Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Occasional palpitations
: Occasional palpitations are a common symptom of supraventricular tachycardia (SVT) with a non-sustained ventricular response. Palpitations are sensations of a rapid, fluttering, or pounding heartbeat, which occur due to the irregular and fast heart rate characteristic of SVT. These palpitations can be intermittent and may vary in intensity, often causing discomfort and anxiety in patients.
B. Weakness
: Weakness can be associated with SVT, but it is not as specific or common as palpitations. Weakness may occur due to the reduced cardiac output and decreased perfusion to the muscles during episodes of rapid heart rate. However, it is not the primary symptom that nurses would anticipate in patients with SVT.
C. Shortness of breath
: Shortness of breath is another symptom that can occur with SVT, especially during prolonged episodes. The rapid heart rate can lead to decreased efficiency in blood circulation, causing the patient to feel breathless. While shortness of breath is a significant symptom, palpitations are more directly associated with the diagnosis of SVT.
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Full Explanation
Choice A Reason:
Occasional palpitations are a common symptom of supraventricular tachycardia (SVT) with a non-sustained ventricular response. Palpitations are sensations of a rapid, fluttering, or pounding heartbeat, which occur due to the irregular and fast heart rate characteristic of SVT. These palpitations can be intermittent and may vary in intensity, often causing discomfort and anxiety in patients.
Choice B Reason:
Weakness can be associated with SVT, but it is not as specific or common as palpitations. Weakness may occur due to the reduced cardiac output and decreased perfusion to the muscles during episodes of rapid heart rate. However, it is not the primary symptom that nurses would anticipate in patients with SVT.
Choice C Reason:
Shortness of breath is another symptom that can occur with SVT, especially during prolonged episodes. The rapid heart rate can lead to decreased efficiency in blood circulation, causing the patient to feel breathless. While shortness of breath is a significant symptom, palpitations are more directly associated with the diagnosis of SVT.
Similar Questions
When teaching a client how to perform pursed lip breathing, which instructions would the nurse include? (Select all that apply)
A. Lean on your back with your knees bent.
This instruction is incorrect. Pursed lip breathing is typically performed in a seated position with the neck and shoulders relaxed. Lying on your back with knees bent is not a recommended position for this breathing technique.
B. Use your abdominal muscles to squeeze air out of your lungs.
This instruction is correct. Using the abdominal muscles helps to expel air more effectively from the lungs, which is a key component of pursed lip breathing. This technique helps to improve ventilation and reduce the work of breathing.
C. Breathe out slowly without puffing your cheeks.
This instruction is correct. Breathing out slowly through pursed lips without puffing the cheeks helps to keep the airways open longer, allowing more air to be expelled from the lungs. This technique is particularly beneficial for individuals with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
D. Focus on inhaling and holding your breath as long as you can.
This instruction is incorrect. The focus of pursed lip breathing is on controlled exhalation rather than holding the breath. Inhaling should be done slowly through the nose, and exhaling should be prolonged through pursed lips.
E. Exhale at least twice the amount of time it took to breathe in.
This instruction is correct. The exhalation phase should be longer than the inhalation phase, typically taking at least twice as long. This helps to improve the efficiency of breathing and reduce shortness of breath.
F. Open your mouth and breathe deeply.
This instruction is incorrect. Pursed lip breathing involves breathing in through the nose and exhaling through pursed lips. Opening the mouth and breathing deeply is not part of this technique.
Full Explanation
Choice A: Lean on your back with your knees bent.
Reason: This instruction is incorrect. Pursed lip breathing is typically performed in a seated position with the neck and shoulders relaxed. Lying on your back with knees bent is not a recommended position for this breathing technique.
Choice B: Use your abdominal muscles to squeeze air out of your lungs.
Reason: This instruction is correct. Using the abdominal muscles helps to expel air more effectively from the lungs, which is a key component of pursed lip breathing. This technique helps to improve ventilation and reduce the work of breathing.
Choice C: Breathe out slowly without puffing your cheeks.
Reason: This instruction is correct. Breathing out slowly through pursed lips without puffing the cheeks helps to keep the airways open longer, allowing more air to be expelled from the lungs. This technique is particularly beneficial for individuals with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
Choice D: Focus on inhaling and holding your breath as long as you can.
Reason: This instruction is incorrect. The focus of pursed lip breathing is on controlled exhalation rather than holding the breath. Inhaling should be done slowly through the nose, and exhaling should be prolonged through pursed lips.
Choice E: Exhale at least twice the amount of time it took to breathe in.
Reason: This instruction is correct. The exhalation phase should be longer than the inhalation phase, typically taking at least twice as long. This helps to improve the efficiency of breathing and reduce shortness of breath.
Choice F: Open your mouth and breathe deeply.
Reason: This instruction is incorrect. Pursed lip breathing involves breathing in through the nose and exhaling through pursed lips. Opening the mouth and breathing deeply is not part of this technique.
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?
A. A 42-year-old man with gastroesophageal reflux disease
: A 42-year-old man with gastroesophageal reflux disease (GERD) is not at the highest risk for obstructive sleep apnea (OSA). While GERD can be associated with OSA, it is not a primary risk factor. The main risk factors for OSA include obesity, age, and anatomical features that can obstruct the airway. Therefore, this individual is not at the greatest risk compared to others.
B. A 55-year-old woman who is 50 lb (23 kg) overweight
: A 55-year-old woman who is 50 lb (23 kg) overweight is at significant risk for developing OSA. Obesity is one of the most critical risk factors for OSA because excess weight can lead to fat deposits around the upper airway, which can obstruct breathing during sleep. Additionally, being overweight increases the likelihood of other conditions that can exacerbate OSA, such as hypertension and metabolic syndrome.
C. A 20-year-old woman who is 8 months pregnant
: A 20-year-old woman who is 8 months pregnant may experience temporary sleep disturbances, including snoring and mild sleep apnea, due to hormonal changes and increased abdominal pressure. However, pregnancy-related sleep apnea is usually transient and resolves after childbirth. Therefore, while she may have an increased risk during pregnancy, it is not as significant as the risk posed by obesity.
D. A 73-year-old man with type 2 diabetes mellitus
: A 73-year-old man with type 2 diabetes mellitus has an increased risk of OSA, as diabetes is associated with obesity and metabolic syndrome, which are risk factors for OSA. However, the presence of diabetes alone does not pose as high a risk as obesity. Therefore, while this individual is at risk, it is not as high as the risk associated with being significantly overweight.
Full Explanation
Choice A Reason:
A 42-year-old man with gastroesophageal reflux disease (GERD) is not at the highest risk for obstructive sleep apnea (OSA). While GERD can be associated with OSA, it is not a primary risk factor. The main risk factors for OSA include obesity, age, and anatomical features that can obstruct the airway. Therefore, this individual is not at the greatest risk compared to others.
Choice B Reason:
A 55-year-old woman who is 50 lb (23 kg) overweight is at significant risk for developing OSA. Obesity is one of the most critical risk factors for OSA because excess weight can lead to fat deposits around the upper airway, which can obstruct breathing during sleep. Additionally, being overweight increases the likelihood of other conditions that can exacerbate OSA, such as hypertension and metabolic syndrome.
Choice C Reason:
A 20-year-old woman who is 8 months pregnant may experience temporary sleep disturbances, including snoring and mild sleep apnea, due to hormonal changes and increased abdominal pressure. However, pregnancy-related sleep apnea is usually transient and resolves after childbirth. Therefore, while she may have an increased risk during pregnancy, it is not as significant as the risk posed by obesity.
Choice D Reason:
A 73-year-old man with type 2 diabetes mellitus has an increased risk of OSA, as diabetes is associated with obesity and metabolic syndrome, which are risk factors for OSA. However, the presence of diabetes alone does not pose as high a risk as obesity. Therefore, while this individual is at risk, it is not as high as the risk associated with being significantly overweight.
Which of the following actions would the nurse take when caring for a client with nasal packing who had surgery 6 hours ago? (Select all that apply)
A. Observe for clear drainage.
Observing for clear drainage is important as it can indicate cerebrospinal fluid (CSF) leakage, especially after nasal or sinus surgery. CSF leakage is a serious complication that requires immediate medical attention. Clear drainage from the nose should be tested for the presence of glucose, which can confirm if it is CSF.
B. Assess for signs of bleeding.
Assessing for signs of bleeding is crucial in the immediate postoperative period. Nasal packing can sometimes mask ongoing bleeding, so it is important to monitor for any signs of excessive blood loss. This includes checking for blood-soaked dressings, frequent swallowing (which can indicate blood trickling down the throat), and changes in vital signs such as increased heart rate and decreased blood pressure.
C. Watch the client for frequent swallowing.
Watching the client for frequent swallowing is important because it can be a sign of posterior nasal bleeding. Blood can trickle down the back of the throat, causing the client to swallow frequently. This is a subtle but significant sign that should prompt further investigation and possible intervention.
D. Change the nasal packing.
This choice is incorrect. Nasal packing should not be changed by the nurse without specific orders from the physician. Changing the packing prematurely can disrupt the surgical site, cause bleeding, and increase the risk of infection. The packing is usually removed by the surgeon or under their direct supervision.
E. Administer a nasal steroid to decrease edema.
Administering a nasal steroid can help reduce inflammation and edema in the nasal passages. However, this should only be done if prescribed by the physician. Nasal steroids can help improve breathing and reduce discomfort, but they must be used according to medical guidance to avoid potential side effects.
Full Explanation
Choice A: Observe for clear drainage.
Reason: Observing for clear drainage is important as it can indicate cerebrospinal fluid (CSF) leakage, especially after nasal or sinus surgery. CSF leakage is a serious complication that requires immediate medical attention. Clear drainage from the nose should be tested for the presence of glucose, which can confirm if it is CSF.
Choice B: Assess for signs of bleeding.
Reason: Assessing for signs of bleeding is crucial in the immediate postoperative period. Nasal packing can sometimes mask ongoing bleeding, so it is important to monitor for any signs of excessive blood loss. This includes checking for blood-soaked dressings, frequent swallowing (which can indicate blood trickling down the throat), and changes in vital signs such as increased heart rate and decreased blood pressure.
Choice C: Watch the client for frequent swallowing.
Reason: Watching the client for frequent swallowing is important because it can be a sign of posterior nasal bleeding. Blood can trickle down the back of the throat, causing the client to swallow frequently. This is a subtle but significant sign that should prompt further investigation and possible intervention.
Choice D: Change the nasal packing.
Reason: This choice is incorrect. Nasal packing should not be changed by the nurse without specific orders from the physician. Changing the packing prematurely can disrupt the surgical site, cause bleeding, and increase the risk of infection. The packing is usually removed by the surgeon or under their direct supervision.
Choice E: Administer a nasal steroid to decrease edema.
Reason: Administering a nasal steroid can help reduce inflammation and edema in the nasal passages. However, this should only be done if prescribed by the physician. Nasal steroids can help improve breathing and reduce discomfort, but they must be used according to medical guidance to avoid potential side effects.