Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide.
Which of the following findings is the nurse's priority?
A. Negative doll's eye reflex
Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of headmovement.
B. Sunken anterior fontanel
A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. Potassium 5.1 mEq/L
A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. Heart rate 162/min
This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heartfailure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
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. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.
B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
Similar Questions
A nurse is providing teaching to a parent of a child who has HIV. Which of the following statements by the parent indicates an understanding of the teaching?
A. "I will ensure that my child is tested for tuberculosis every year."
This is the correct statement. Children with HIV are at increased risk for tuberculosis (TB) infection. Therefore, regular testing for TB is an important part of their healthcare.
B. "My child will need to double his medications for the next 6 months."
Doubling medications without specific guidance from the healthcare provider can be dangerous and is not recommended. It's important for the parent to follow the prescribed medication regimen as directed.
C. "The risk of transmission decreases once my child is on zidovudine for 2 weeks."
While zidovudine (AZT) is an important medication for HIV treatment, the statement is not accurate. The risk of transmission does not decrease after only 2 weeks of treatment. It takes longer for the viral load to decrease significantly.
D. "My child will need to repeat his childhood immunizations once he is in remission."
Children with HIV do not necessarily need to repeat their childhood immunizations once they are in remission. However, the timing and need for vaccinations may beindividualized based on the child's specific circumstances and immune status. This statement does not demonstrate a clear understanding of the teaching.
Full Explanation
A. This is the correct statement. Children with HIV are at increased risk for tuberculosis (TB) infection. Therefore, regular testing for TB is an important part of their healthcare.
B. Doubling medications without specific guidance from the healthcare provider can be dangerous and is not recommended. It's important for the parent to follow the prescribed medication regimen as directed.
C. While zidovudine (AZT) is an important medication for HIV treatment, the statement is not accurate. The risk of transmission does not decrease after only 2 weeks of
treatment. It takes longer for the viral load to decrease significantly.
D. Children with HIV do not necessarily need to repeat their childhood immunizations once they are in remission. However, the timing and need for vaccinations may be
individualized based on the child's specific circumstances and immune status. This statement does not demonstrate a clear understanding of the teaching.
A nurse is admitting a child who has acute epiglottitis. Which of the following actions should the nurse take?
A. Assist the child into supine position.
Assisting the child into a supine position is contraindicated in acute epiglottitis. This can lead to airway obstruction. The child should be allowed to assume a position of comfort, which is typically sitting up and leaning forward.
B. Obtain a throat culture.
While obtaining a throat culture may be indicated for diagnostic purposes, it is not the first priority in the care of a child with acute epiglottitis. The immediate concern is ensuring airway patency and providing appropriate respiratory support.
C. Initiate droplet isolation precautions.
This is the correct action. Acute epiglottitis is a potentially life-threatening condition that can rapidly lead to airway obstruction. Initiating droplet isolation precautions helps protect healthcare providers and other patients from potential transmission of the causative organism (often Haemophilus influenzae type B).
D. Check oxygen saturation every 4 hr.
Checking oxygen saturation every 4 hours is important for monitoring respiratory status, but in the case of acute epiglottitis, continuous monitoring of oxygen saturation is often necessary due to the risk of sudden airway obstruction. This action does not address the immediate priority of ensuring a patent airway.
Full Explanation
A. Assisting the child into a supine position is contraindicated in acute epiglottitis. This can lead to airway obstruction. The child should be allowed to assume a position of comfort, which is typically sitting up and leaning forward.
B. While obtaining a throat culture may be indicated for diagnostic purposes, it is not the first priority in the care of a child with acute epiglottitis. The immediate concern is ensuring airway patency and providing appropriate respiratory support.
C. This is the correct action. Acute epiglottitis is a potentially life-threatening condition that can rapidly lead to airway obstruction. Initiating droplet isolation precautions helps protect healthcare providers and other patients from potential transmission of the causative organism (often Haemophilus influenzae type B).
D. Checking oxygen saturation every 4 hours is important for monitoring respiratory status, but in the case of acute epiglottitis, continuous monitoring of oxygen saturation is often necessary due to the risk of sudden airway obstruction. This action does not address the immediate priority of ensuring a patent airway.
A nurse is providing teaching to the parents of a child who has impetigo. Which of the following instructions should the nurse include in the teaching?
A. Seal soft toys in a plastic bag for 14 days.
There is no need to seal soft toys in a plastic bag for 14 days as impetigo is not typically spread through inanimate objects. However, it is important to discourage the child from scratching the lesions to prevent further spread.
B. Soak hairbrushes in boiling water for 10 min.
Soaking hairbrushes in boiling water is not necessary for the management of impetigo.Impetigo is caused by bacteria, not lice, so boiling hairbrushes is not a standard recommendation for this condition.
C. Apply bactericidal ointment to lesions.
This is the correct instruction. Applying a bactericidal ointment (e.g., mupirocin) to the impetigo lesions is a common treatment approach. This helps to eliminate the bacteria causing the infection and promote healing.
D. Administer acyclovir PO two times per day.
Administering acyclovir is not indicated for impetigo. Acyclovir is an antiviralmedication used to treat viral infections, such as herpes simplex virus. Impetigo is caused by bacterial infection, not a virus.
Full Explanation
A. There is no need to seal soft toys in a plastic bag for 14 days as impetigo is not typically spread through inanimate objects. However, it is important to discourage the child from scratching the lesions to prevent further spread.
B. Soaking hairbrushes in boiling water is not necessary for the management of impetigo.
Impetigo is caused by bacteria, not lice, so boiling hairbrushes is not a standard recommendation for this condition.
C. This is the correct instruction. Applying a bactericidal ointment (e.g., mupirocin) to the impetigo lesions is a common treatment approach. This helps to eliminate the bacteria causing the infection and promote healing.
D. Administering acyclovir is not indicated for impetigo. Acyclovir is an antiviral
medication used to treat viral infections, such as herpes simplex virus. Impetigo is caused by bacterial infection, not a virus.