Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus (RSV). Which of the following actions should the nurse take?
A. Request an x-ray of the preschooler's neck.
B. Initiate droplet precautions.
Initiate droplet precautions. The rationale is that RSV is a highly contagious viral infection that causes respiratory tract inflammation and can spread through respiratory droplets from coughing or sneezing. The nurse should wear a mask and gloves when caring for the preschooler and isolate them from other children to prevent transmission.
C. Administer fluconazole to the preschooler.
D. Monitor the preschooler's urine for protein
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is B.
Initiate droplet precautions. The rationale is that RSV is a highly contagious viral infection that causes respiratory tract inflammation and can spread through respiratory droplets from coughing or sneezing. The nurse should wear a mask and gloves when caring for the preschooler and isolate them from other children to prevent transmission.
Similar Questions
A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
A. Cover the wound with sterile, saline-soaked gauze.
Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.
B. Raise the head of the bed to a 45° angle.
C. Hold gentle, direct pressure on the protruding organ
D. Place the client's knees in an extended position.
Full Explanation
Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.
A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives. Which of the following findings is a contraindication for this client?
A. History of ectopic pregnancy
B. Vaginal yeast infection
C. Hypertension
The rationale is that oral contraceptives contain synthetic hormones that can increase blood pressure and increase the risk of cardiovascular events such as stroke, heart attack, or blood clots. The nurse should advise the client to avoid oral contraceptives if she has hypertension or other risk factors for cardiovascular disease and suggest alternative methods of birth control.
D. Irregular menses
Full Explanation
The correct answer is C.
Hypertension. The rationale is that oral contraceptives contain synthetic hormones that can increase blood pressure and increase the risk of
cardiovascular events such as stroke, heart attack or blood clots. The nurse should advise the client to avoid oral contraceptives if she has hypertension or other risk factors for cardiovascular disease and suggest alternative methods of birth control.
A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?
A. Document the infiltration.
B. Stop the infusion.
The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action accordingto the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.
C. Elevate the arm.
D. Apply a warm compress.
Full Explanation
The correct answer is B.
Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action according to the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.