Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy.
The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining.
Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea.
The last dose was administered at 0700.
The client is currently describing pain at a level 2 on a 0 to 10 pain scale.
The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain.
The last dose was administered at 1000." Which additional information should the PACU nurse report?
A. History of vomiting at home for 3 days prior to surgery.
History of vomiting at home for 3 days prior to surgery. Rationale: This information is relevant to the client's surgical history and may impact their current condition. It is essential to inform the receiving nurse about this history to ensure appropriate postoperative care.
B. Soft abdomen, absent bowel sounds, no bleeding on dressing.
Soft abdomen, absent bowel sounds, no bleeding on dressing. Rationale: While this information is important for assessing the client's postoperative status, it is less urgent than the history of vomiting. The abdominal assessment suggests normal findings after surgery.
C. Declining to take ice chips for complaints of dry mouth.
Declining to take ice chips for complaints of dry mouth. Rationale: While this information indicates the client's complaint of dry mouth, it is not as critical as the history of vomiting or the assessment of surgical outcomes.
D. Peripheral pulses present with full range of motion of both legs.
Peripheral pulses present with full range of motion of both legs. Rationale: This information is important but primarily related to the client's vascular and neurological status. It may not be as immediately relevant as the history of vomiting in the context of a recent surgery.
This question is an excerpt from Nurse Dive's nursing test bank - HESI PN Exit 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
History of vomiting at home for 3 days prior to surgery. Rationale: This information is relevant to the client's surgical history and may impact their current condition. It is essential to inform the receiving nurse about this history to ensure appropriate postoperative care.
Choice B rationale:
Soft abdomen, absent bowel sounds, no bleeding on dressing. Rationale: While this information is important for assessing the client's postoperative status, it is less urgent than the history of vomiting. The abdominal assessment suggests normal findings after surgery.
Choice C rationale:
Declining to take ice chips for complaints of dry mouth. Rationale: While this information indicates the client's complaint of dry mouth, it is not as critical as the history of vomiting or the assessment of surgical outcomes.
Choice D rationale:
Peripheral pulses present with full range of motion of both legs. Rationale: This information is important but primarily related to the client's vascular and neurological status. It may not be as immediately relevant as the history of vomiting in the context of a recent surgery.
Similar Questions
While changing a client's postoperative dressing, the nurse observes purulent drainage at the site.
Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
A. Serum sodium level.
Serum sodium level. Rationale: While electrolyte imbalances can be significant, in the context of purulent drainage at a postoperative site, monitoring serum sodium levels is not the top priority. Other laboratory values are more relevant in this situation.
B. Hematocrit.
Hematocrit. Rationale: Hematocrit measures the proportion of red blood cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.
C. Neutrophil count.
Neutrophil count. Rationale: Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.
D. Platelet count.
Platelet count. Rationale: Platelet count measures the number of blood clotting cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.
Full Explanation
Choice A rationale:
Serum sodium level. Rationale: While electrolyte imbalances can be significant, in the context of purulent drainage at a postoperative site, monitoring serum sodium levels is not the top priority. Other laboratory values are more relevant in this situation.
Choice B rationale:
Hematocrit. Rationale: Hematocrit measures the proportion of red blood cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.
Choice C rationale:
Neutrophil count. Rationale: Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.
Choice D rationale:
Platelet count. Rationale: Platelet count measures the number of blood clotting cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.
Which is the best approach for the nurse to use when interviewing a client about intimate partner violence?
A. Ask questions in a vague, non-specific format.
Asking questions in a vague, non-specific format is not the best approach for addressing intimate partner violence. This approach may confuse the client or make them feel uncomfortable, as they may not know what specific information the nurse is seeking. It is essential to use clear and direct communication when addressing sensitive issues like intimate partner violence.
B. Begin with questions that are less sensitive in nature.
Beginning with questions that are less sensitive in nature is the preferred approach when interviewing a client about intimate partner violence. This allows the nurse to establish rapport and build trust with the client before delving into more sensitive topics. Starting with less sensitive questions can help the client feel more comfortable and willing to share information about their situation.
C. Get the most difficult questions over with first.
Getting the most difficult questions over with first is not the best approach when addressing intimate partner violence. Starting with the most challenging questions may cause the client to become defensive or unwilling to cooperate. It is essential to build a therapeutic relationship before discussing sensitive topics to ensure the client's emotional safety and willingness to disclose information.
D. Share personal values to put the client at ease.
Sharing personal values to put the client at ease is not an appropriate approach when addressing intimate partner violence. It can be perceived as unprofessional and may compromise the objectivity and neutrality of the nurse in providing care. The focus should be on the client's needs and concerns, not the nurse's personal beliefs.
Full Explanation
Choice A rationale:
Asking questions in a vague, non-specific format is not the best approach for addressing intimate partner violence. This approach may confuse the client or make them feel uncomfortable, as they may not know what specific information the nurse is seeking. It is essential to use clear and direct communication when addressing sensitive issues like intimate partner violence.
Choice B rationale:
Beginning with questions that are less sensitive in nature is the preferred approach when interviewing a client about intimate partner violence. This allows the nurse to establish rapport and build trust with the client before delving into more sensitive topics. Starting with less sensitive questions can help the client feel more comfortable and willing to share information about their situation.
Choice C rationale:
Getting the most difficult questions over with first is not the best approach when addressing intimate partner violence. Starting with the most challenging questions may cause the client to become defensive or unwilling to cooperate. It is essential to build a therapeutic relationship before discussing sensitive topics to ensure the client's emotional safety and willingness to disclose information.
Choice D rationale:
Sharing personal values to put the client at ease is not an appropriate approach when addressing intimate partner violence. It can be perceived as unprofessional and may compromise the objectivity and neutrality of the nurse in providing care. The focus should be on the client's needs and concerns, not the nurse's personal beliefs.
The nurse observes an 18-month-old toddler keeping a bottle of milk in the mouth throughout the history-taking and assessment process during a well-child visit.
The mother confirms that the child has a bottle available most of the day and remarks that it makes a great pacifier.
Which response should the nurse provide?
A. A bottle is generally much better than using a pacifier.
A bottle is generally much better than using a pacifier. This statement is not accurate. Prolonged bottle use, especially with sugary liquids like milk, can have adverse effects on a child's dental health. It can lead to an increased risk of cavities, similar to prolonged pacifier use.
B. The bottle will assist in preventing thumb sucking.
The bottle will assist in preventing thumb sucking. This statement is incorrect. While a bottle may provide comfort to a child, it does not prevent thumb sucking. Thumb sucking is a separate behavior that may also have dental implications if it persists beyond a certain age.
C. Prolonged bottle use can increase the risk for cavities.
Prolonged bottle use can increase the risk for cavities. This response is correct. Prolonged bottle use, especially with milk or sugary beverages, can expose the child's teeth to prolonged contact with sugars, increasing the risk of cavities. It's important for the nurse to educate the mother about the potential dental risks associated with extended bottle use.
D. Using milk rather than juice helps to avoid tooth decay.
Using milk rather than juice helps to avoid tooth decay. While milk is generally considered a healthier choice than juice, the key issue in this scenario is the prolonged use of the bottle, regardless of its content. Prolonged bottle use with any liquid, including milk, can still increase the risk of cavities.
Full Explanation
Choice A rationale:
A bottle is generally much better than using a pacifier. This statement is not accurate. Prolonged bottle use, especially with sugary liquids like milk, can have adverse effects on a child's dental health. It can lead to an increased risk of cavities, similar to prolonged pacifier use.
Choice B rationale:
The bottle will assist in preventing thumb sucking. This statement is incorrect. While a bottle may provide comfort to a child, it does not prevent thumb sucking. Thumb sucking is a separate behavior that may also have dental implications if it persists beyond a certain age.
Choice C rationale:
Prolonged bottle use can increase the risk for cavities. This response is correct. Prolonged bottle use, especially with milk or sugary beverages, can expose the child's teeth to prolonged contact with sugars, increasing the risk of cavities. It's important for the nurse to educate the mother about the potential dental risks associated with extended bottle use.
Choice D rationale:
Using milk rather than juice helps to avoid tooth decay. While milk is generally considered a healthier choice than juice, the key issue in this scenario is the prolonged use of the bottle, regardless of its content. Prolonged bottle use with any liquid, including milk, can still increase the risk of cavities.