The following are the most common nursing questions for nursing students:
- The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. Which action, made by the nursing assistant, would require instruction? Expert Answers: The nursing assistant places the drainage bag on the client’s abdomen for transport
A major goal when caring for a catheterized pt is to prevent infection. Select all the nursing actions that apply.
- Which nursing intervention should the nurse care for the client with pyelonephritis implement?
Expert answers: Teach the client to increase fluid intake up to 3 liters per day.
- While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate?
Expert Answer: Periods Of Febrile Episodes Coupled With Periods Of Acceptable Temperature Values Is A Relapsing Type Of Fever. These Periods Are Often Longer Than 24 Hours. In A Sustained Fever, The Body Temperature Remains Constantly Above 38oC With Little Fluctuations
- For a client with an endotracheal (et) tube, which nursing action is the most important?
- A client comes to the clinic for a follow-up visit. During the interview, the client states, “Sometimes when I have to urinate I can’t control it, and do not reach the bathroom in time.” The nurse suspects that the client is experiencing which type of incontinence? a) Urge
d) Overflow Expert answer: Urge. Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an overdistended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has a function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet.
- Which nursing intervention is essential in caring for a client with compartment syndrome?
- Which type of incontinence refers to the involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure? Expert Answer: Stress Incontinence – is an involuntary loss of urine due to increased intra-abdominal pressure during coughing, sneezing, laughing or other physical activities that increase intra-abdominal pressure.
- Following percutaneous nephrolithotomy, the client is at greatest risk for which nursing diagnosis?
- Which nursing diagnosis would best apply to a child with rheumatic fever?
- For a client with graves’ disease which nursing intervention promotes comfort?
- NUR 332: A client taking abacavir has developed a fever and rash. What is the priority nursing action?
Expert Answer: Report to the health care provider: Fever and a rash could be indicative of a hypersensitivity reaction. Hypersensitivity reactions are also known as anaphylactic reactions and often involve skin rashes, fever, and bronchopulmonary issues such as bronchial constriction. The health care provider should be notified immediately and the medication stopped. Interventions need to be taken to assure that the client’s airway is not compromised.
- Which nursing diagnosis takes the highest priority for a client with hyperthyroidism?
- Which condition is most likely to have a nursing diagnosis of fluid volume deficit?
- Which nursing action associated with successful tube feedings follows recommended guidelines? a) Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract.
b) Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid.
c) Check the residual before each feeding or every Expert Answer: C Check the residual before each feeding or every 4 to 8 hours during a continuous feeding.
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- Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
- In a client with burns on the legs, which nursing intervention helps prevent contractures?
- Which nursing intervention is most appropriate for a client with multiple myeloma?
- How long does it take to get a nursing degree?
- Which client requires immediate nursing intervention?
- A priority nursing intervention for a client with hypervolemia involves one of the following?
Expert Answer: Monitoring respiratory status for signs and symptoms of pulmonary complications.
- Which nursing action is appropriate when providing foot care for a client?
Which is an insensible mechanism of fluid loss?
Expert Answer: Breathing
- What is the primary goal of nursing care during the emergent phase after a burn injury?
- Which is an appropriate nursing goal for the client who has ulcerative colitis? The client:
- What happens when one spouse goes to a nursing home
- A client is diagnosed with pyelonephritis. Which nursing action is a priority for care now?
- Which of the following defines nursing bottle tooth decay?
- The nursing diagnosis risk for sensory deprivation is best suited for which client?
- A client’s chest tube has accidentally dislodged. What is the nursing action of highest priority?
Expert Answer: A chest tube falling out is an emergency. Immediately apply pressure to the chest tube insertion site and apply sterile gauze or place a sterile Jelonet gauze and dry dressing over the insertion site and ensure a tight seal. Apply to dress when the patient exhales. If a patient goes into respiratory distress, call a code. Notify primary health care provider to reinsert new chest tube drainage system.
- A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish?
Expert Answer: Remove the air that is present in the intrapleural space.
- Which of the following is an inappropriate nursing action by the surgical nurse?
- Which activity is the clearest example of the evaluation step in the nursing process? Expert Answer: checking the client’s blood pressure 30 minutes after administering captopril. Rationale: Evaluating is measuring the extent to which a patient achieved outcome.-if you don’t have a well-written goal, you will not be able to know if you were successful.
-need a goal to make an evaluation
- A client has a bone marrow biopsy done. Which nursing intervention is the priority post-procedure?
A nurse is providing care for a client recovering from gastric bypass surgery. During an assessment, the client exhibits pallor, perspiration, palpitations, headache, feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. The nurse suspects:
Expert Answers: Vasomotor symptoms associated with dumping syndromeEarly manifestations of dumping syndrome occur 15 to 30 minutes after eating. Signs and symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, diarrhea, nausea, and the desire to lie down.Dehiscence of the surgical wound is characterized by pain and a pulling or popping feeling at the surgical site. Peritonitis presents with a rigid, boardlike abdomen, tenderness, and fever. The client’s signs and symptoms aren’t a normal reaction to surgery.
- NSG 2400: What is the focus of nursing care for a newborn with respiratory distress syndrome (rds)?
Expert Answer: Temperature control is an important facet of the care of the infant with respiratory distress and both hypothermia and hyperthermia should be avoided. The temperature should be maintained in the neutral thermal range.
Nursing care focus on the following:
1. Keeping the infant in a warm environment
2. Turning the infant frequently to prevent apnea
3. Tapping the infant’s toes to stimulate deep breathing
4. Maintaining the infant’s oxygen administration level at the same rate
Which medication classification represents a proton (gastric acid) pump inhibitor?
Expert Answer: Omeprazole
Omeprazole decreases gastric acid by slowing the hydrogen-potassium adenosine triphosphatase pump on the surface of the parietal cells. Sucralfate is a cytoprotective drug. Famotidine is a histamine-2 receptor antagonist. Metronidazole is an antibiotic, specifically an amebicide.
- Which nursing diagnosis is most appropriate for an elderly client with poor dentition?
- Which nursing care should be provided to a client who has undergone unilateral adrenalectomy?
- What is an appropriate nursing intervention for a neonate with respiratory distress syndrome (rds)?
- The student nurse asks, “what is interstitial fluid?” What is the appropriate nursing response?
Expert Answer: Interstitial fluid is a fluid that fills the spaces around the cells. It comes from materials leaking out of blood vessels. Interstitial fluid is made up of salts, glucose, fatty acids, and minerals like magnesium, potassium, and calcium. It serves cells with oxygen and nutrients and also eliminates waste materials from them. The process of generating interstitial fluid is continuous, new Interstitial fluid replaces the old fluid, which drains in lymph vessels.
- What would be the priority nursing diagnosis for a patient who is prescribed epoetin alfa? Expert Answer: Before initiating Epogen. Following initiation of therapy and after each dose adjustment, monitor hemoglobin weekly until the hemoglobin level is stable and sufficient to minimize the need for RBC transfusion
- What is the nursing assessment process? Expert Answer: Nursing assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. Patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
- Which client situation most likely warrants a time-lapse nursing assessment? Expert Answer: An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse’s scheduled monthly visit.
- Which action will the nurse perform in the assessment phase of the nursing process? Expert Answer: Interaction with the patient is essential during the assessment phase. The nurse should talk to the patient and conduct an interview with the patient to ensure their medical history is complete. This should include family history and past medical events.
- What is the optimal nursing intervention to minimize perineal edema after an episiotomy?
- What are nursing interventions to promote/encourage clients’ coping in stressful situations?
- Which assessment finding would best support a nursing diagnosis of dysfunctional grieving? Expert Answer: The nurse should define dysfunctional grieving as the experience of distress, and accompanying sadness that fails to follow norms
- How to transfer a patient from one nursing home to another
- Which nursing action will best promote pain management for a client in the postoperative phase?
- Which nursing student would most likely be held liable for negligence?
- What is the priority nursing intervention during the admission of a primigravida in labor?
- What is the priority nursing intervention for a client with severe preeclampsia?
- What is the primary focus of nursing care in the “family as context” approach?
- Which is a true statement regarding the nursing considerations in the administration of metronidazole?
- The nurse is performing a nutritional assessment of an obese client who visits a weight control clinic. What information should the nurse take into consideration when planning a weight-reduction plan for this client? Expert Answer: Psychological reasons for overeating should be explored, such as eating as a release for boredom.
- Which statement regarding Roy’s theory of nursing needs correction? A. The Roy adaptation model views the environment as an adaptive system.
B. The need for nursing care occurs when the client cannot adapt to internal and external environmental demands.
C.The goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness.
D. All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.
Expert Answer: A
- An infant who underwent open repair of a fractured sternum now has a chest tube. What should the nurse explain to the parents concerning the chest tube? Expert Answers: •The infant will not feel any discomfort.
•It is inserted to drain the chest cavity of air.
•The tube has been inserted in case of an emergency.
•It will be removed when the infant tolerates feedings.
•It is inserted to drain the chest cavity of air.
- The nurse researches factors that may alter nutrition. Which statements accurately describe factors that influence nutritional status? Select all that apply. Expert Answer: •During pregnancy and lactation, nutrient requirements increase. • Nutritional needs per unit of body weight are greater in infancy than at any other time in life.
• Men and women differ in their nutrient requirements.
- Which nursing intervention is appropriate for a client with a closed-reduction extremity fracture?
- A client is admitted to the postanesthesia care unit after segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do?
Expert Answer: •Raise the drainage system to bed level and check its patency.
•Clamp the tube when moving the client from the bed to a chair.
•Mark the time and fluid level on the side of the drainage chamber.
•Secure the chest catheter to the wound dressing with a sterile safety pin
- Which general nursing measure is used for a client with a fracture reduction?
- Which nursing assessment finding indicates the client has not met expected outcomes?
- A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do?
Expert Answers: •Obtain a new sterile drainage system. •Use two clamps to close the drainage tube •Place the client in the high-Fowler position •Reconnect the client’s tube to the drainage system
- What purpose does block and parish nursing services in preventive and primary care services?
Expert Answers: Block and parish nursing provides services to older clients or those who are unable to leave their homes. Block and parish nursing provides primary care to a specific client population that lives in a specific community.
- A nurse is working in the pediatric unit. Which assignment best demonstrates primary care nursing?
Expert Answers: 1. Caring for the same child from admission to discharge
2. Caring for different children each shift to gain nursing experience
3. Taking vital signs of every child hospitalized in the unit
4. Assuming the charge nurse role instead of participating in direct child care
- A 5-year-old child is returned to the pediatric intensive care unit after cardiac surgery. The child has a left chest tube attached to water-seal drainage, an intravenous line running of D5½NS at 4 mL/hr, and a double-lumen nasogastric tube connected to continuous suction. A cardiac monitor is in place, as is a dressing on the left side of the chest dressing. What is the priority nursing intervention?
1. Auscultating breath sounds
2. Testing the level of consciousness
3. Measuring drainage from both tubes
4. Determining the suction pressure of the nasogastric tube
- Ms. Simpson, age 72 years, is being seen in the clinic with a suspected bladder tumor. These tumors occur more frequently in men than women and usually affect clients 50 years of age and older. The use of tobacco products is the leading cause of bladder cancer. You are asking Ms. Simpson about symptoms that she has had that brought her to the clinic. What is the most common first symptom of a malignant tumor of the bladder? a) Urgency
c) Painless hematuria
d) Dysuria Expert Answer: C Painless hematuria. The most common first symptom of a malignant tumor of the bladder is painless hematuria. Additional early symptoms include UTI with symptoms such as fever, dysuria, urgency, and frequency. Painless hematuria is the most common, however.