Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a 10-month-old child who was brought to the emergency department by his parents following a head injury.
Which of the following actions should the nurse take first?
A. Assess respiratory status.
The first action the nurse should take is to assess the respiratory status of the infant. After a head injury, it is important to ensure that the child’s airway is clear and that they are breathing adequately. This is a crucial step in providing care for a patient with a head injury.
B. Inspect for fluid leaking from the ears.
Choice B is wrong because inspecting for fluid leaking from the ears is not the first priority.
C. Examine the scalp for lacerations.
Choice C is wrong because examining the scalp for lacerations is not the first priority.
D. Check pupil reactions.
Choice D is wrong because checking pupil reactions is not the first priority.
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 first action the nurse should take is to assess the respiratory status of the infant.
After a head injury, it is important to ensure that the child’s airway is clear and that they are breathing adequately.
This is a crucial step in providing care for a patient with a head injury.
Choice B is wrong because inspecting for fluid leaking from the ears is not the first priority.
Choice C is wrong because examining the scalp for lacerations is not the first priority.
Choice D is wrong because checking pupil reactions is not the first priority.
Similar Questions
A nurse is planning care for an 8-month-old infant who has heart failure. Which of the following actions should the nurse include in the plan of care?
A. Administer cool, humidified oxygen via nasal cannula.
Infants with heart failure often present with breathing trouble1, and administering oxygen can help improve oxygen delivery.
B. Place the infant in a prone position.
Choice B is wrong because placing an infant in a prone position does not help with heart failure.
C. Repeat a digoxin dosage if the infant vomits within 1 hr of administration.
Choice C is wrong because if an infant vomits within 1 hour of administration of digoxin, the dosage should not be repeated without consulting a healthcare provider.
D. Provide less frequent, higher volume feedings.
Choice D is wrong because infants with heart failure may have feeding issues and providing less frequent, higher volume feedings may not be helpful34.
Full Explanation
Infants with heart failure often present with breathing trouble1, and administering oxygen can help improve oxygen delivery.
Choice B is wrong because placing an infant in a prone position does not help with heart failure.
Choice C is wrong because if an infant vomits within 1 hour of administration of digoxin, the dosage should not be repeated without consulting a healthcare provider.
Choice D is wrong because infants with heart failure may have feeding issues and providing less frequent, higher volume feedings may not be helpful34.
A nurse is caring for an adolescent who is 1 hr postoperative following an appendectomy.
Which of the following findings should the nurse report to the provider?
A. Muscle rigidity.
Muscle rigidity following an appendectomy could be a sign of a serious complication such as peritonitis and should be reported to the provider immediately.
B. Abdominal pain.
Choice B is wrong because abdominal pain is a common occurrence following an appendectomy and may not necessarily require immediate attention from the provider.
C. Temperature 36.4° C (97.5° F).
Choice C is wrong because a temperature of 36.4° C (97.5° F) is within the normal range.
D. Heart rate 63/min.
Choice D is wrong because a heart rate of 63/min is within the normal range for an adolescent.
Full Explanation
Muscle rigidity following an appendectomy could be a sign of a serious complication such as peritonitis and should be reported to the provider immediately.
Choice B is wrong because abdominal pain is a common occurrence following an appendectomy and may not necessarily require immediate attention from the provider.
Choice C is wrong because a temperature of 36.4° C (97.5° F) is within the normal range.
Choice D is wrong because a heart rate of 63/min is within the normal range for an adolescent.
A charge nurse is planning care for an infant who has failure to thrive. Which of the following actions should the nurse include in the plan of care?
A. Give the infant fruit juice between feedings.
Choice A is wrong because giving an infant fruit juice between feedings does not address the underlying causes of failure to thrive.
B. Use half-strength formula when feeding the infant.
Choice B is wrong because using half-strength formula when feeding the infant can exacerbate the problem by providing insufficient nutrition.
C. Assign consistent nursing staff to care for the infant.
Consistent care from the same nursing staff can help establish a routine and build trust between the infant and caregivers.
D. Keep the infant in a visually stimulating environment.
Choice D is wrong because keeping the infant in a visually stimulating environment does not address the underlying causes of failure to thrive.
Full Explanation
Consistent care from the same nursing staff can help establish a routine and build trust between the infant and caregivers.
Choice A is wrong because giving an infant fruit juice between feedings does not address the underlying causes of failure to thrive.
Choice B is wrong because using half-strength formula when feeding the infant can exacerbate the problem by providing insufficient nutrition.
Choice D is wrong because keeping the infant in a visually stimulating environment does not address the underlying causes of failure to thrive.