Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a child who has bacterial meningitis. Which of the following findings should indicate to the nurse that the child can be removed from droplet precautions?
A. Absent nuchal rigidity
Absent nuchal rigidity is a positive sign in the context of managing bacterialmeningitis, but it alone does not determine when droplet precautions can be discontinued.
B. Negative cerebrospinal fluid culture
This is the correct answer. A negative cerebrospinal fluid (CSF) culture indicates that the bacterial infection has been effectively treated. Once the CSF culture is negative, the child is no longer considered contagious and can be removed from droplet precautions.
C. Antibiotics initiated 24 hr ago
The initiation of antibiotics is an important step in treating bacterial meningitis, but the passage of time alone does not indicate when precautions can be discontinued. Theeffectiveness of treatment is better determined by laboratory and clinical indicators.
D. Temperature below 37.4° C (99.3° F)
The temperature is an important clinical parameter, but a temperature below 37.4° C (99.3° F) alone does not determine when droplet precautions can be discontinued. The decision is based on the resolution of the infectious process, as indicated by negative cultures.
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Full Explanation
A. Absent nuchal rigidity is a positive sign in the context of managing bacterial
meningitis, but it alone does not determine when droplet precautions can be discontinued.
B. This is the correct answer. A negative cerebrospinal fluid (CSF) culture indicates that the bacterial infection has been effectively treated. Once the CSF culture is negative, the child is no longer considered contagious and can be removed from droplet precautions.
C. The initiation of antibiotics is an important step in treating bacterial meningitis, but the passage of time alone does not indicate when precautions can be discontinued. The
effectiveness of treatment is better determined by laboratory and clinical indicators.
D. The temperature is an important clinical parameter, but a temperature below 37.4° C (99.3° F) alone does not determine when droplet precautions can be discontinued. The decision is based on the resolution of the infectious process, as indicated by negative cultures.
Similar Questions
A nurse is preparing to administer immunizations to a 3-month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?
A. Provide a pacifier coated with an oral sucrose solution prior to the injections.
This is the correct action. Offering a pacifier coated with an oral sucrose solution before the injections can provide comfort and help alleviate pain associated with the immunizations.
B. Inject the immunizations into the deltoid muscle.
Administering immunizations into the deltoid muscle is not recommended for infants.For young infants, immunizations are typically given in the anterolateral thigh muscle.
C. Use a 20-gauge needle for the injections.
Using a 20-gauge needle is not recommended for infants, as it is a larger gauge and may cause more discomfort. A smaller gauge needle is typically used for infantimmunizations.
D. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections.
Applying eutectic mixture of local anesthetics (EMLA) cream immediately before the injections is not a standard practice for routine infant immunizations. It may not be necessary for most infants and could increase the overall time and complexity of the procedure.
Full Explanation
A. This is the correct action. Offering a pacifier coated with an oral sucrose solution before the injections can provide comfort and help alleviate pain associated with the immunizations.
B. Administering immunizations into the deltoid muscle is not recommended for infants.
For young infants, immunizations are typically given in the anterolateral thigh muscle.
C. Using a 20-gauge needle is not recommended for infants, as it is a larger gauge and may cause more discomfort. A smaller gauge needle is typically used for infant
immunizations.
D. Applying an eutectic mixture of local anesthetics (EMLA) cream immediately before the injections is not a standard practice for routine infant immunizations. It may not be necessary for most infants and could increase the overall time and complexity of the procedure.
A nurse is prioritizing care for four clients. Which of the following clients should the nurse assess first?
A. An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10
An adolescent in skin traction reporting a pain level of 7 requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
B. An adolescent who has sickle cell anemia and slurred speech
This client should be assessed first. Slurred speech in an adolescent with sickle cell anemia is a potential sign of a cerebral event, such as a stroke or a transient ischemic attack (TIA), and requires immediate evaluation.
C. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin
The toddler with a new diagnosis of osteomyelitis requiring an IV bolus of nafcillin should be assessed promptly, but this is not as urgent as the potential neurological symptom described in option B.
D. A toddler who has a partial-thickness burn on his right hand and requires a dressing change
The toddler with a partial-thickness burn on the right hand requiring a dressing change also requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
Full Explanation
A. An adolescent in skin traction reporting a pain level of 7 requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
B. This client should be assessed first. Slurred speech in an adolescent with sickle cell anemia is a potential sign of a cerebral event, such as a stroke or a transient ischemic attack (TIA), and requires immediate evaluation.
C. The toddler with a new diagnosis of osteomyelitis requiring an IV bolus of nafcillin should be assessed promptly, but this is not as urgent as the potential neurological symptom described in option B.
D. The toddler with a partial-thickness burn on the right hand requiring a dressing change also requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
A nurse is reviewing the complete blood count results for a child who is receiving treatment for acute lymphoblastic leukemia. Which of the following findings should indicate to the nurse that the treatment is having a therapeutic effect?
A. WBC count 15,000/mm3
WBC count 15,000/mm3 is elevated, which may indicate ongoing leukemia activity. It does not necessarily indicate a therapeutic effect.
B. RBC count 5/mm3
RBC count 5/mm3 is extremely low and indicates severe anemia. This finding suggests that the treatment may not be having the desired therapeutic effect.
C. Hemoglobin 6.8 g/dL
Hemoglobin 6.8 g/dL is very low and indicates severe anemia. This is a concerning finding and suggests that the treatment may not be effective.
D. Platelet count 98,000/mm3
This is the correct answer. A platelet count of 98,000/mm3 is within a range that is generally considered acceptable for a child receiving treatment for leukemia. While it is lower than normal, it is not severely low and suggests that the treatment may be having a therapeutic effect.
Full Explanation
A. WBC count 15,000/mm3 is elevated, which may indicate ongoing leukemia activity. It does not necessarily indicate a therapeutic effect.
B. RBC count 5/mm3 is extremely low and indicates severe anemia. This finding suggests that the treatment may not be having the desired therapeutic effect.
C. Hemoglobin 6.8 g/dL is very low and indicates severe anemia. This is a concerning finding and suggests that the treatment may not be effective.
D. This is the correct answer. A platelet count of 98,000/mm3 is within a range that is generally considered acceptable for a child receiving treatment for leukemia. While it is lower than normal, it is not severely low and suggests that the treatment may be having a therapeutic effect.