Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 2-year-old child presents to the emergency department with a barking cough, stridor, and a hoarse voice that worsens at night. The child is afebrile but appears anxious and has labored breathing. The nurse suspects croup as the diagnosis. Which of the following interventions should the nurse prioritize to manage the child's symptoms and prevent further respiratory distress?
A. Administer a dose of oral antibiotics to treat the infection
Croup is usually viral in origin (most commonly parainfluenza virus), so antibiotics are not indicated unless there is evidence of a secondary bacterial infection. Routine antibiotic administration does not improve viral croup and can contribute to antibiotic resistance.
B. Place the child in a supine position to facilitate airflow to the lungs
Placing the child in a supine position may worsen airway obstruction and increase respiratory effort. Children with croup often assume an upright or sitting position to maximize airway patency and ease breathing.
C. Encourage the child to lie down to conserve energy
Encouraging the child to lie down to conserve energy is not appropriate. Lying down can exacerbate airway obstruction in croup, increase stridor, and worsen respiratory distress.
D. Provide a cool mist humidifier or take the child outside into cool night air
Providing a cool mist humidifier or taking the child outside into cool night air helps reduce airway inflammation and swelling in the upper airway. Cool air can soothe the larynx, decrease stridor, and ease the barking cough. These noninvasive measures are first-line interventions to manage mild to moderate croup and prevent progression to severe respiratory distress. Supporting the child in an upright, calm position while monitoring oxygenation and respiratory effort is also essential.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Demsn 650 Pediatrics Proctored Exam. Take the full exam now
Full Explanation
A. Croup is usually viral in origin (most commonly parainfluenza virus), so antibiotics are not indicated unless there is evidence of a secondary bacterial infection. Routine antibiotic administration does not improve viral croup and can contribute to antibiotic resistance.
B. Placing the child in a supine position may worsen airway obstruction and increase respiratory effort. Children with croup often assume an upright or sitting position to maximize airway patency and ease breathing.
C. Encouraging the child to lie down to conserve energy is not appropriate. Lying down can exacerbate airway obstruction in croup, increase stridor, and worsen respiratory distress.
D. Providing a cool mist humidifier or taking the child outside into cool night air helps reduce airway inflammation and swelling in the upper airway. Cool air can soothe the larynx, decrease stridor, and ease the barking cough. These noninvasive measures are first-line interventions to manage mild to moderate croup and prevent progression to severe respiratory distress. Supporting the child in an upright, calm position while monitoring oxygenation and respiratory effort is also essential.
Similar Questions
A 30-year-old Rh-negative pregnant woman is at 17 weeks gestation and has an Rh-positive partner. She has had no prior sensitization. She asks the nurse when she will receive Rho(D) immune globulin. Which of the following is the best response?
A. "Rho(D) immune globulin is only given after delivery, so you don't need it now."
Rho(D) immune globulin is not given only after delivery. Administering it after delivery alone prevents sensitization for future pregnancies but does not provide prophylaxis during the current pregnancy.
B. "You only need Rho(D) immune globulin after your second pregnancy"
The woman does not only receive Rho(D) immune globulin after her second pregnancy. Prophylaxis is necessary during the current pregnancy if she is Rh-negative and the fetus is at risk of being Rh-positive.
C. You will receive Rho(D) immune globulin monthly during pregnancy and then after 72 hours after delivery"
Rho(D) immune globulin is not given monthly during pregnancy. Standard prophylaxis involves a scheduled dose at 28 weeks gestation, with an additional dose postpartum if the newborn is Rh-positive. More frequent dosing is only indicated if there is a significant risk of fetal-maternal hemorrhage (e.g., miscarriage, trauma, amniocentesis).
D. "You will receive Rho(D) immune globulin at 28 weeks of pregnancy and again within 72 hours after delivery if your baby is Rh-positive to prevent your immune system from becoming sensitized."
The recommended schedule for Rh-negative women without prior sensitization is to receive a prophylactic dose of Rho(D) immune globulin at 28 weeks gestation and again within 72 hours after delivery if the newborn is Rh-positive. This prevents the mother’s immune system from producing antibodies against Rh-positive fetal red blood cells, reducing the risk of hemolytic disease in current or future pregnancies. Administration is also indicated after events that increase fetal-maternal blood mixing.
Full Explanation
A. Rho(D) immune globulin is not given only after delivery. Administering it after delivery alone prevents sensitization for future pregnancies but does not provide prophylaxis during the current pregnancy.
B. The woman does not only receive Rho(D) immune globulin after her second pregnancy. Prophylaxis is necessary during the current pregnancy if she is Rh-negative and the fetus is at risk of being Rh-positive.
C. Rho(D) immune globulin is not given monthly during pregnancy. Standard prophylaxis involves a scheduled dose at 28 weeks gestation, with an additional dose postpartum if the newborn is Rh-positive. More frequent dosing is only indicated if there is a significant risk of fetal-maternal hemorrhage (e.g., miscarriage, trauma, amniocentesis).
D. The recommended schedule for Rh-negative women without prior sensitization is to receive a prophylactic dose of Rho(D) immune globulin at 28 weeks gestation and again within 72 hours after delivery if the newborn is Rh-positive. This prevents the mother’s immune system from producing antibodies against Rh-positive fetal red blood cells, reducing the risk of hemolytic disease in current or future pregnancies. Administration is also indicated after events that increase fetal-maternal blood mixing.
The nurse is performing an assessment on a pregnant patient with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?
A. Complaints of feeling hot when the room is cold.
Feeling hot when the room is cold is not a typical sign or complication of severe preeclampsia. This symptom is more related to general temperature sensitivity and does not indicate the hematologic or vascular complications associated with preeclampsia.
B. Evidence of bleeding, such as in gums, petechiae, and purpura.
Evidence of bleeding, including gums bleeding, petechiae, and purpura, may indicate thrombocytopenia or a progression toward HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a severe complication of preeclampsia. These findings suggest impaired coagulation and increased risk of bleeding, which are life-threatening if not promptly managed. Monitoring for such hematologic complications is essential in severe preeclampsia.
C. Edema of the lower extremities.
Edema of the lower extremities is common in normal pregnancy and mild preeclampsia, but it is not a specific sign of a serious complication. While generalized edema can indicate worsening preeclampsia, isolated lower-extremity edema is not as closely associated with life-threatening complications as bleeding or hematologic abnormalities.
D. Periods of fetal movement followed by quiet periods.
Periods of fetal movement followed by quiet periods are typical fetal behavior and do not indicate a maternal complication of preeclampsia. Monitoring for changes in fetal movement is important, but this finding alone does not reflect maternal complications of severe preeclampsia.
Full Explanation
A. Feeling hot when the room is cold is not a typical sign or complication of severe preeclampsia. This symptom is more related to general temperature sensitivity and does not indicate the hematologic or vascular complications associated with preeclampsia.
B. Evidence of bleeding, including gums bleeding, petechiae, and purpura, may indicate thrombocytopenia or a progression toward HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a severe complication of preeclampsia. These findings suggest impaired coagulation and increased risk of bleeding, which are life-threatening if not promptly managed. Monitoring for such hematologic complications is essential in severe preeclampsia.
C. Edema of the lower extremities is common in normal pregnancy and mild preeclampsia, but it is not a specific sign of a serious complication. While generalized edema can indicate worsening preeclampsia, isolated lower-extremity edema is not as closely associated with life-threatening complications as bleeding or hematologic abnormalities.
D. Periods of fetal movement followed by quiet periods are typical fetal behavior and do not indicate a maternal complication of preeclampsia. Monitoring for changes in fetal movement is important, but this finding alone does not reflect maternal complications of severe preeclampsia.
A nurse is reviewing the provider's plan of care for an 8-year-old child whose height has dropped from the 25th percentile to the 5th percentile over the past year. The parents ask what test can help determine whether their child's bone growth is delayed. Which diagnostic test should the nurse anticipate?
A. Routine abdominal ultrasound
A routine abdominal ultrasound is not used to assess bone age or growth delays. While abdominal ultrasounds can detect organ abnormalities, they provide no information about skeletal maturation.
B. Complete blood count (CBC)
A complete blood count (CBC) evaluates blood cell levels and can detect anemia or infection, but it does not provide information about bone growth or skeletal development.
C. Hand-wrist X-ray
A hand-wrist X-ray is the standard diagnostic test to assess bone age and skeletal maturation. By comparing the X-ray of the child’s hand and wrist bones to standardized age-related charts (such as the Greulich and Pyle atlas), providers can determine if the child’s skeletal growth is appropriate for chronological age. This helps identify growth delays, endocrine disorders, or other conditions affecting stature.
D. Anthropometric hand-wrist measurement
Anthropometric hand-wrist measurement refers to physical measurements of the hand and wrist, which do not provide sufficient information to determine bone age or detect growth delays. X-ray imaging is required for accurate assessment of skeletal maturity.
Full Explanation
A. A routine abdominal ultrasound is not used to assess bone age or growth delays. While abdominal ultrasounds can detect organ abnormalities, they provide no information about skeletal maturation.
B. A complete blood count (CBC) evaluates blood cell levels and can detect anemia or infection, but it does not provide information about bone growth or skeletal development.
C. A hand-wrist X-ray is the standard diagnostic test to assess bone age and skeletal maturation. By comparing the X-ray of the child’s hand and wrist bones to standardized age-related charts (such as the Greulich and Pyle atlas), providers can determine if the child’s skeletal growth is appropriate for chronological age. This helps identify growth delays, endocrine disorders, or other conditions affecting stature.
D. Anthropometric hand-wrist measurement refers to physical measurements of the hand and wrist, which do not provide sufficient information to determine bone age or detect growth delays. X-ray imaging is required for accurate assessment of skeletal maturity.