Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. The child's oxygen saturation is 96% on room air.
The child's oxygen saturation is 96% on room air. This is a normal oxygen saturation level for an infant on room air and does not indicate neurological impairment. Normal oxygen saturation levels are typically between 95% and 100%.
B. The child reports pain as 8 on a scale of 0 to 10.
The child reports pain as 8 on a scale of 0 to 10. A 6-month-old infant cannot verbally report pain on a numeric scale. Pain assessment in infants is typically done using behavioral and physiological indicators, not a numeric scale. This choice is not relevant for this age group.
C. The child is drowsy but responds immediately to verbal stimuli.
The child is drowsy but responds immediately to verbal stimuli. This could be an indication of neurological impairment. While infants can sleep a lot, being excessively drowsy and requiring verbal stimuli to respond could suggest an altered level of consciousness, which warrants further assessment for potential neurological issues.
D. The child's blood pressure is 100/60 mm Hg.
The child's blood pressure is 100/60 mm Hg. This is within normal limits for a 6-month-old infant and does not indicate neurological impairment. Normal blood pressure for infants ranges from about 70-100/50-65 mm Hg.
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Full Explanation
A. The child's oxygen saturation is 96% on room air. This is a normal oxygen saturation level for an infant on room air and does not indicate neurological impairment. Normal oxygen saturation levels are typically between 95% and 100%.
B. The child reports pain as 8 on a scale of 0 to 10. A 6-month-old infant cannot verbally report pain on a numeric scale. Pain assessment in infants is typically done using behavioral and physiological indicators, not a numeric scale. This choice is not relevant for this age group.
C. The child is drowsy but responds immediately to verbal stimuli. This could be an indication of neurological impairment. While infants can sleep a lot, being excessively drowsy and requiring verbal stimuli to respond could suggest an altered level of consciousness, which warrants further assessment for potential neurological issues.
D. The child's blood pressure is 100/60 mm Hg. This is within normal limits for a 6-month-old infant and does not indicate neurological impairment. Normal blood pressure for infants ranges from about 70-100/50-65 mm Hg.
Similar Questions
A nurse is planning care for a school-age child following the application of a plaster cast for a right forearm fracture. Which of the following interventions should the nurse plan to implement?
A. Apply plastic covering to the cast until dry.
Apply plastic covering to the cast until dry. Covering the cast with plastic can cause moisture accumulation, which can delay drying and increase the risk of infection and skin irritation. The cast should be allowed to dry naturally and in a well-ventilated area.
B. Apply pieces of moleskin around the edges of the cast.
Apply pieces of moleskin around the edges of the cast. Applying moleskin around the edges of the cast helps to protect the skin from irritation and potential injury from the rough edges of the cast. This is an appropriate intervention.
C. Use tips of fingers to reposition the cast until dry.
Use tips of fingers to reposition the cast until dry. Using the tips of fingers to handle the cast while it is drying can create indentations, leading to pressure points and potential skin breakdown. The cast should be handled with the palms of the hands to avoid indentations.
D. Maintain casted extremity below heart level.
Maintain casted extremity below heart level. The casted extremity should be elevated above heart level, especially in the first 24-48 hours, to reduce swelling and promote venous return. Keeping it below heart level can increase swelling.
Full Explanation
A. Apply plastic covering to the cast until dry. Covering the cast with plastic can cause moisture accumulation, which can delay drying and increase the risk of infection and skin irritation. The cast should be allowed to dry naturally and in a well-ventilated area.
B. Apply pieces of moleskin around the edges of the cast. Applying moleskin around the edges of the cast helps to protect the skin from irritation and potential injury from the rough edges of the cast. This is an appropriate intervention.
C. Use tips of fingers to reposition the cast until dry. Using the tips of fingers to handle the cast while it is drying can create indentations, leading to pressure points and potential skin breakdown. The cast should be handled with the palms of the hands to avoid indentations.
D. Maintain casted extremity below heart level. The casted extremity should be elevated above heart level, especially in the first 24-48 hours, to reduce swelling and promote venous return. Keeping it below heart level can increase swelling.
A nurse is caring for an infant who weighs 7.8 kg (17.2 lb) and was admitted yesterday for treatment of moderate dehydration. Which of the following findings indicates to the nurse that the infant's condition is improving?
A. Respiratory rate 70/min
Respiratory rate 70/min: A respiratory rate of 70/min is high for an infant and may indicate ongoing respiratory distress or other issues. Normal respiratory rates for infants are generally 30-60 breaths per minute. This does not indicate improvement.
B. Capillary refill is greater than 3 seconds.
Capillary refill is greater than 3 seconds. Capillary refill time greater than 3 seconds indicates poor perfusion, which can be a sign of continued dehydration or shock. This does not indicate improvement.
C. Dry mucous membranes
Dry mucous membranes: Dry mucous membranes are a sign of dehydration. For an infant's condition to be improving, mucous membranes should be moist.
D. Fontanelle is level and soft.
Fontanelle is level and soft. A level and soft fontanelle indicates that the infant is likely well-hydrated. Sunken fontanelles are a sign of dehydration, so this finding suggests improvement in the infant’s hydration status.
Full Explanation
A. Respiratory rate 70/min: A respiratory rate of 70/min is high for an infant and may indicate ongoing respiratory distress or other issues. Normal respiratory rates for infants are generally 30-60 breaths per minute. This does not indicate improvement.
B. Capillary refill is greater than 3 seconds. Capillary refill time greater than 3 seconds indicates poor perfusion, which can be a sign of continued dehydration or shock. This does not indicate improvement.
C. Dry mucous membranes: Dry mucous membranes are a sign of dehydration. For an infant's condition to be improving, mucous membranes should be moist.
D. Fontanelle is level and soft. A level and soft fontanelle indicates that the infant is likely well-hydrated. Sunken fontanelles are a sign of dehydration, so this finding suggests improvement in the infant’s hydration status.
A nurse in a pediatric clinic is assessing a 6-month-old infant. Which of the following findings should the nurse identify as an indication of a visual Impairment?
A. The infant reacts to bright light.
The infant reacts to bright light. Reacting to bright light is a normal response and indicates that the infant can see. This does not indicate a visual impairment.
B. The infant's corneal light reflex is symmetrical.
The infant's corneal light reflex is symmetrical. A symmetrical corneal light reflex indicates proper eye alignment and does not suggest a visual impairment.
C. The infant does not fixate and follow an object.
The infant does not fixate and follow an object. By 6 months, an infant should be able to fixate on and follow an object. Failure to do so can be an indication of a visual impairment.
D. The infant's red reflex is present bilaterally.
The infant's red reflex is present bilaterally. A normal red reflex in both eyes indicates that the eyes are clear and healthy. Absence of the red reflex could suggest a problem, but its presence does not indicate impairment.
Full Explanation
A. The infant reacts to bright light. Reacting to bright light is a normal response and indicates that the infant can see. This does not indicate a visual impairment.
B. The infant's corneal light reflex is symmetrical. A symmetrical corneal light reflex indicates proper eye alignment and does not suggest a visual impairment.
C. The infant does not fixate and follow an object. By 6 months, an infant should be able to fixate on and follow an object. Failure to do so can be an indication of a visual impairment.
D. The infant's red reflex is present bilaterally. A normal red reflex in both eyes indicates that the eyes are clear and healthy. Absence of the red reflex could suggest a problem, but its presence does not indicate impairment.