Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A child with severe anemia requires a unit of red blood cells (RBCs). The nurse explains to the child that the transfusion is necessary to:
A. help her body stop bleeding by forming a clot
Option A is incorrect because red blood cell transfusion is not given to help the body stop bleeding by forming a clot. Platelets are responsible for clot formation, not red blood cells.
B. Fight the infection that she now has
Option B is incorrect because a red blood cell transfusion is not used to fight infections. White blood cells and the immune system are responsible for fighting infections.
C. Increase her energy so she will not be so tired
Severe anemia is a condition characterized by a significant decrease in the number of red blood cells or hemoglobin in the blood, leading to reduced oxygen-carrying capacity. This can result in fatigue, weakness, and shortness of breath in the affected individual. A red blood cell transfusion is given to a child with severe anemia to increase the number of red blood cells and, consequently, the hemoglobin level in the blood. This helps improve oxygen delivery to tissues and organs, which can lead to increased energy levels and reduced fatigue.
D. allows her parents to come visit her
Option D is incorrect because a red blood cell transfusion is not given to allow her parents to come to visit her. Transfusions are medical treatments to address specific medical conditions and are not related to visitation rights.
This question is an excerpt from Nurse Dive's nursing test bank - SIMMONS U BSN PEDIATRICS PROCTORED EXAM. Take the full exam now
Full Explanation
Severe anemia is a condition characterized by a significant decrease in the number of red blood cells or hemoglobin in the blood, leading to reduced oxygen-carrying capacity. This can result in fatigue, weakness, and shortness of breath in the affected individual.
A red blood cell transfusion is given to a child with severe anemia to increase the number of red blood cells and, consequently, the hemoglobin level in the blood. This helps improve oxygen delivery to tissues and organs, which can lead to increased energy levels and reduced fatigue.
Option A is incorrect because red blood cell transfusion is not given to help the body stop bleeding by forming a clot. Platelets are responsible for clot formation, not red blood cells.
Option B is incorrect because a red blood cell transfusion is not used to fight infections. White blood cells and the immune system are responsible for fighting infections.
Option D is incorrect because a red blood cell transfusion is not given to allow her parents to come to visit her. Transfusions are medical treatments to address specific medical conditions and are not related to visitation rights.
Similar Questions
A parent tells a nurse that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that the toddler is at risk for which of the following disorders?
A. Obesity
Option A (Obesity) and option B (Diabetes mellitus) are not directly related to the toddler's milk consumption. Obesity may be a concern if the child consumes excessive calories overall, but it is not specifically associated with milk intake. Similarly, diabetes mellitus is not directly related to milk consumption.
B. Diabetes mellitus
Option A (Obesity) and option B (Diabetes mellitus) are not directly related to the toddler's milk consumption. Obesity may be a concern if the child consumes excessive calories overall, but it is not specifically associated with milk intake. Similarly, diabetes mellitus is not directly related to milk consumption.
C. Iron deficiency anemia
Consuming a large amount of milk, such as a quart a day, can lead to iron deficiency anemia in toddlers. Milk is a poor source of iron, and excessive milk intake can displace other iron-rich foods from the toddler's diet. Iron deficiency anemia occurs when the body lacks sufficient iron to produce enough hemoglobin, which is essential for oxygen transport in the blood. Toddlers are particularly vulnerable to iron deficiency anemia because they have increased iron needs for growth and development.
D. Rickets
Option D (Rickets) is caused by a deficiency of vitamin D, not iron. Rickets results in weakened and deformed bones, and it is usually associated with inadequate sunlight exposure and insufficient dietary vitamin D. While milk is often fortified with vitamin D, excessive milk intake can displace other vitamin D sources in the diet and contribute to an increased risk of rickets, but the primary concern with excessive milk intake is iron deficiency anemia.
Full Explanation
Consuming a large amount of milk, such as a quart a day, can lead to iron deficiency anemia in toddlers. Milk is a poor source of iron, and excessive milk intake can displace other iron-rich foods from the toddler's diet.
Iron deficiency anemia occurs when the body lacks sufficient iron to produce enough hemoglobin, which is essential for oxygen transport in the blood. Toddlers are particularly vulnerable to iron deficiency anemia because they have increased iron needs for growth and development.
Option A (Obesity) and option B (Diabetes mellitus) are not directly related to the toddler's milk consumption. Obesity may be a concern if the child consumes excessive calories overall, but it is not specifically associated with milk intake. Similarly, diabetes mellitus is not directly related to milk consumption.
Option D (Rickets) is caused by a deficiency of vitamin D, not iron. Rickets results in weakened and deformed bones, and it is usually associated with inadequate sunlight exposure and insufficient dietary vitamin D. While milk is often fortified with vitamin D, excessive milk intake can displace other vitamin D sources in the diet and contribute to an increased risk of rickets, but the primary concern with excessive milk intake is iron deficiency anemia.
A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer?
(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the dose of acetaminophen for a child, the nurse needs to convert the child's weight from pounds to kilograms and then multiply it by the prescribed dose per kilogram. The formula is:
Weight in kg = Weight in lb / 2.2
Dose in mg = Weight in kg x Dose per kg
Dose in mL = Dose in mg / Concentration in mg/mL
Using the given information, the nurse can plug in the values and solve for the dose in mL:
Weight in kg = 28 / 2.2 = 12.73
Dose in mg = 12.73 x 10 = 127.3
Dose in mL = 127.3 / 120 x 5 = 5.3
Therefore, the nurse should administer 5.3 mL of acetaminophen to the child.
A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?
A. 13% weight loss
Infants with severe dehydration can experience significant weight loss due to fluid loss through vomiting and diarrhea. A 13% weight loss indicates a severe degree of dehydration and is a crucial finding in assessing the severity of the condition.
B. Bulging anterior fontanel
While a bulging anterior fontanel can be a sign of increased intracranial pressure, it is not typically associated with severe dehydration. In fact, severe dehydration often leads to a sunken fontanel rather than a bulging one. However, it's important to note that a sunken fontanel would be a more expected finding in dehydration.
C. Bradypnea
Bradypnea refers to abnormally slow breathing rate. In severe dehydration, the body often responds with compensatory mechanisms such as increased respiratory rate (tachypnea) to maintain oxygen levels. Bradypnea is not a typical finding in severe dehydration unless there are other concurrent issues affecting respiratory function.
D. Capillary refill 3 seconds
Capillary refill time is a measure of peripheral perfusion. In severe dehydration, capillary refill time is usually prolonged (>3 seconds) due to decreased circulating volume. However, a capillary refill time of 3 seconds is within the normal range and may not necessarily indicate severe dehydration on its own.