Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing, and urticaria after receiving an IV medication. Which of the following actions should the nurse take first?
A. Administer methylprednisolone.
Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severeanaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.
B. Administer oxygen.
Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,low blood pressure, and hives.
C. Administer epinephrine.
This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.
D. Administer a nebulized bronchodilator.
Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first- line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing theallergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.
This question is an excerpt from Nurse Dive's nursing test bank - RN Nursing Care of Children 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
A. Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severe
anaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.
B. Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,
low blood pressure, and hives.
C. This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.
D. Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first-line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing the
allergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.
Similar Questions
A nurse is teaching the guardian of a 5-year-old child who has encopresis about the management of the condition. Which of the following statements by the guardian indicates an understanding of the teaching?
A. "I will have my child try to defecate 15 minutes after each meal."
This statement demonstrates an understanding of a helpful strategy for managing encopresis. Having the child try to defecate 15 minutes after each meal can take advantage of the body's natural reflexes and increase the likelihood of regular bowel movements.
B. "I will limit my child's fluid intake."
Limiting fluid intake is not a recommended strategy for managing encopresis. Maintaining proper hydration is important for overall health.
C. "I will have my child sit on the toilet for 20 minutes at a time."
Having the child sit on the toilet for extended periods of time may lead to frustration and aversion to toilet training. It is not a recommended approach.
D. "I will increase my child's dairy intake."
Increasing dairy intake is not a specific strategy for managing encopresis. In fact, some dairy products can contribute to constipation in some individuals. A balanced diet with an appropriate amount of fiber is important for bowel regularity.
Full Explanation
A. This statement demonstrates an understanding of a helpful strategy for managing encopresis. Having the child try to defecate 15 minutes after each meal can take advantage of the body's natural reflexes and increase the likelihood of regular bowel movements.
B. Limiting fluid intake is not a recommended strategy for managing encopresis.
Maintaining proper hydration is important for overall health.
C. Having the child sit on the toilet for extended periods of time may lead to frustration and aversion to toilet training. It is not a recommended approach.
D. Increasing dairy intake is not a specific strategy for managing encopresis. In fact, some dairy products can contribute to constipation in some individuals. A balanced diet with an appropriate amount of fiber is important for bowel regularity.
A nurse is communicating with a child who has hearing loss. Which of the following actions should the nurse take?
A. Change positions frequently to maintain the child's attention.
Changing positions frequently may be distracting and confusing for the child. It is important to find a comfortable and quiet environment for communication.
B. Exaggerate the pronunciation of words.
Exaggerating the pronunciation of words may distort the natural flow of speech and make it more difficult for the child to understand. It is best to speak clearly and at a normal pace.
C. Use light touch when initiating conversation.
Using light touch when initiating conversation is not effective for a child with hearing loss, as they rely primarily on visual and auditory cues for communication.
D. Maintain a neutral facial expression when speaking to the child.
This is the correct action. Maintaining a neutral facial expression allows the child to observe facial cues and expressions that are important for understanding non-verbal communication. It also helps create a comfortable and natural environment for conversation.
Full Explanation
A. Changing positions frequently may be distracting and confusing for the child. It is important to find a comfortable and quiet environment for communication.
B. Exaggerating the pronunciation of words may distort the natural flow of speech and make it more difficult for the child to understand. It is best to speak clearly and at a normal pace.
C. Using light touch when initiating conversation is not effective for a child with hearing loss, as they rely primarily on visual and auditory cues for communication.
D. This is the correct action. Maintaining a neutral facial expression allows the child to observe facial cues and expressions that are important for understanding non-verbal communication. It also helps create a comfortable and natural environment for conversation.
A nurse is caring for a school-age child who has pertussis. Which of the following actions should the nurse take?
A. Place the child in a protected environment for 48 hr.
Placing the child in a protected environment for 48 hours is not a necessary measure for managing pertussis. Pertussis is transmitted through respiratory droplets, and standard precautions are typically sufficient.
B. Administer the pertussis vaccine.
Administering the pertussis vaccine is a preventive measure, but it is not a treatment for an active infection. In this case, the child already has pertussis, so administering the vaccine will not address the current illness.
C. Restrict oral fluids to 500 mL per day.
Restricting oral fluids to 500 mL per day is not a recommended intervention for pertussis. Maintaining hydration is important, and fluid intake should be based on the child's needs.
D. Report the diagnosis to the public health department.
This is the correct action. Reporting the diagnosis of pertussis to the public health department is a crucial step in preventing the spread of the disease. It allows for contact tracing and appropriate public health measures to be implemented to limit furthertransmission.
Full Explanation
A. Placing the child in a protected environment for 48 hours is not a necessary measure for managing pertussis. Pertussis is transmitted through respiratory droplets, and standard precautions are typically sufficient.
B. Administering the pertussis vaccine is a preventive measure, but it is not a treatment for an active infection. In this case, the child already has pertussis, so administering the vaccine will not address the current illness.
C. Restricting oral fluids to 500 mL per day is not a recommended intervention for pertussis. Maintaining hydration is important, and fluid intake should be based on the child's needs.
D. This is the correct action. Reporting the diagnosis of pertussis to the public health department is a crucial step in preventing the spread of the disease. It allows for contact tracing and appropriate public health measures to be implemented to limit further
transmission.