Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a child who is to receive the first dose of IV gentamicin. Which of the following actions should the nurse take?
A. Monitor for constipation.
"Monitor for constipation." Constipation is not a common adverse effect of gentamicin. More concerning side effects include nephrotoxicity and ototoxicity.
B. Maintain strict 1&O.
"Maintain strict I&O." Gentamicin can cause nephrotoxicity, so it is essential to monitor intake and output (I&O) closely to assess kidney function and detect early signs of renal impairment.
C. Initiate airborne precautions.
"Initiate airborne precautions." Gentamicin is an antibiotic and does not require airborne precautions. Airborne precautions are used for infections like tuberculosis, measles, and varicella.
D. Encourage bed rest.
"Encourage bed rest." Gentamicin does not require bed rest. However, if the child experiences dizziness due to ototoxicity (another adverse effect), activity may need to be limited.
This question is an excerpt from Nurse Dive's nursing test bank - Ati rn paediatrics nursing proctored exam 2023. Take the full exam now
Full Explanation
A. "Monitor for constipation." Constipation is not a common adverse effect of gentamicin. More concerning side effects include nephrotoxicity and ototoxicity.
B. "Maintain strict I&O." Gentamicin can cause nephrotoxicity, so it is essential to monitor intake and output (I&O) closely to assess kidney function and detect early signs of renal impairment.
C. "Initiate airborne precautions." Gentamicin is an antibiotic and does not require airborne precautions. Airborne precautions are used for infections like tuberculosis, measles, and varicella.
D. "Encourage bed rest." Gentamicin does not require bed rest. However, if the child experiences dizziness due to ototoxicity (another adverse effect), activity may need to be limited.
Similar Questions
A nurse is providing teaching to the guardian of a school-age child who has acute diarrhea. Which of the following instructions should the nurse include in the teaching?
A. Provide chicken or beef broth until the diarrhea subsides.
"Provide chicken or beef broth until the diarrhea subsides." Broth can be high in sodium, which is not ideal for rehydrating a child with diarrhea. Clear fluids and oral rehydration solutions are better choices.
B. Encourage intake of carbonated beverages diluted with water.
"Encourage intake of carbonated beverages diluted with water." Carbonated beverages can irritate the stomach and exacerbate diarrhea. Instead, clear fluids or oral rehydration solutions are recommended.
C. Provide the child with a bananas, rice, applesauce, and toast (BRAT) diet.
"Provide the child with a bananas, rice, applesauce, and toast (BRAT) diet." The BRAT diet is outdated and not recommended anymore because it lacks essential nutrients. Instead, the child should be provided with a balanced diet, including foods like rice, potatoes, and lean meats, along with fluids for rehydration.
D. Administer oral hydration solution after each diarrheal stool.
"Administer oral hydration solution after each diarrheal stool." Oral rehydration solutions (ORS) help replace lost fluids and electrolytes. Administering ORS after each stool helps prevent dehydration, which is a common complication of diarrhea.
Full Explanation
A. "Provide chicken or beef broth until the diarrhea subsides." Broth can be high in sodium, which is not ideal for rehydrating a child with diarrhea. Clear fluids and oral rehydration solutions are better choices.
B. "Encourage intake of carbonated beverages diluted with water." Carbonated beverages can irritate the stomach and exacerbate diarrhea. Instead, clear fluids or oral rehydration solutions are recommended.
C. "Provide the child with a bananas, rice, applesauce, and toast (BRAT) diet." The BRAT diet is outdated and not recommended anymore because it lacks essential nutrients. Instead, the child should be provided with a balanced diet, including foods like rice, potatoes, and lean meats, along with fluids for rehydration.
D. "Administer oral hydration solution after each diarrheal stool." Oral rehydration solutions (ORS) help replace lost fluids and electrolytes. Administering ORS after each stool helps prevent dehydration, which is a common complication of diarrhea.
A nurse is teaching the guardian of a child who is suspected of having cystic fibrosis and is scheduled for a sweat chloride test. Which of the following statements should the nurse include?
A. "Two separate samples will be collected to ensure accuracy of the test results."
"Two separate samples will be collected to ensure accuracy of the test results." For accuracy, the sweat chloride test is typically done with two separate samples to confirm the diagnosis of cystic fibrosis. The results are compared to ensure consistency.
B. "It will take approximately 3 hours to complete the test."
"It will take approximately 3 hours to complete the test." The sweat chloride test typically takes around 30 to 60 minutes, not 3 hours. The process of stimulating sweat production and collecting it is usually brief.
C. "Your child will need to receive sedation to minimize pain during the test."
"Your child will need to receive sedation to minimize pain during the test." The sweat chloride test is non-invasive and does not require sedation. It involves the application of a sweat-stimulating chemical, and the child may feel mild discomfort but does not require sedation.
D. "Your child should avoid eating and drinking 6 hours prior to the test."
"Your child should avoid eating and drinking 6 hours prior to the test." There are no specific fasting requirements before a sweat chloride test, although the child may be asked to stay well-hydrated to help produce sweat during the test.
Full Explanation
A. "Two separate samples will be collected to ensure accuracy of the test results." For accuracy, the sweat chloride test is typically done with two separate samples to confirm the diagnosis of cystic fibrosis. The results are compared to ensure consistency.
B. "It will take approximately 3 hours to complete the test." The sweat chloride test typically takes around 30 to 60 minutes, not 3 hours. The process of stimulating sweat production and collecting it is usually brief.
C. "Your child will need to receive sedation to minimize pain during the test." The sweat chloride test is non-invasive and does not require sedation. It involves the application of a sweat-stimulating chemical, and the child may feel mild discomfort but does not require sedation.
D. "Your child should avoid eating and drinking 6 hours prior to the test." There are no specific fasting requirements before a sweat chloride test, although the child may be asked to stay well-hydrated to help produce sweat during the test.
A nurse is providing teaching to the parents of a toddler who is exhibiting negativism during mealtimes. Which of the following statements by the nurse is appropriate?
A. "Ask her if she is ready to eat her sandwich for lunch."
"Ask her if she is ready to eat her sandwich for lunch." Asking if the child is ready to eat might increase resistance, as toddlers often assert their autonomy by saying "no." This does not provide an option that would allow the toddler to make a choice.
B. "Ask her if she would like to have her favorite sandwich for lunch."
"Ask her if she would like to have her favorite sandwich for lunch." This is a yes/no question which might lead to refusal, especially if the child is already in a stage of negativism, where they are more likely to resist being told what to do.
C. "Tell her that she may have a sandwich or soup for lunch."
"Tell her that she may have a sandwich or soup for lunch." Offering choices between two acceptable options gives the toddler a sense of control, which can help reduce oppositional behavior. This approach aligns with the developmental stage of toddlers who are asserting independence.
D. "Tell her she is having her favorite sandwich for lunch."
"Tell her she is having her favorite sandwich for lunch." Telling the child what they will have to eat might lead to resistance. Providing a choice rather than making a statement gives the child more agency in their decision-making.
Full Explanation
A. "Ask her if she is ready to eat her sandwich for lunch." Asking if the child is ready to eat might increase resistance, as toddlers often assert their autonomy by saying "no." This does not provide an option that would allow the toddler to make a choice.
B. "Ask her if she would like to have her favorite sandwich for lunch." This is a yes/no question which might lead to refusal, especially if the child is already in a stage of negativism, where they are more likely to resist being told what to do.
C. "Tell her that she may have a sandwich or soup for lunch." Offering choices between two acceptable options gives the toddler a sense of control, which can help reduce oppositional behavior. This approach aligns with the developmental stage of toddlers who are asserting independence.
D. "Tell her she is having her favorite sandwich for lunch." Telling the child what they will have to eat might lead to resistance. Providing a choice rather than making a statement gives the child more agency in their decision-making.