Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which nursing action should be included in the plan of care for a patient returning to the surgical unit after a left modified radical mastectomy with dissection of axillary lymph nodes?
A. Post a sign at the bedside warning against venipunctures or blood pressures in the left arm.
Post-surgery, there's a risk of lymphedema in the affected arm, so avoiding procedures like venipuncture or blood pressure measurements in the left arm helps prevent complications.
B. Obtain a permanent breast prosthesis before the patient is discharged from the hospital.
Obtaining a permanent breast prosthesis is a consideration post- recovery but not an immediate priority upon return to the surgical unit.
C. Teach the patient to use the ordered patient-controlled analgesia every 10 minutes.
Patient-controlled analgesia instructions are important but don't specifically address immediate care after mastectomy.
D. Insist that the patient examine the surgical incision when the initial dressings are removed.
Insisting that the patient examine the surgical incision might not be appropriate upon return to the unit, and it's typically done by healthcare professionals during dressing changes.
This question is an excerpt from Nurse Dive's nursing test bank - Interprofessional Care of the Client and Family Across the Lifespan II Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale: Post-surgery, there's a risk of lymphedema in the affected arm, so avoiding procedures like venipuncture or blood pressure measurements in the left arm helps prevent complications.
Choice B rationale: Obtaining a permanent breast prosthesis is a consideration post- recovery but not an immediate priority upon return to the surgical unit.
Choice C rationale: Patient-controlled analgesia instructions are important but don't specifically address immediate care after mastectomy.
Choice D rationale: Insisting that the patient examine the surgical incision might not be appropriate upon return to the unit, and it's typically done by healthcare professionals during dressing changes.
Similar Questions
The newly diagnosed patient with type 2 diabetes has been prescribed metformin (Glucophage). What should the nurse tell the patient to best explain how this medication works?
A. Increases insulin release from the pancreas, inhibits glucagon secretion, and decreases gastric emptying.
Metformin does not significantly affect insulin release from the pancreas or glucagon secretion but reduces glucose production by the liver and enhances insulin sensitivity in tissues.
B. Reduces glucose production by the liver and enhances insulin sensitivity.
Metformin primarily works by reducing glucose production in the liver and improving the body's response to insulin, thereby lowering blood sugar levels.
C. Slows the absorption of carbohydrate in the small intestine.
Metformin does not notably slow carbohydrate absorption in the small intestine.
D. Increases insulin production from the pancreas.
Metformin does not directly increase insulin production from the pancreas.
Full Explanation
Choice A rationale: Metformin does not significantly affect insulin release from the pancreas or glucagon secretion but reduces glucose production by the liver and enhances insulin sensitivity in tissues.
Choice B rationale: Metformin primarily works by reducing glucose production in the liver and improving the body's response to insulin, thereby lowering blood sugar levels.
Choice C rationale: Metformin does not notably slow carbohydrate absorption in the small intestine.
Choice D rationale: Metformin does not directly increase insulin production from the pancreas.
A client who is fully awake after a gastroscopy asks the nurse for something to drink.
After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?
A. Provide thickened fluids with a straw.
Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.
B. Listen to bilateral lung and bowel sounds.
While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.
C. Check the client's Hypoglossal nerve and Vestibulocochlear cranial nerve function.
Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.
D. Check the client's Glossopharyngeal nerve and Vagus cranial nerve function.
Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.
Full Explanation
Choice A rationale: Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.
Choice B rationale: While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.
Choice C rationale: Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.
Choice D rationale: Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.
A client is discharged to home following hospitalization for percutaneous endoscopic gastrostomy tube placement to assist with nutrition. The client's primary diagnosis is amyotrophic lateral sclerosis (ALS). The client can transfer from the bed to a chair but can't walk.
The client and their family are concerned about the client's ability to maintain mobility at the highest possible level following a surgical procedure. The nursing diagnosis most appropriate for this client is ...
A. Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate.
In ALS, impaired physical mobility due to decreased motor agility and the inability to ambulate is a direct consequence of the disease.
B. Hopelessness related to impaired ability to cope.
Hopelessness might be a possible emotional response but doesn't address the client's physical limitations due to ALS.
C. Caregiver role strain related to care recipient's unrealistic expectations of caregiver.
Caregiver role strain is related to the family's ability to manage caregiving responsibilities and is not the primary concern for the client's physical mobility.
D. Impaired memory related to reduced quality and quantity of information processed.
Impaired memory is not the primary issue in ALS; the client's inability to ambulate due to decreased motor function is the main focus for this nursing diagnosis.
Full Explanation
Choice A rationale: In ALS, impaired physical mobility due to decreased motor agility and the inability to ambulate is a direct consequence of the disease.
Choice B rationale: Hopelessness might be a possible emotional response but doesn't address the client's physical limitations due to ALS.
Choice C rationale: Caregiver role strain is related to the family's ability to manage caregiving responsibilities and is not the primary concern for the client's physical mobility.
Choice D rationale: Impaired memory is not the primary issue in ALS; the client's inability to ambulate due to decreased motor function is the main focus for this nursing diagnosis.