethoxazole. In fact, the medication can make the skin more sensitive to the sun, increasing the risk of sunburn.
C. Take Kaopectate daily to prevent diarrhea.
Taking Kaopectate daily to prevent diarrhea is not a standard instruction for patients taking trimethoprim-sulfamethoxazole. Diarrhea can be a side effect of the medication, but it should be managed under the guidance of a healthcare provider.
D. Take the drug every morning at the same time as hydrochlorothiazide.
There is no specific instruction to take trimethoprim-sulfamethoxazole every morning at the same time as hydrochlorothiazide. The timing of medication administration should be determined by the healthcare provider based on the patient’s overall treatment plan.
Full Explanation
Choice A rationale
Trimethoprim-sulfamethoxazole is an antibiotic used to treat or prevent bacterial infections. One of the key instructions for patients taking this medication is to increase fluid intake to 3 to
4 liters per 24 hours. This is because the medication can crystallize in the urine, which can lead to kidney stones or damage if the patient is not adequately hydrated.
Choice B rationale
Spending time in the sun does not improve the metabolism of trimethoprim-sulfamethoxazole. In fact, the medication can make the skin more sensitive to the sun, increasing the risk of sunburn.
Choice C rationale
Taking Kaopectate daily to prevent diarrhea is not a standard instruction for patients taking trimethoprim-sulfamethoxazole. Diarrhea can be a side effect of the medication, but it should be managed under the guidance of a healthcare provider.
Choice D rationale
There is no specific instruction to take trimethoprim-sulfamethoxazole every morning at the same time as hydrochlorothiazide. The timing of medication administration should be determined by the healthcare provider based on the patient’s overall treatment plan.
A newly diagnosed diabetic client is 24 hours post-op following abdominal surgery.
The 0700 blood glucose level is 200 mg/dl and the nurse administers 4 units of insulin aspart subcutaneously per the prescribed sliding scale.
When should the nurse first assess the client for signs and symptoms of hypoglycemia?
A. 0800
Hypoglycemia, or low blood sugar, can occur after insulin administration. However, the onset of hypoglycemia is not immediate. Insulin aspart, a rapid-acting insulin, has a peak action time of approximately 1-3 hours after administration. Therefore, assessing the patient for signs and symptoms of hypoglycemia at 0800, one hour after administration, may be too early.
B. 0730
Assessing the patient for signs and symptoms of hypoglycemia at 0730, 30 minutes after insulin administration, is too early. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
C. 1130
Assessing the patient for signs and symptoms of hypoglycemia at 1130, four and a half hours after insulin administration, may be too late. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
D. 1000
Assessing the patient for signs and symptoms of hypoglycemia at 1000, three hours after insulin administration, is within the peak action time of insulin aspart. Therefore, this is the most appropriate time to start assessing the patient for signs and symptoms of hypoglycemia.
Full Explanation
Choice A rationale
Hypoglycemia, or low blood sugar, can occur after insulin administration. However, the onset of hypoglycemia is not immediate. Insulin aspart, a rapid-acting insulin, has a peak action time of approximately 1-3 hours after administration. Therefore, assessing the patient for signs and symptoms of hypoglycemia at 0800, one hour after administration, may be too early.
Choice B rationale
Assessing the patient for signs and symptoms of hypoglycemia at 0730, 30 minutes after insulin administration, is too early. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
Choice C rationale
Assessing the patient for signs and symptoms of hypoglycemia at 1130, four and a half hours after insulin administration, may be too late. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
Choice D rationale
Assessing the patient for signs and symptoms of hypoglycemia at 1000, three hours after insulin administration, is within the peak action time of insulin aspart. Therefore, this is the most appropriate time to start assessing the patient for signs and symptoms of hypoglycemia.
Which clinical manifestation should the nurse anticipate as an expected finding for a client diagnosed with deep vein thrombosis (DVT)?
A. Widespread edema of the affected extremity.
Deep vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in a deep vein, usually in the leg. One of the most common symptoms of DVT is swelling of the affected extremity. This occurs because the blood clot obstructs the flow of blood, causing fluid to build up in the tissues.
B. Small area of redness of the affected extremity.
While redness can be a symptom of DVT, it is not typically confined to a small area. Instead, redness associated with DVT is usually more widespread and is often accompanied by other symptoms such as swelling and pain.
C. Cool, mottled affected extremity.
A cool, mottled extremity is not a typical symptom of DVT34. DVT usually causes the affected area to feel warmer than the surrounding areas due to inflammation caused by the blood clot.
D. Positive bilateral peripheral pulses.
The presence of bilateral peripheral pulses is not a specific finding for DVT34. In fact, the presence of strong peripheral pulses may suggest that blood flow is not significantly obstructed.
Full Explanation
Choice A rationale
Deep vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in a deep vein, usually in the leg. One of the most common symptoms of DVT is swelling of the affected extremity. This occurs because the blood clot obstructs the flow of blood, causing fluid to build up in the tissues.
Choice B rationale
While redness can be a symptom of DVT, it is not typically confined to a small area. Instead, redness associated with DVT is usually more widespread and is often accompanied by other symptoms such as swelling and pain.
Choice C rationale
A cool, mottled extremity is not a typical symptom of DVT34. DVT usually causes the affected area to feel warmer than the surrounding areas due to inflammation caused by the blood clot.
Choice D rationale
The presence of bilateral peripheral pulses is not a specific finding for DVT34. In fact, the presence of strong peripheral pulses may suggest that blood flow is not significantly obstructed.