Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a school-age child following a femoral venous cardiac catheterization. Which of the following actions should the nurse take?
A. Perform a sterile dressing change 8 hr after the procedure.
"Perform a sterile dressing change 8 hr after the procedure." The initial dressing should be left in place for at least 24 hours, and any dressing changes should be performed per facility protocol.
B. Keep the affected extremity straight for 4 hr.
"Keep the affected extremity straight for 4 hr." After a femoral venous cardiac catheterization, the child should keep the affected extremity straight for about 4 to 6 hours to prevent bleeding or hematoma formation at the insertion site.
C. Assess the pulses above the catheterization site.
"Assess the pulses above the catheterization site." The pulses below the site (distal pulses) should be assessed, not above. This is important to check for adequate circulation and potential complications such as clot formation or arterial obstruction.
D. Maintain NPO status for 24 hr following the procedure.
"Maintain NPO status for 24 hr following the procedure." The child should typically resume oral intake as soon as they are fully awake and able to tolerate fluids, usually within a few hours post-procedure.
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. "Perform a sterile dressing change 8 hr after the procedure." The initial dressing should be left in place for at least 24 hours, and any dressing changes should be performed per facility protocol.
B. "Keep the affected extremity straight for 4 hr." After a femoral venous cardiac catheterization, the child should keep the affected extremity straight for about 4 to 6 hours to prevent bleeding or hematoma formation at the insertion site.
C. "Assess the pulses above the catheterization site." The pulses below the site (distal pulses) should be assessed, not above. This is important to check for adequate circulation and potential complications such as clot formation or arterial obstruction.
D. "Maintain NPO status for 24 hr following the procedure." The child should typically resume oral intake as soon as they are fully awake and able to tolerate fluids, usually within a few hours post-procedure.
Similar Questions
A nurse is caring for an adolescent who is scheduled for insertion of an intrauterine device. Which of the following actions should the nurse take?
A. Encourage the adolescent to wait to ask questions about the device until after its insertion.
"Encourage the adolescent to wait to ask questions about the device until after its insertion." The adolescent should be encouraged to ask questions before the procedure to ensure informed consent and understanding.
B. Call the adolescent's guardian to obtain verbal consent prior to the procedure.
"Call the adolescent's guardian to obtain verbal consent prior to the procedure." In many areas, adolescents can provide consent for reproductive health services, including contraception, without parental consent.
C. Reschedule the procedure until the client's guardian provides written consent.
"Reschedule the procedure until the client's guardian provides written consent." Most states and healthcare policies allow minors to consent to birth control procedures without requiring parental involvement.
D. Witness the adolescent's signature on the consent form.
"Witness the adolescent's signature on the consent form." The nurse should witness and document the adolescent’s informed consent, as they have the right to make decisions regarding their reproductive health.
Full Explanation
A. "Encourage the adolescent to wait to ask questions about the device until after its insertion." The adolescent should be encouraged to ask questions before the procedure to ensure informed consent and understanding.
B. "Call the adolescent's guardian to obtain verbal consent prior to the procedure." In many areas, adolescents can provide consent for reproductive health services, including contraception, without parental consent.
C. "Reschedule the procedure until the client's guardian provides written consent." Most states and healthcare policies allow minors to consent to birth control procedures without requiring parental involvement.
D. "Witness the adolescent's signature on the consent form." The nurse should witness and document the adolescent’s informed consent, as they have the right to make decisions regarding their reproductive health.
A nurse is caring for an adolescent who is postoperative following epidural anesthesia. Which of the following findings should the nurse expect?
A. Hypertension
"Hypertension" Epidural anesthesia typically causes hypotension, not hypertension, due to vasodilation and decreased sympathetic nervous system activity.
B. Mild sedation
"Mild sedation" While some systemic absorption of anesthetics may occur, epidural anesthesia primarily affects sensory and motor function rather than causing significant sedation.
C. Urinary retention
"Urinary retention" Epidural anesthesia can inhibit bladder sensation and detrusor muscle function, leading to urinary retention. The nurse should monitor urine output and assess for bladder distention.
D. Respiratory depression
"Respiratory depression" While respiratory depression can occur with high doses of opioids administered through an epidural, it is not a common expected effect of epidural anesthesia alone.
Full Explanation
A. "Hypertension" Epidural anesthesia typically causes hypotension, not hypertension, due to vasodilation and decreased sympathetic nervous system activity.
B. "Mild sedation" While some systemic absorption of anesthetics may occur, epidural anesthesia primarily affects sensory and motor function rather than causing significant sedation.
C. "Urinary retention" Epidural anesthesia can inhibit bladder sensation and detrusor muscle function, leading to urinary retention. The nurse should monitor urine output and assess for bladder distention.
D. "Respiratory depression" While respiratory depression can occur with high doses of opioids administered through an epidural, it is not a common expected effect of epidural anesthesia alone.
A nurse is caring for a pediatric client receiving radiation therapy to the abdominal area. Which of the following statements by the nurse promotes proper skin integrity for the client?
A. "Do not wash the area with strong soaps and do not rub the area dry, just pat it dry."
"Do not wash the area with strong soaps and do not rub the area dry, just pat it dry." Radiation therapy can cause skin irritation and dryness. Using mild soap, lukewarm water, and gently patting the area dry helps prevent further irritation and promotes skin integrity.
B. "Apply some triple antibiotic ointment to help the dryness and itching."
"Apply some triple antibiotic ointment to help the dryness and itching." Antibiotic ointments are not recommended unless there is an infection. Instead, radiation patients should use gentle, fragrance-free moisturizers as directed by their provider.
C. "You should get an abdominal binder and try to keep the area covered."
"You should get an abdominal binder and try to keep the area covered." Tight or restrictive clothing can further irritate the skin and increase the risk of breakdown in the radiation-exposed area.
D. "You need to keep the area exposed to air and direct sunshine."
"You need to keep the area exposed to air and direct sunshine." Direct sun exposure can worsen radiation burns and should be avoided. The skin in the treated area is more sensitive to UV rays and at a higher risk for damage.
Full Explanation
A. "Do not wash the area with strong soaps and do not rub the area dry, just pat it dry." Radiation therapy can cause skin irritation and dryness. Using mild soap, lukewarm water, and gently patting the area dry helps prevent further irritation and promotes skin integrity.
B. "Apply some triple antibiotic ointment to help the dryness and itching." Antibiotic ointments are not recommended unless there is an infection. Instead, radiation patients should use gentle, fragrance-free moisturizers as directed by their provider.
C. "You should get an abdominal binder and try to keep the area covered." Tight or restrictive clothing can further irritate the skin and increase the risk of breakdown in the radiation-exposed area.
D. "You need to keep the area exposed to air and direct sunshine." Direct sun exposure can worsen radiation burns and should be avoided. The skin in the treated area is more sensitive to UV rays and at a higher risk for damage.