Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse knows that the first-line treatment for localized inflammation (for example, on a patient’s ankle) is RICE.
This acronym means:
A. Removal (of object), Integrity checks, Condition (treat underlying), Edema relief.
Choice A is wrong because Removal (of object), Integrity checks, Condition (treat underlying), Edema relief are not related to RICE and do not form a coherent treatment regimen.
B. Rest, Ibuprofen, Circulatory checks, Elevation.
Choice B is wrong because Ibuprofen is not part of RICE and may have side effects such as stomach irritation or bleeding. Circulatory checks are not necessary unless the compression bandage is too tight.
C. Redness, Immune response, Cellular regulation, Event.
Choice C is wrong because Redness, Immune response, Cellular regulation, Event are not treatments but symptoms or processes of inflammation.
D. Rest, Ice, Compression, Elevation.
This is a method of self-care to use right after you experience a minor injury such as a sprain or strain, a minor bone injury, or a sports injury. It quickly treats pain and swelling by reducing inflammation.
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
This is a method of self-care to use right after you experience a minor injury such as a sprain or strain, a minor bone injury, or a sports injury. It quickly treats pain and swelling by reducing inflammation.
Choice A is wrong because Removal (of object), Integrity checks, Condition (treat underlying), Edema relief are not related to RICE and do not form a coherent treatment regimen.
Choice B is wrong because Ibuprofen is not part of RICE and may have side effects such as stomach irritation or bleeding.
Circulatory checks are not necessary unless the compression bandage is too tight.
Choice C is wrong because Redness, Immune response, Cellular regulation, Event are not treatments but symptoms or processes of inflammation.
Similar Questions
A nurse is utilizing the cognitive domain of learning to teach a patient about the prevention of inflammation.
Which of the following is an appropriate goal for this patient?
A. Patient will check his blood sugar every day until his follow-up appointment.
Choice A is wrong because it belongs to the psychomotor domain of learning, which reflects learning behavior achieved through neuromuscular motor activities. Checking blood sugar is a physical skill, not a cognitive one.
B. Patient will discuss their feelings about required dietary changes (anti inflammatory diet) by discharge.
Choice B is wrong because it belongs to the affective domain of learning, which characterizes the emotional arena reflected by learners’ beliefs, values and interests. Discussing feelings about dietary changes is an affective outcome, not a cognitive one.
C. Patient will state 3 ways to avoid his known triggers (cat dander and pollen) by the end of the shift.
This is because the cognitive domain of learning involves knowledge and understanding of information. By stating 3 ways to avoid his triggers, the patient demonstrates that he has learned and comprehended the information about prevention of inflammation.
D. Patient will demonstrate proper use of inhaler by end of the shift.
Choice D is wrong because it also belongs to the psychomotor domain of learning, as it involves demonstrating proper use of inhaler, which is another physical skill.
Full Explanation
This is because the cognitive domain of learning involves knowledge and understanding of information. By stating 3 ways to avoid his triggers, the patient demonstrates that he has learned and comprehended the information about prevention of inflammation.
Choice A is wrong because it belongs to the psychomotor domain of learning, which reflects learning behavior achieved through neuromuscular motor activities. Checking blood sugar is a physical skill, not a cognitive one.
Choice B is wrong because it belongs to the affective domain of learning, which characterizes the emotional arena reflected by learners’ beliefs, values and interests.
Discussing feelings about dietary changes is an affective outcome, not a cognitive one.
Choice D is wrong because it also belongs to the psychomotor domain of learning, as it involves demonstrating proper use of inhaler, which is another physical skill.
A nurse is caring for a patient with a BMI of.
Appropriate nursing interventions include:
A. Hourly vital signs.
Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.
B. Implementing all fall risk precautions.
Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.
C. Utilizing bariatric bed and trapeze bar.
A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.
D. Supine positioning.
Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration. The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.
Full Explanation
A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.
These interventions can promote comfort, safety, and independence for the patient.
Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.
Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.
Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.
The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.
The RN identifies that a client is at risk for impaired skin integrity.
Which interventions should the nurse add to this client’s plan of care?
A. Place the patient in a side-lying position only.
Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.
B. Massage bony prominences.
Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.
C. Use positioning devices such as foam wedges.
This intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.
D. Keep the head of the bed elevated higher than 30 degrees. E. Inspect skin every shift.
Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.
Full Explanation
his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.
Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.
Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.
Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.
Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.
Normal ranges for skin integrity are:
• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.
• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.
• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.