Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a child who received partial-thickness burns to over 50% of his body 10 days ago and has splints over his joints to prevent contractures. Which of the following actions should the nurse take? (Select all that apply.)
A. Provide a high-calorie det
Providing a high-calorie diet is important for a child with extensive burns to support wound healing and recovery.
B. Monitor intake and output.
Monitoring intake and output is crucial to assess fluid balance and ensure that the child is receiving enough fluids and nutrients for healing.
C. Change dressings using aseptic technique
Changing dressings using aseptic technique helps prevent infection, which is a significant risk in burn wounds.
D. Remove splints during sleep
Removing splints during sleep is not recommended, as they are in place to prevent contractures. They should be worn consistently, including during sleep.
E. Administer analgesics IM
Administering analgesics IM (intramuscularly) is not typically indicated. Pain management can be achieved through various routes, and IM administration may not be necessary. Additionally, it's important to consider the child's pain level and choose the most appropriate and effective route for analgesia.
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. Providing a high-calorie diet is important for a child with extensive burns to support wound healing and recovery.
B. Monitoring intake and output is crucial to assess fluid balance and ensure that the child is receiving enough fluids and nutrients for healing.
C. Changing dressings using an aseptic technique helps prevent infection, which is a significant risk in burn wounds.
D. Removing splints during sleep is not recommended, as they are in place to prevent contractures. They should be worn consistently, including during sleep.
E. Administering analgesics IM (intramuscularly) is not typically indicated. Pain
management can be achieved through various routes, and IM administration may not be necessary. Additionally, it's important to consider the child's pain level and choose the most appropriate and effective route for analgesia.
Similar Questions
A nurse is teaching about growth and development to a parent of a 12-year-old child. The nurse should instruct the parent to expect the child to exhibit which of the following characteristics during early adolescence?
A. Increased self-esteem
Increased self-esteem is a positive aspect of development, but it may not be a consistent characteristic during early adolescence. Self-esteem can fluctuate based on various factors.
B. Mood swings
Mood swings are common during early adolescence due to hormonal changes and the emotional challenges that come with this stage of development. It's important for parents to be understanding and supportive during this time.
C. Decelerating growth rate
The growth rate during early adolescence may vary from person to person, but it generally accelerates rather than decelerates. This period is associated with rapid physical growth, known as the adolescent growth spurt.
D. Emotional separation from parents
Emotional separation from parents is a normal part of adolescent development, but it tends to become more prominent in later adolescence rather than early adolescence. During early adolescence, there may be a mix of seeking independence and still relying on parental support and guidance.
Full Explanation
A. Increased self-esteem is a positive aspect of development, but it may not be a consistent characteristic during early adolescence. Self-esteem can fluctuate based on various factors.
B. Mood swings are common during early adolescence due to hormonal changes and the emotional challenges that come with this stage of development. It's important for parents to be understanding and supportive during this time.
C. The growth rate during early adolescence may vary from person to person, but it generally accelerates rather than decelerates. This period is associated with rapid physical growth, known as the adolescent growth spurt.
D. Emotional separation from parents is a normal part of adolescent development, but it tends to become more prominent in later adolescence rather than early adolescence. During early adolescence, there may be a mix of seeking independence and still relying on parental support and guidance.
A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the insertion of an IV catheter. Which of the following actions should the nurse plan to take?
A. Avoid removing the cream prior to the procedure.
The cream should be removed after it has been on the skin for the recommended amount of time. It is typically wiped off before the procedure.
B. Gently rub the cream into the skin.
Correct. To ensure proper absorption, the cream should be gently rubbed into the skin.This helps the medication to penetrate the skin and provide local anesthesia.
C. Wash the site with alcohol prior to applying the cream.
Washing the site with alcohol before applying the cream is not necessary and may cause unnecessary skin irritation.
D. Apply the cream 1 hr before the procedure.
Lidocaine and prilocaine cream typically requires about 30 minutes to take effect. It does not need to be applied 1 hour before the procedure.
Full Explanation
A. The cream should be removed after it has been on the skin for the recommended amount of time. It is typically wiped off before the procedure.
B. The medication should applied repeatedly to provide analgesia
C. Washing the site with alcohol before applying the cream is not necessary and may cause unnecessary skin irritation.
D. Lidocaine and prilocaine cream typically require about 60 minutes to take effect.
A nurse in an emergency department is caring for a preschool-age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?
A. Hyperpyrexia
Hyperpyrexia, or extremely high fever, is a potential complication of acuteacetylsalicylic acid (aspirin) poisoning. It can occur due to the toxic effects of salicylates on the hypothalamus, which regulates body temperature.
B. Polyuria
Polyuria (excessive urination) is not a typical finding associated with acute acetylsalicylic acid poisoning.
C. Jaundice
Jaundice (yellowing of the skin and eyes) is not a typical finding associated with acute acetylsalicylic acid poisoning.
D. Neck vein distention
Neck vein distention is not a typical finding associated with acute acetylsalicylic acid poisoning. It may be a sign of increased central venous pressure, which is not directly related to salicylate toxicity.
Full Explanation
A. Hyperpyrexia, or extremely high fever, is a potential complication of acute
acetylsalicylic acid (aspirin) poisoning. It can occur due to the toxic effects of salicylates on the hypothalamus, which regulates body temperature.
B. Polyuria (excessive urination) is not a typical finding associated with acute acetylsalicylic acid poisoning.
C. Jaundice (yellowing of the skin and eyes) is not a typical finding associated with acute acetylsalicylic acid poisoning.
D. Neck vein distention is not a typical finding associated with acute acetylsalicylic acid poisoning. It may be a sign of increased central venous pressure, which is not directly related to salicylate toxicity.