Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
For which of the following findings should the nurse intervene?
A. Brisk capillary refill
Brisk capillary refill is a normal finding and does not require intervention.
B. Tachypnea
Tachypnea, or rapid breathing, is a common symptom of respiratory syncytial virus (RSV) infection in infants. It can indicate that the infant is having difficulty breathing and needs immediate intervention.
C. Rhinorrhea
Rhinorrhea, or a runny nose, is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
D. Coughing
Coughing is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Pediatrics Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale
Brisk capillary refill is a normal finding and does not require intervention.
Choice B rationale
Tachypnea, or rapid breathing, is a common symptom of respiratory syncytial virus (RSV) infection in infants. It can indicate that the infant is having difficulty breathing and needs immediate intervention.
Choice C rationale
Rhinorrhea, or a runny nose, is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
Choice D rationale
Coughing is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
Similar Questions
A nurse is assessing a toddler who is 8 hr. postoperative following a cardiac catheterization procedure.
Which of the following findings should the nurse report to the provider?
A. Weak pedal pulse distal to the site
A weak pedal pulse distal to the site of a cardiac catheterization procedure could indicate a vascular complication, such as a hematoma or thrombosis, and should be reported to the provider immediately.
B. Blood pressure 102/58mm Hg
A blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not need to be reported to the provider.
C. Bilateral cool extremities
Bilateral cool extremities can be a normal finding in a child who is recovering from anesthesia. However, if coolness is accompanied by other signs of poor perfusion, such as pallor or delayed capillary refill, it should be reported to the provider.
D. Serum glucose 90mg/dL
A serum glucose level of 90 mg/dL is within the normal range for a toddler and does not need to be reported to the provider.
Full Explanation
Choice A rationale
A weak pedal pulse distal to the site of a cardiac catheterization procedure could indicate a vascular complication, such as a hematoma or thrombosis, and should be reported to the provider immediately.
Choice B rationale
A blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not need to be reported to the provider.
Choice C rationale
Bilateral cool extremities can be a normal finding in a child who is recovering from anesthesia. However, if coolness is accompanied by other signs of poor perfusion, such as pallor or delayed capillary refill, it should be reported to the provider.
Choice D rationale
A serum glucose level of 90 mg/dL is within the normal range for a toddler and does not need to be reported to the provider.
A nurse is evaluating a 6-year-old child who has cystic fibrosis and has been receiving chest physiotherapy treatment.
The nurse should identify which of the following findings as an indication of the therapy has been effective?
A. Increased urine output
Increased urine output is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
B. increase expectoration
Increased expectoration, or coughing up and spitting out mucus, is a sign that chest physiotherapy is effective. The goal of chest physiotherapy is to help clear the thick, sticky mucus from the lungs of children with cystic fibrosis. Reduced pain is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
C. reduced pain
D. increased heart rate .
An increased heart rate is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
Full Explanation
Choice A rationale
Increased urine output is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
Choice B rationale
Increased expectoration, or coughing up and spitting out mucus, is a sign that chest physiotherapy is effective. The goal of chest physiotherapy is to help clear the thick, sticky mucus from the lungs of children with cystic fibrosis.
Reduced pain is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
Choice D rationale
An increased heart rate is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full thickness burn to 10% of this body.
Which of the following findings should the nurse report to the provider?
A. Increased restlessness
Increased restlessness in a toddler with a full-thickness burn may indicate hypoxia, pain, or shock. These conditions require immediate medical attention to prevent further complications and ensure proper management of the burn injury.
B. Respiratory rate 25/min
A respiratory rate of 25 breaths per minute is within the normal range for a toddler. It does not require immediate reporting to the provider.
C. Bowel sounds 20/min
Bowel sounds of 20/min are within the normal range (5-30 sounds per minute). This finding does not indicate any gastrointestinal complications that need to be reported to the provider.
D. Urinary output 35 mL/hr
A urinary output of 35 mL/hr is lower than the expected urine output for a toddler. In a child of this weight, the expected urine output is typically higher. This finding may indicate decreased renal perfusion, which should be reported to the provider for further evaluation.
Full Explanation
The correct answer is Choice A.
Choice A rationale: Increased restlessness in a toddler with a full-thickness burn may indicate hypoxia, pain, or shock. These conditions require immediate medical attention to prevent further complications and ensure proper management of the burn injury.
Choice B rationale: A respiratory rate of 25/min is within the normal range for toddlers (20-30 breaths per minute). This finding does not indicate an immediate concern that requires reporting to the provider.
Choice C rationale: Bowel sounds of 20/min are within the normal range (5-30 sounds per minute). This finding does not indicate any gastrointestinal complications that need to be reported to the provider.
Choice D rationale: Urinary output of 35 mL/hr is within the normal range for toddlers (1-2 mL/kg/hr). This finding indicates adequate kidney function and hydration status, so it does not require immediate reporting.