Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in the emergency department is assessing a toddler who has hyperpyrexia, severe dyspnea, and is drooling.
Which of the following actions should the nurse take first?
A. Administer an antibiotic to the toddler.
Choice A is wrong because administering an antibiotic is not the priority intervention for a toddler with airway obstruction.
B. Obtain a blood culture from the toddler.
Choice B is wrong because obtaining a blood culture is not the priority intervention for a toddler with airway obstruction.
C. Insert an IV catheter for the toddler.
Choice C is wrong because inserting an IV catheter is not the priority intervention for a toddler with airway obstruction.
D. Prepare the toddler for nasotracheal intubation.
The nurse should prepare the toddler for nasotracheal intubation first because the toddler is experiencing severe dyspnea and drooling, which are signs of airway obstruction. Nasotracheal intubation will help to secure the toddler’s airway and improve their breathing.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Nursing Care of Children 2019 Proctored Exam. Take the full exam now
Full Explanation
The nurse should prepare the toddler for nasotracheal intubation first because the toddler is experiencing severe dyspnea and drooling, which are signs of airway obstruction.
Nasotracheal intubation will help to secure the toddler’s airway and improve their breathing.
Choice A is wrong because administering an antibiotic is not the priority intervention for a toddler with airway obstruction.
Choice B is wrong because obtaining a blood culture is not the priority intervention for a toddler with airway obstruction.
Choice C is wrong because inserting an IV catheter is not the priority intervention for a toddler with airway obstruction.
Similar Questions
A nurse is preparing to administer an enteral feeding to an adolescent who has an NG tube.
Which of the following actions should the nurse take first?
A. Flush the tube with water.
Choice A is wrong because flushing the tube with water should be done after confirming the placement of the NG tube.
B. Attach the feeding bag tubing to the end of the NG tube.
Choice B is wrong because attaching the feeding bag tubing to the end of the NG tube should be done after confirming the placement of the NG tube.
C. Check the pH of the gastric secretions.
The nurse should first check the pH of the gastric secretions to confirm the placement of the NG tube before administering the enteral feeding.
D. Set the administration rate on the feeding pump.
Choice D is wrong because setting the administration rate on the feeding pump should be done after confirming the placement of the NG tube.
Full Explanation
The nurse should first check the pH of the gastric secretions to confirm the placement of the NG tube before administering the enteral feeding.
Choice A is wrong because flushing the tube with water should be done after confirming the placement of the NG tube.
Choice B is wrong because attaching the feeding bag tubing to the end of the NG tube should be done after confirming the placement of the NG tube.
Choice D is wrong because setting the administration rate on the feeding pump should be done after confirming the placement of the NG tube.
A nurse is planning care for a school-age child who was admitted from the emergency department 2 hr ago.
Which of the following interventions should the nurse include to promote adequate sleep for the child?
A. Follow the child's home sleep routine to reduce anxiety.
Following the child’s home sleep routine can help reduce anxiety and promote adequate sleep. Children thrive on routine and consistency, and maintaining their usual sleep routine can provide a sense of familiarity and comfort in an unfamiliar environment.
B. Leave the lights on in the child's room to promote safety.
Choice B is wrong because leaving the lights on can disrupt the child’s sleep.
C. Allow the child to adjust their bedtime to promote autonomy.
Choice C is wrong because allowing the child to adjust their bedtime may disrupt their sleep routine and lead to inadequate sleep.
D. Provide the child with calming activities prior to bedtime to reduce stress.
Choice D is a good option, but following the child’s home sleep routine is the best way to promote adequate sleep.
Full Explanation
Following the child’s home sleep routine can help reduce anxiety and promote adequate sleep.
Children thrive on routine and consistency, and maintaining their usual sleep routine can provide a sense of familiarity and comfort in an unfamiliar environment.
Choice B is wrong because leaving the lights on can disrupt the child’s sleep.
Choice C is wrong because allowing the child to adjust their bedtime may disrupt their sleep routine and lead to inadequate sleep.
Choice D is a good option, but following the child’s home sleep routine is the best way to promote adequate sleep.
A nurse is performing a cranial nerve assessment on a school-age child.
Which of the following findings indicates proper functioning of the child's trigeminal nerve?
A. The child maintains balance when standing with eyes closed.
Choice A is wrong because it assesses the vestibulocochlear nerve, not the trigeminal nerve.
B. The child has symmetrical jaw strength when biting down.
The trigeminal nerve is responsible for sensation in the face and motor functions such as biting and chewing. Symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve.
C. The child exhibits a gag reflex when stimulated with a tongue blade.
Choice C is wrong because it assesses the glossopharyngeal and vagus nerves, not the trigeminal nerve.
D. The child correctly identifies specific scents.
Choice D is wrong because it assesses the olfactory nerve, not the trigeminal nerve.
Full Explanation
The trigeminal nerve is responsible for sensation in the face and motor functions such as biting and chewing.
Symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve.
Choice A is wrong because it assesses the vestibulocochlear nerve, not the trigeminal nerve.
Choice C is wrong because it assesses the glossopharyngeal and vagus nerves, not the trigeminal nerve.
Choice D is wrong because it assesses the olfactory nerve, not the trigeminal nerve.