Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an acute pediatric unit is assessing a 5-year-old child following an asthma event.
The child's caregiver expects the child to use an inhaler without supervision. The nurse can apply which of the following interventions as protective factors for the child?
A. Provide information on child development to the caregiver on when a child should be able to use an inhaler without supervision.
Providing information on child development helps the caregiver set realistic expectations about when a child is developmentally ready to self-administer medications independently.
B. Provide the child with a pamphlet on how to use an inhaler,
Giving a pamphlet to a 5-year-old is not effective, since children at this age typically cannot read or fully comprehend instructions.
C. Teach the child how to use the inhaler.
Teaching the child how to use the inhaler supports skill-building and fosters independence while still requiring supervision.
D. Refer the caregiver to the asthma educator.
Referring the caregiver to an asthma educator ensures they receive specialized guidance for ongoing asthma management.
E. Ask the caregiver, "what worries you about your child?"
Asking the caregiver about their worries encourages open communication, strengthens trust, and allows the nurse to address specific concerns.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Custom Nur209 Final Assessment Sp 2024 Proctored Exam. Take the full exam now
Full Explanation
A. Providing information on child development helps the caregiver set realistic expectations about when a child is developmentally ready to self-administer medications independently.
B. Giving a pamphlet to a 5-year-old is not effective, since children at this age typically cannot read or fully comprehend instructions.
C. Teaching the child how to use the inhaler supports skill-building and fosters independence while still requiring supervision.
D. Referring the caregiver to an asthma educator ensures they receive specialized guidance for ongoing asthma management.
E. Asking the caregiver about their worries encourages open communication, strengthens trust, and allows the nurse to address specific concerns.
Similar Questions
A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?
A. "I'll let my baby drain one breast at each feeding."
"I'll let my baby drain one breast at each feeding." This statement indicates understanding because allowing the baby to empty one breast at each feeding helps in relieving breast engorgement by effectively removing milk. It promotes better milk flow and prevents overproduction.
B. "I'll feed my baby every 2 hours."
Feeding the baby every 2 hours is a common recommendation, but it may not specifically address breast engorgement management.
C. "I'll apply cold compresses 20 minutes before each feeding."
Cold compresses can help reduce discomfort from engorgement, but they should be applied after feeding, not before.
D. "I'll try drinking an herbal tea to reduce the engorgement."
While herbal teas can sometimes provide relief for engorgement, this statement does not address the direct management of engorgement through breastfeeding techniques.
Full Explanation
A. "I'll let my baby drain one breast at each feeding."
Rationale:
A. "I'll let my baby drain one breast at each feeding." This statement indicates understanding because allowing the baby to empty one breast at each feeding helps in relieving breast engorgement by effectively removing milk. It promotes better milk flow and prevents overproduction.
B. Feeding the baby every 2 hours is a common recommendation, but it may not specifically address breast engorgement management.
C. Cold compresses can help reduce discomfort from engorgement, but they should be applied after feeding, not before.
D. While herbal teas can sometimes provide relief for engorgement, this statement does not address the direct management of engorgement through breastfeeding techniques.
A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?
A. Administer oxygen via face mask.
Administering oxygen to the mother increases oxygen delivery to the fetus and helps improve fetal oxygenation.
B. Position the client on her side.
Positioning the client on her side can sometimes help alleviate late decelerations by improving uterine perfusion, but administering oxygen is the priority intervention to address fetal hypoxiA.
C. Increase the infusion rate of the IV fluid.
Increasing IV fluid infusion rate may not directly address the underlying cause of late decelerations and may not improve fetal oxygenation.
D. Elevate the client's legs.
Elevating the client's legs is not a priority intervention for addressing late decelerations.Administering oxygen is more critical to improving fetal oxygenation in this situation.
Full Explanation
- A. Administer oxygen via face mask.
- Administering oxygen can be beneficial as it increases maternal oxygenation, which can improve fetal oxygenation. However, it is not the first-line action for late decelerations. Late decelerations are a sign of uteroplacental insufficiency, and while oxygen helps, repositioning the mother is more critical to address the root cause. Oxygen administration is a supportive measure but does not directly address the potential compression of the umbilical cord or placental perfusion issues.
- B. Position the client on her side.
Positioning the client on her side, specifically the left side, can improve uteroplacental circulation, addressing the cause of late decelerations. This position helps to relieve pressure on the inferior vena cava, enhancing blood flow to the placenta and fetus. It is a non-invasive, immediate intervention that can potentially correct the issue of late decelerations quickly.
- C. Increase the infusion rate of the IV fluid. Increasing the infusion rate of IV fluids can improve maternal blood volume, potentially improving placental perfusion. However, this action is not as immediate in effect as repositioning the client and is considered a secondary measure. It may be used in conjunction with other actions but should not be the priority intervention for late decelerations.
- D. Elevate the client's legs.
Elevating the client's legs can increase venous return to the heart, potentially improving maternal cardiac output and placental blood flow. However, this action is less effective than lateral positioning in addressing uteroplacental insufficiency. It is not the first-line response for late decelerations and may not provide the immediate correction needed.
A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?
A. Ask a psychiatrist to talk with the parents.
Asking a psychiatrist to talk with the parents may not be the most appropriate immediateaction when abuse is suspected. Reporting to the authorities should take precedence to ensure the child's safety.
B. Obtain a detailed history.
Obtaining a detailed history is important but should be done after reporting the suspected abuse to the authorities.
C. Separate the child from the parents.
Separating the child from the parents may not be feasible or appropriate in all situations.Reporting to the authorities is the priority action to ensure proper investigation and protection of the child.
D. Report the suspected abuse to the authorities.
Report the suspected abuse to the authorities. Suspected child abuse must be reportedimmediately to the appropriate authorities, such as child protective services or law enforcement, for further investigation and intervention to ensure the safety and well-being of the child.
Full Explanation
Rationale:
A. Asking a psychiatrist to talk with the parents may not be the most appropriate immediate
action when abuse is suspected. Reporting to the authorities should take precedence to ensure the child's safety.
B. Obtaining a detailed history is important but should be done after reporting the suspected abuse to the authorities.
C. Separating the child from the parents may not be feasible or appropriate in all situations.
Reporting to the authorities is the priority action to ensure proper investigation and protection of the child.
D. Report the suspected abuse to the authorities. Suspected child abuse must be reported
immediately to the appropriate authorities, such as child protective services or law enforcement, for further investigation and intervention to ensure the safety and well-being of the child.