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NurseDive Free Nursing Practice Question
A 7-year-old female child admitted to pre-op for scheduled surgery. Focused assessment completed. Lung sounds are clear to auscultation (CTA), heart sounds clear with normal sinus rhythm, skin clear with no breakdown.
- Abdomen soft with bowel sounds heard in all 4 quadrants.
- A feeding tube is present on the abdomen
- Site is clean and clear.
- Consents for surgery signed by parent at preadmission visit.
- Peripheral IV (PIV) 22 gauge inserted in right forearm with assistance from another nurse.
- Cried throughout procedure.
- Comforted by parent and use of touch music.
- IV fluids at 75 mL/hr started.
Client transported to operating room (OR) and The nurse is developing the plan of care for the child. To provide atraumatic care for this child post-operatively, what will be the priority?
A. Pain assessments
Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child. The child cried throughout the procedure and will likely experience discomfort and pain after the surgery. It is important to assess the child's pain levels regularly using appropriate pain assessment tools and provide appropriate pain management interventions to ensure their comfort and well-being. While antibiotics may be prescribed if there is a surgical site infection or specific indications for their use, it is not mentioned as a priority in this scenario. The focus is on providing atraumatic care post-operatively, and pain assessment takes precedence. Occupational therapy, physical therapy, and wound care are important components of the child's overall care, but they may not be the immediate priority post-operatively. These interventions can be incorporated into the plan of care as needed, but addressing pain is of utmost importance in the immediate post-operative period.
B. Antibiotics
C. Occupational therapy
D. Wound care
E. Physical therapy
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Full Explanation
Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child. The child cried throughout the procedure and will likely experience discomfort and pain after the surgery. It is important to assess the child's pain levels regularly using appropriate pain assessment tools and provide appropriate pain management interventions to ensure their comfort and well-being.
While antibiotics may be prescribed if there is a surgical site infection or specific indications for their use, it is not mentioned as a priority in this scenario. The focus is on providing atraumatic care post-operatively, and pain assessment takes precedence.
Occupational therapy, physical therapy, and wound care are important components of the child's overall care, but they may not be the immediate priority post-operatively.
These interventions can be incorporated into the plan of care as needed, but addressing pain is of utmost importance in the immediate post-operative period.
Similar Questions
The client is a 7-year-old with spastic cerebral palsy (CP) admitted to pre-op for heel cord lengthening. Child has cognitive and speech delays. Experiences absent seizures numerous times daily according to parent. Surgery went well for bilateral heel cords lengthening. The nurse is updating the plan of care.
Select 5 findings that would require immediate action prior to the nurse administering this pain medication
A. Correct dosage of medication
Before administering pain medication, the nurse must verify that the prescribed dosage is appropriate for the child's age, weight, and condition. Ensuring the correct dosage helps prevent medication errors and potential adverse effects.
B. Vital signs with SaO2
It is important to assess the child's vital signs, including oxygen saturation (SaO2), to ensure their stability and identify any signs of respiratory distress or other abnormalities that may impact medication administration.
C. Pain report from parent
Considering the child has cognitive and speech delays, the input from the parent regarding the child's pain is valuable. The nurse should assess and consider the parent's report of the child's pain in conjunction with other assessment findings to ensure effective pain management.
D. Valid pain assessment tool
It is important to use a validated pain assessment tool that is appropriate for the child's age and cognitive abilities. This allows for a comprehensive and accurate assessment of the child's pain level, helping guide appropriate pain management interventions.
E. Identify allergies
Prior to administering any medication, it is crucial to verify if the child has any known allergies to medications. This information is essential for ensuring the safety of the child and preventing any potential allergic reactions.
F. Subjective pain assessment
Subjective pain assessment is mentioned as a finding but may not require immediate action, as it needs to be combined with other assessment data for a comprehensive evaluation.
Full Explanation
It is important to assess the child's vital signs, including oxygen saturation (SaO2), to ensure their stability and identify any signs of respiratory distress or other abnormalities that may impact medication administration.
Prior to administering any medication, it is crucial to verify if the child has any known allergies to medications. This information is essential for ensuring the safety of the child and preventing any potential allergic reactions.
Before administering pain medication, the nurse must verify that the prescribed dosage is appropriate for the child's age, weight, and condition. Ensuring the correct dosage helps prevent medication errors and potential adverse effects.
It is important to use a validated pain assessment tool that is appropriate for the child's age and cognitive abilities. This allows for a comprehensive and accurate assessment of the child's pain level, helping guide appropriate pain management interventions.
Considering the child has cognitive and speech delays, the input from the parent regarding the child's pain is valuable. The nurse should assess and consider the parent's report of the child's pain in conjunction with other assessment findings to ensure effective pain management.
Subjective pain assessment is mentioned as a finding but may not require immediate action, as it needs to be combined with other assessment data for a comprehensive evaluation.
A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL (109 g/L), hematocrit 29% (0.29), hepatitis surface antigen positive, group B Streptococcus positive, and rubella non- immune.
Which intervention should the nurse implement?
Reference Range
- Hemaglobin [Reference Range:12-16 g/dL (120-160 g/L)]
- Hematrocrit [Reference Range:Pregnant female: 37% to 47% (0.37 to 0.47 volume fraction)] Hepatitis Surface Antigen [Reference Range: negative]
- Group B Streptococcus [Reference Range: negative]
A. Transfuse two units packed red blood cells.
Transfusion of packed red blood cells is not indicated based on the hemoglobin and hematocrit values provided. The client's hemoglobin and hematocrit levels, although lower than the reference range, are not critically low and do not necessarily require a blood transfusion.
B. Administer ampicillin 2 grams intravenously.
The client's labs indicate that she has a positive result for group B Streptococcus (GBS) and hepatitis surface antigen, and she is also identified as rubella non-immune. Ampicillin is the recommended antibiotic for intrapartum prophylaxis against GBS infection to reduce the risk of transmission to the newborn. Administering ampicillin intravenously would help protect the newborn from potential GBS-related complications.
C. Inject hepatitis B immune globulin 0.5 mL.
Injecting hepatitis B immune globulin is not the appropriate intervention in this case. The client is positive for hepatitis surface antigen, indicating active infection, and requires appropriate medical management, which may include antiviral treatment.
D. Give measles, mumps, rubella vaccine 0.5 mL.
Administering the measles, mumps, rubella vaccine is contraindicated during pregnancy. Vaccination for rubella is typically recommended prior to conception or postpartum to prevent congenital rubella syndrome.
Full Explanation
The client's labs indicate that she has a positive result for group B Streptococcus (GBS) and hepatitis surface antigen, and she is also identified as rubella non-immune.
Ampicillin is the recommended antibiotic for intrapartum prophylaxis against GBS infection to reduce the risk of transmission to the newborn. Administering ampicillin intravenously would help protect the newborn from potential GBS-related complications. Transfusion of packed red blood cells is not indicated based on the hemoglobin and hematocrit values provided. The client's hemoglobin and hematocrit levels, although lower than the reference range, are not critically low and do not necessarily require a blood transfusion.
Injecting hepatitis B immune globulin is not the appropriate intervention in this case. The client is positive for hepatitis surface antigen, indicating active infection, and requires appropriate medical management, which may include antiviral treatment.
Administering the measles, mumps, rubella vaccine is contraindicated during pregnancy. Vaccination for rubella is typically recommended prior to conception or postpartum to prevent congenital rubella syndrome.
The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity?
A. Low bioavailability.
Low bioavailability refers to the fraction of an administered dose that reaches the systemic circulation in an active form. While low bioavailability can affect the effectiveness of a drug, it does not directly imply a need for closer monitoring for drug toxicity.
B. Short half life.
Short half-life refers to the time it takes for half of the drug concentration in the body to be eliminated. While drugs with short half-lives may require more frequent dosing, this property does not inherently suggest a need for closer monitoring for drug toxicity.
C. Highly protein bound.
The property of the drugs that, if shared by both, indicates a need to closely monitor the client for drug toxicity is: Highly protein bound. When a drug is highly protein bound, it means that a significant portion of the drug molecules bind to proteins in the bloodstream. This binding can affect the availability and distribution of the drug in the body. If two drugs are highly protein bound and administered together, they may compete for binding sites on the proteins, leading to increased levels of unbound (free) drug in the bloodstream. This can result in higher drug concentrations and an increased risk of drug toxicity. Closely monitoring the client for drug toxicity is necessary when drugs are highly protein bound because there is a potential for increased drug levels and associated adverse effects. Monitoring for signs and symptoms of drug toxicity, as well as routine laboratory tests to assess liver and kidney function, may be necessary in these cases.
D. High therapeutic index.
High therapeutic index indicates a wide margin of safety for a drug, meaning that the effective dose is significantly lower than the toxic dose. A high therapeutic index implies that the drug has a wide safety margin and is less likely to cause drug toxicity.
Full Explanation
The property of the drugs that, if shared by both, indicates a need to closely monitor the client for drug toxicity is:
Highly protein bound.
When a drug is highly protein bound, it means that a significant portion of the drug molecules bind to proteins in the bloodstream. This binding can affect the availability and distribution of the drug in the body. If two drugs are highly protein bound and administered together, they may compete for binding sites on the proteins, leading to increased levels of unbound (free) drug in the bloodstream. This can result in higher drug concentrations and an increased risk of drug toxicity.
Closely monitoring the client for drug toxicity is necessary when drugs are highly protein bound because there is a potential for increased drug levels and associated adverse effects. Monitoring for signs and symptoms of drug toxicity, as well as routine laboratory tests to assess liver and kidney function, may be necessary in these cases.
The other properties listed do not necessarily indicate a need for closer monitoring for drug toxicity:
- Low bioavailability refers to the fraction of an administered dose that reaches the systemic circulation in an active form. While low bioavailability can affect the effectiveness of a drug, it does not directly imply a need for closer monitoring for drug toxicity.
- Short half-life refers to the time it takes for half of the drug concentration in the body to be eliminated. While drugs with short half-lives may require more frequent dosing, this property does not inherently suggest a need for closer monitoring for drug toxicity.
- High therapeutic index indicates a wide margin of safety for a drug, meaning that the effective dose is significantly lower than the toxic dose. A high therapeutic index implies that the drug has a wide safety margin and is less likely to cause drug toxicity.