Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?
A. Drank a glass of water in the past 2 hours.
Choice A Reason: Drinking a glass of water in the past 2 hours is not typically a concern unless the patient has been instructed to fast. For most cardiac catheterization procedures, patients are asked to fast for a certain period before the procedure to reduce the risk of aspiration. However, small sips of water may be allowed with medications.
B. Reports left chest wall pain prior to admission.
Choice B Reason: While reports of left chest wall pain are clinically significant and warrant investigation, they are not as immediately concerning for the angioplasty procedure itself. Chest pain is a symptom that may have led to the decision to perform angioplasty but does not pose an immediate risk of complication during the procedure as an allergy might.
C. Experiences facial swelling after eating crab.
Choice C Reason: As previously mentioned, experiencing facial swelling after eating crab is indicative of a shellfish allergy. This is important because the contrast dye used in angioplasty may contain iodine, and patients with shellfish allergies could have an increased risk of an allergic reaction to the iodine in the dye. It is essential to explore this further to take necessary precautions, such as premedication with antihistamines or using a different contrast agent.
D. Verbalizes a fear of being in a confined space.
Choice D Reason: Verbalizing a fear of being in a confined space, or claustrophobia, is a psychological concern that should be addressed to ensure the patient’s comfort during the procedure. However, it does not pose a direct risk to the safety of the angioplasty procedure like an allergic reaction does. Managing patient anxiety is important, but it is not the most critical factor to explore prior to the procedure.
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Full Explanation
The correct answer is: C. Experiences facial swelling after eating crab.
Choice A Reason: Drinking a glass of water in the past 2 hours is not typically a concern unless the patient has been instructed to fast. For most cardiac catheterization procedures, patients are asked to fast for a certain period before the procedure to reduce the risk of aspiration. However, small sips of water may be allowed with medications.
Choice B Reason: While reports of left chest wall pain are clinically significant and warrant investigation, they are not as immediately concerning for the angioplasty procedure itself. Chest pain is a symptom that may have led to the decision to perform angioplasty but does not pose an immediate risk of complication during the procedure as an allergy might.
Choice C Reason: As previously mentioned, experiencing facial swelling after eating crab is indicative of a shellfish allergy. This is important because the contrast dye used in angioplasty may contain iodine, and patients with shellfish allergies could have an increased risk of an allergic reaction to the iodine in the dye. It is essential to explore this further to take necessary precautions, such as premedication with antihistamines or using a different contrast agent.
Choice D Reason: Verbalizing a fear of being in a confined space, or claustrophobia, is a psychological concern that should be addressed to ensure the patient’s comfort during the procedure. However, it does not pose a direct risk to the safety of the angioplasty procedure like an allergic reaction does. Managing patient anxiety is important, but it is not the most critical factor to explore prior to the procedure.
Similar Questions
Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?
A. Buttered whole wheat toast and coffee.
B. Sausage, poached eggs, and milk.
C. Granola, strawberries, and tea.
D. Oatmeal, banana, and herbal tea.
This breakfast selection is the most appropriate for a 16-year-old with diarrhea. Oatmeal is a bland and easily digestible food that can help to firm up the stool. Bananas are a good source of potassium and can help replace electrolytes that may be lost through diarrhea. Herbal tea is a non-caffeinated option that can help to soothe the digestive system. It is important to avoid foods that are greasy, high in fat, or spicy, as they can worsen diarrhea symptoms.
Full Explanation
This breakfast selection is the most appropriate for a 16-year-old with diarrhea. Oatmeal is a bland and easily digestible food that can help to firm up the stool. Bananas are a good source of potassium and can help replace electrolytes that may be lost through diarrhea. Herbal tea is a non-caffeinated option that can help to soothe the digestive system. It is important to avoid foods that are greasy, high in fat, or spicy, as they can worsen diarrhea symptoms.
While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylococcus aureus (MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, which intervention is most important for the nurse to implement?
A. Report any increase in the white blood cell count.
This choice is wrong because reporting an increase in the white blood cell count is a reactive measure rather than a preventive intervention. While a normal white blood cell count is typically between 5,000 and 10,000 cells/mcL, an elevation indicates that an infection has already established itself. The question asks for the most important intervention to reduce the risk of recurrence, which requires proactive wound management.
B. Instruct the family to adhere to contact precautions.
Contact precautions prevent the horizontal transmission of resistant pathogens between the patient and others. While vital for institutional infection control and public health safety, these measures do not directly address the localized physiological environment of the patient's own surgical incision.
C. Change the surgical dressing readily when soiled.
Saturated dressings create a warm, moist environment that facilitates capillary action, pulling contaminants into the wound. Maintaining a dry, sterile environment inhibits the colonization of methicillin-resistant Staphylococcus aureus, as moisture promotes the rapid exponential growth of these resistant gram-positive cocci.
D. Wear a face mask while performing wound care.
Face masks primarily provide protection against respiratory droplet transmission. While beneficial for preventing the introduction of oropharyngeal flora into a sterile field, they are less critical than moisture control for preventing MRSA recurrence, which is primarily spread through direct or indirect contact.
Full Explanation
The clinical scenario involves postoperative management of a surgical site in a patient colonized with methicillin-resistant Staphylococcus aureus. Successful intervention requires applying principles of wound hygiene, bacterial proliferation kinetics, and aseptic technique to mitigate localized moisture which fosters rapid staphylococcal replication and subsequent infection.
Choice A rationale: Elevated white blood cell counts, typically exceeding 11,000 mm3, indicate a systemic inflammatory response or active infection. While monitoring hematologic data is essential for detection, it is a reactive measure rather than a proactive intervention to prevent localized MRSA recurrence.
Choice B rationale: Contact precautions prevent the horizontal transmission of resistant pathogens between the patient and others. While vital for institutional infection control and public health safety, these measures do not directly address the localized physiological environment of the patient's own surgical incision.
Choice C rationale: Saturated dressings create a warm, moist environment that facilitates capillary action, pulling contaminants into the wound. Maintaining a dry, sterile environment inhibits the colonization of methicillin-resistant Staphylococcus aureus, as moisture promotes the rapid exponential growth of these resistant gram-positive cocci.
Choice D rationale: Face masks primarily provide protection against respiratory droplet transmission. While beneficial for preventing the introduction of oropharyngeal flora into a sterile field, they are less critical than moisture control for preventing MRSA recurrence, which is primarily spread through direct or indirect contact.
After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3 mg/dL (22.9 μmol/L). Which action should the nurse implement?
Creatinine [Reference Range: 0.5 to 1.1 mg/dL (44 to 97 μmol/L)]
A. Initiate the urine collection as prescribed.
Initiating the urine collection without reporting the low serum creatinine is inappropriate. A value of 0.3 mg/dL is below the reference range and may indicate significant muscle wasting or severe malnutrition.
B. Evaluate the client's serum BUN level.
Evaluating the BUN level provides information about hydration and renal perfusion, but it does not address the immediate clinical significance of an abnormally low creatinine level in an older adult client.
C. Notify the healthcare provider of the results.
The nurse must notify the provider because a creatinine level of 0.3 mg/dL is abnormally low. In older adults, this often reflects low muscle mass, which significantly impacts how drug dosages are calculated.
D. Assess the client for signs of hypokalemia.
Assessing for hypokalemia is not directly indicated by a low creatinine level. While electrolyte monitoring is important in drug toxicity, it is not the priority action linked to this specific lab finding.
Full Explanation
Choice A rationale: Initiating the urine collection without reporting the low serum creatinine is inappropriate. A value of 0.3 mg/dL is below the reference range and may indicate significant muscle wasting or severe malnutrition.
Choice B rationale: Evaluating the BUN level provides information about hydration and renal perfusion, but it does not address the immediate clinical significance of an abnormally low creatinine level in an older adult client.
Choice C rationale: The nurse must notify the provider because a creatinine level of 0.3 mg/dL is abnormally low. In older adults, this often reflects low muscle mass, which significantly impacts how drug dosages are calculated.
Choice D rationale: Assessing for hypokalemia is not directly indicated by a low creatinine level. While electrolyte monitoring is important in drug toxicity, it is not the priority action linked to this specific lab finding.