Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a school-age child who is receiving IV fluids to treat dehydration. Which of the following findings should indicate to the nurse that the fluid replacement therapy has been effective?
A. Capillary refill less than 2 seconds
"Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.
B. Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)
"Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.
C. Voiding less than 1 mL/kg/hr
"Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.
D. Tachycardia
"Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.
This question is an excerpt from Nurse Dive's nursing test bank - Ati rn paediatrics nursing proctored exam 2023. Take the full exam now
Full Explanation
A. "Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.
B. "Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.
C. "Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.
D. "Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.
Similar Questions
A nurse in a clinic is assessing an infant who has diarrhea, is lethargic, and has dry skin. Which of the following findings indicates moderate dehydration?
A. Decreased respiratory rate
"Decreased respiratory rate." Moderate dehydration typically causes tachypnea (increased respiratory rate), not a decreased respiratory rate. This is the body's response to metabolic acidosis caused by fluid loss.
B. Bulging anterior fontanel
"Bulging anterior fontanel." A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel due to fluid loss.
C. Mottled skin
"Mottled skin." Mottled skin can be a sign of severe dehydration or shock, but it is not a definitive indicator of moderate dehydration.
D. Capillary refill 3 seconds
"Capillary refill 3 seconds." A capillary refill time of 2–3 seconds is indicative of moderate dehydration. In severe dehydration, capillary refill would be greater than 4 seconds.
Full Explanation
A. "Decreased respiratory rate." Moderate dehydration typically causes tachypnea (increased respiratory rate), not a decreased respiratory rate. This is the body's response to metabolic acidosis caused by fluid loss.
B. "Bulging anterior fontanel." A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel due to fluid loss.
C. "Mottled skin." Mottled skin can be a sign of severe dehydration or shock, but it is not a definitive indicator of moderate dehydration.
D. "Capillary refill 3 seconds." A capillary refill time of 2–3 seconds is indicative of moderate dehydration. In severe dehydration, capillary refill would be greater than 4 seconds.
A nurse is caring for a child who is to receive the first dose of IV gentamicin. Which of the following actions should the nurse take?
A. Monitor for constipation.
"Monitor for constipation." Constipation is not a common adverse effect of gentamicin. More concerning side effects include nephrotoxicity and ototoxicity.
B. Maintain strict 1&O.
"Maintain strict I&O." Gentamicin can cause nephrotoxicity, so it is essential to monitor intake and output (I&O) closely to assess kidney function and detect early signs of renal impairment.
C. Initiate airborne precautions.
"Initiate airborne precautions." Gentamicin is an antibiotic and does not require airborne precautions. Airborne precautions are used for infections like tuberculosis, measles, and varicella.
D. Encourage bed rest.
"Encourage bed rest." Gentamicin does not require bed rest. However, if the child experiences dizziness due to ototoxicity (another adverse effect), activity may need to be limited.
Full Explanation
A. "Monitor for constipation." Constipation is not a common adverse effect of gentamicin. More concerning side effects include nephrotoxicity and ototoxicity.
B. "Maintain strict I&O." Gentamicin can cause nephrotoxicity, so it is essential to monitor intake and output (I&O) closely to assess kidney function and detect early signs of renal impairment.
C. "Initiate airborne precautions." Gentamicin is an antibiotic and does not require airborne precautions. Airborne precautions are used for infections like tuberculosis, measles, and varicella.
D. "Encourage bed rest." Gentamicin does not require bed rest. However, if the child experiences dizziness due to ototoxicity (another adverse effect), activity may need to be limited.
A nurse is providing teaching to the guardian of a school-age child who has acute diarrhea. Which of the following instructions should the nurse include in the teaching?
A. Provide chicken or beef broth until the diarrhea subsides.
"Provide chicken or beef broth until the diarrhea subsides." Broth can be high in sodium, which is not ideal for rehydrating a child with diarrhea. Clear fluids and oral rehydration solutions are better choices.
B. Encourage intake of carbonated beverages diluted with water.
"Encourage intake of carbonated beverages diluted with water." Carbonated beverages can irritate the stomach and exacerbate diarrhea. Instead, clear fluids or oral rehydration solutions are recommended.
C. Provide the child with a bananas, rice, applesauce, and toast (BRAT) diet.
"Provide the child with a bananas, rice, applesauce, and toast (BRAT) diet." The BRAT diet is outdated and not recommended anymore because it lacks essential nutrients. Instead, the child should be provided with a balanced diet, including foods like rice, potatoes, and lean meats, along with fluids for rehydration.
D. Administer oral hydration solution after each diarrheal stool.
"Administer oral hydration solution after each diarrheal stool." Oral rehydration solutions (ORS) help replace lost fluids and electrolytes. Administering ORS after each stool helps prevent dehydration, which is a common complication of diarrhea.
Full Explanation
A. "Provide chicken or beef broth until the diarrhea subsides." Broth can be high in sodium, which is not ideal for rehydrating a child with diarrhea. Clear fluids and oral rehydration solutions are better choices.
B. "Encourage intake of carbonated beverages diluted with water." Carbonated beverages can irritate the stomach and exacerbate diarrhea. Instead, clear fluids or oral rehydration solutions are recommended.
C. "Provide the child with a bananas, rice, applesauce, and toast (BRAT) diet." The BRAT diet is outdated and not recommended anymore because it lacks essential nutrients. Instead, the child should be provided with a balanced diet, including foods like rice, potatoes, and lean meats, along with fluids for rehydration.
D. "Administer oral hydration solution after each diarrheal stool." Oral rehydration solutions (ORS) help replace lost fluids and electrolytes. Administering ORS after each stool helps prevent dehydration, which is a common complication of diarrhea.