Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a preschooler who has a gastrostomy tube. Which of the following actions should the nurse take?
A. Use barrier ointments around the site.
"Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. Cleanse the tube site with hydrogen peroxide.
"Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. Maintain tension between the tubing and the site.
"Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. Place a transparent occlusive dressing over the site.
"Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.
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. "Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. "Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. "Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. "Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.
Similar Questions
A nurse is planning care for a school-age child who has acute glomerulonephritis. Which of the following interventions should the nurse include?
A. Monitor blood pressure every 4 hr.
"Monitor blood pressure every 4 hr." Acute glomerulonephritis can cause hypertension due to fluid retention and impaired kidney function. Regular monitoring is essential to detect and manage hypertension early.
B. Increase fluid consumption.
"Increase fluid consumption." Fluid intake is often restricted to prevent fluid overload, especially if there is hypertension, edema, or decreased urine output.
C. Implement a protein-restricted diet.
"Implement a protein-restricted diet." A protein-restricted diet is not necessary unless the child has severe renal impairment. In most cases, moderate protein intake is recommended.
D. Collect and strain all urine for sediment.
"Collect and strain all urine for sediment." While hematuria (blood in urine) is common in acute glomerulonephritis, straining urine for sediment is not a standard intervention for this condition.
Full Explanation
A. "Monitor blood pressure every 4 hr." Acute glomerulonephritis can cause hypertension due to fluid retention and impaired kidney function. Regular monitoring is essential to detect and manage hypertension early.
B. "Increase fluid consumption." Fluid intake is often restricted to prevent fluid overload, especially if there is hypertension, edema, or decreased urine output.
C. "Implement a protein-restricted diet." A protein-restricted diet is not necessary unless the child has severe renal impairment. In most cases, moderate protein intake is recommended.
D. "Collect and strain all urine for sediment." While hematuria (blood in urine) is common in acute glomerulonephritis, straining urine for sediment is not a standard intervention for this condition.
A school nurse is providing teaching to the guardian of a child who has pediculosis. Which of the following statements by the guardian indicates an understanding of the teaching?
A. "I will seal nonwashable items in a plastic bag for 1 week."
"I will seal nonwashable items in a plastic bag for 1 week." Nonwashable items (e.g., stuffed animals, pillows) should be sealed in a plastic bag for at least 2 weeks, not just 1 week, to ensure all lice and nits die.
B. "I will place hairbrushes, combs, and hair accessories in boiling water for 10 minutes."
"I will place hairbrushes, combs, and hair accessories in boiling water for 10 minutes." Boiling these items in water for at least 5–10 minutes effectively kills lice and nits.
C. "I will wash my child's clothing and bedding using a double rinse."
"I will wash my child's clothing and bedding using a double rinse." Clothing and bedding should be washed in hot water (at least 130°F or 54°C) and dried on high heat, but a double rinse is not necessary.
D. "I will use the medicated shampoo on my child's hair daily for 3 days."
"I will use the medicated shampoo on my child's hair daily for 3 days." Medicated lice shampoos should be used once, followed by a repeat application in 7–10 days if needed. Daily use is not recommended due to potential toxicity and irritation.
Full Explanation
A. "I will seal nonwashable items in a plastic bag for 1 week." Nonwashable items (e.g., stuffed animals, pillows) should be sealed in a plastic bag for at least 2 weeks, not just 1 week, to ensure all lice and nits die.
B. "I will place hairbrushes, combs, and hair accessories in boiling water for 10 minutes." Boiling these items in water for at least 5–10 minutes effectively kills lice and nits.
C. "I will wash my child's clothing and bedding using a double rinse." Clothing and bedding should be washed in hot water (at least 130°F or 54°C) and dried on high heat, but a double rinse is not necessary.
D. "I will use the medicated shampoo on my child's hair daily for 3 days." Medicated lice shampoos should be used once, followed by a repeat application in 7–10 days if needed. Daily use is not recommended due to potential toxicity and irritation.
A nurse is providing teaching to the guardian of an infant who has heart failure. Which of the following instructions should the nurse include?
A. Place the infant in a supine position.
"Place the infant in a supine position." Infants with heart failure often have difficulty breathing, so placing them in a semi-upright position (e.g., in a car seat or with the head elevated) can help with breathing and reduce cardiac workload.
B. Allow the infant to sleep through night feedings.
"Allow the infant to sleep through night feedings." Infants with heart failure have increased metabolic demands and may fatigue easily during feedings. Small, frequent feedings (including nighttime feedings) are important to ensure adequate nutrition.
C. Minimize the infant's environmental stimuli.
"Minimize the infant's environmental stimuli." Excessive stimulation can increase the infant’s metabolic and oxygen demands, worsening heart failure symptoms. Keeping the environment calm and quiet helps reduce stress on the heart.
D. Bathe the infant every day.
"Bathe the infant every day." While hygiene is important, daily baths can be too exhausting for an infant with heart failure. Instead, bathing should be limited to as needed (e.g., sponge baths) to prevent excessive fatigue.
Full Explanation
A. "Place the infant in a supine position." Infants with heart failure often have difficulty breathing, so placing them in a semi-upright position (e.g., in a car seat or with the head elevated) can help with breathing and reduce cardiac workload.
B. "Allow the infant to sleep through night feedings." Infants with heart failure have increased metabolic demands and may fatigue easily during feedings. Small, frequent feedings (including nighttime feedings) are important to ensure adequate nutrition.
C. "Minimize the infant's environmental stimuli." Excessive stimulation can increase the infant’s metabolic and oxygen demands, worsening heart failure symptoms. Keeping the environment calm and quiet helps reduce stress on the heart.
D. "Bathe the infant every day." While hygiene is important, daily baths can be too exhausting for an infant with heart failure. Instead, bathing should be limited to as needed (e.g., sponge baths) to prevent excessive fatigue.