Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a school-age child who has a new prescription for Buck's traction. Which of the following actions should the nurse take?
A. Adjust the weights to allow the child to turn.
Adjusting the weights to allow the child to turn is incorrect because the traction system must remain continuous and properly aligned at all times. Weights should hang freely without interference to maintain consistent traction force. Altering or adjusting weights can disrupt alignment and compromise treatment effectiveness.
B. Perform pin care every 24 hr.
Performing pin care every 24 hours is incorrect because Buck’s traction is a skin traction system and does not involve pins. Pin care is only required for skeletal traction where pins are inserted into bone. Since Buck’s traction uses straps and adhesive, pin care is not applicable.
C. Ensure the pulley mechanism is attached to the child' skin.
Ensuring the pulley mechanism is attached to the child’s skin is incorrect because the pulley system is not attached to the skin but to the traction frame or bed. The skin is only involved through adhesive traction materials. Attaching mechanical components to the skin would be unsafe and inappropriate.
D. Offer opioid medications frequently to reduce pain.
Offering opioid medications frequently to reduce pain is appropriate because Buck’s traction and underlying fracture can cause significant pain. Adequate pain control promotes comfort, cooperation, and effective alignment. Opioids are commonly used for moderate to severe pain in pediatric orthopedic injuries when appropriately prescribed and monitored.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Paediatrics Nursing 2023 Proctored Exam. Take the full exam now
Full Explanation
Buck’s traction is a form of skin traction commonly used in pediatric clients with lower extremity fractures to reduce muscle spasms, maintain alignment, and promote comfort prior to definitive treatment. It involves applying a pulling force using weights and a pulley system. Proper nursing care focuses on maintaining correct alignment, preventing complications, and ensuring adequate pain control. Because fractures and traction can cause significant discomfort, effective analgesia is an important part of care.
Rationale:
A. Adjusting the weights to allow the child to turn is incorrect because the traction system must remain continuous and properly aligned at all times. Weights should hang freely without interference to maintain consistent traction force. Altering or adjusting weights can disrupt alignment and compromise treatment effectiveness.
B. Performing pin care every 24 hours is incorrect because Buck’s traction is a skin traction system and does not involve pins. Pin care is only required for skeletal traction where pins are inserted into bone. Since Buck’s traction uses straps and adhesive, pin care is not applicable.
C. Ensuring the pulley mechanism is attached to the child’s skin is incorrect because the pulley system is not attached to the skin but to the traction frame or bed. The skin is only involved through adhesive traction materials. Attaching mechanical components to the skin would be unsafe and inappropriate.
D. Offering opioid medications frequently to reduce pain is appropriate because Buck’s traction and underlying fracture can cause significant pain. Adequate pain control promotes comfort, cooperation, and effective alignment. Opioids are commonly used for moderate to severe pain in pediatric orthopedic injuries when appropriately prescribed and monitored.
Similar Questions
A nurse is caring for a child who has impetigo contagiosa that developed in the hospital. Which of the following actions should the nurse take?
A. Initiate contact isolation precautions.
Initiating contact isolation precautions is correct because impetigo is spread through direct skin-to-skin contact and contaminated surfaces. Contact precautions include gloves, gown use, and proper hand hygiene to prevent transmission. This is essential in a hospital setting to control nosocomial spread of the infection.
B. Administer amphotericin B IV.
Amphotericin B IV is an antifungal medication used for severe systemic fungal infections, not bacterial skin infections like impetigo. Since impetigo is caused by bacteria, antifungal therapy is ineffective and inappropriate. Antibiotics, either topical or systemic, are the correct treatment approach.
C. Report the disease to the state health department.
Reporting the disease to the state health department is not required for impetigo contagiosa because it is a common, non-reportable skin infection. It requires infection control measures within the hospital, but it does not meet criteria for mandatory public health reporting.
D. Apply lidocaine ointment topically.
Applying lidocaine ointment topically is not appropriate because impetigo does not typically cause pain requiring local anesthetic treatment. The condition is managed with antibacterial therapy rather than symptomatic anesthetic relief. Additionally, topical anesthetics may irritate broken skin and are not indicated.
Full Explanation
Impetigo contagiosa is a highly contagious superficial bacterial skin infection commonly caused by Staphylococcus aureus or Streptococcus pyogenes. It is characterized by honey-colored crusted lesions and spreads easily through direct contact with infected skin or contaminated objects. In the hospital setting, preventing transmission is a priority to protect other patients and healthcare workers. Infection control measures are essential alongside antibiotic therapy to limit spread.
Rationale:
A. Initiating contact isolation precautions is correct because impetigo is spread through direct skin-to-skin contact and contaminated surfaces. Contact precautions include gloves, gown use, and proper hand hygiene to prevent transmission. This is essential in a hospital setting to control nosocomial spread of the infection.
B. Amphotericin B IV is an antifungal medication used for severe systemic fungal infections, not bacterial skin infections like impetigo. Since impetigo is caused by bacteria, antifungal therapy is ineffective and inappropriate. Antibiotics, either topical or systemic, are the correct treatment approach.
C. Reporting the disease to the state health department is not required for impetigo contagiosa because it is a common, non-reportable skin infection. It requires infection control measures within the hospital, but it does not meet criteria for mandatory public health reporting.
D. Applying lidocaine ointment topically is not appropriate because impetigo does not typically cause pain requiring local anesthetic treatment. The condition is managed with antibacterial therapy rather than symptomatic anesthetic relief. Additionally, topical anesthetics may irritate broken skin and are not indicated.
A nurse is assessing a client who is receiving radiation therapy to the chest. The client reports having an area of dry skin where they received radiation. Which of the following interventions should the nurse suggest to the client?
A. Apply an over-the-counter skin lotion to the area as needed.
Applying an over-the-counter skin lotion as needed is not recommended unless specifically approved by the radiation oncology provider. Many lotions contain perfumes, alcohol, or other irritants that can worsen skin breakdown or interfere with radiation effects. Only prescribed or approved products should be used on irradiated skin.
B. Clean the area daily with a solution of chlorhexidine and water.
Cleaning the area daily with chlorhexidine and water is inappropriate because chlorhexidine can be too harsh and may further irritate already sensitive radiation-treated skin. The area should be washed gently with mild soap and lukewarm water, avoiding strong antiseptics. Harsh cleansing agents increase dryness and discomfort.
C. Cover the area with protective clothing if exposed to the sun.
Covering the area with protective clothing if exposed to the sun is correct because irradiated skin becomes highly sensitive to sunlight and can burn easily. Direct sun exposure can worsen dryness, erythema, and tissue damage. Loose, soft clothing helps protect the area while minimizing friction and additional irritation.
D. Remove skin markings for the radiation fields following therapy.
Removing skin markings for the radiation fields is incorrect because these markings guide accurate and consistent delivery of radiation therapy. Erasing them may disrupt treatment precision and require remarking by the provider. Clients should be instructed to preserve these markings until treatment is completed.
Full Explanation
Radiation therapy to the chest commonly causes localized skin reactions because rapidly dividing skin cells are sensitive to radiation exposure. Clients may develop dryness, erythema, peeling, and irritation in the treatment field, similar to a sunburn. Nursing care focuses on protecting the affected skin, preventing further irritation, and promoting healing without disrupting treatment planning. Proper skin care teaching is essential to reduce complications and improve comfort during therapy.
Rationale:
A. Applying an over-the-counter skin lotion as needed is not recommended unless specifically approved by the radiation oncology provider. Many lotions contain perfumes, alcohol, or other irritants that can worsen skin breakdown or interfere with radiation effects. Only prescribed or approved products should be used on irradiated skin.
B. Cleaning the area daily with chlorhexidine and water is inappropriate because chlorhexidine can be too harsh and may further irritate already sensitive radiation-treated skin. The area should be washed gently with mild soap and lukewarm water, avoiding strong antiseptics. Harsh cleansing agents increase dryness and discomfort.
C. Covering the area with protective clothing if exposed to the sun is correct because irradiated skin becomes highly sensitive to sunlight and can burn easily. Direct sun exposure can worsen dryness, erythema, and tissue damage. Loose, soft clothing helps protect the area while minimizing friction and additional irritation.
D. Removing skin markings for the radiation fields is incorrect because these markings guide accurate and consistent delivery of radiation therapy. Erasing them may disrupt treatment precision and require remarking by the provider. Clients should be instructed to preserve these markings until treatment is completed.
A nurse in the emergency department is assessing a preschooler who was brought in by a parent and has injuries consistent with physical maltreatment. Which of the following actions should the nurse take when interviewing the child?
A. Document subjective information after the interview.
Documentation after the interview should focus on objective findings and the child’s exact words rather than subjective interpretation. Recording subjective information can introduce bias and may weaken the legal value of the documentation. Accurate documentation should be factual, precise, and completed promptly, but the nurse should avoid relying on subjective statements.
B. Encourage the parent to remain with the child.
Encouraging the parent to remain with the child is inappropriate when physical maltreatment is suspected because the caregiver may be the source of abuse or may influence the child’s responses. The child should be interviewed separately in a safe environment where they can speak freely without fear of intimidation or pressure. Privacy helps improve the reliability of the information obtained.
C. Conduct the interview in a semi-private room.
Conducting the interview in a semi-private room is not appropriate because confidentiality and safety are essential during abuse assessment. A fully private setting is necessary to protect the child’s emotional well-being and to allow open communication without interruptions or exposure to others. Semi-private spaces may increase anxiety and limit disclosure.
D. Allow the child to have their favorite stuffed animal.
Allowing the child to have their favorite stuffed animal provides comfort, reduces anxiety, and helps establish a sense of safety during the interview. Familiar objects can be especially reassuring for preschool children in stressful healthcare situations. This supports therapeutic communication and helps the child feel more secure while discussing sensitive experiences.
Full Explanation
When assessing a child with suspected physical maltreatment, the nurse must create a safe, calm, and supportive environment that encourages honest communication while minimizing fear and anxiety. Preschool children may feel frightened, confused, or reluctant to speak, especially in unfamiliar emergency settings. Therapeutic communication should be developmentally appropriate and nonthreatening. Comfort measures that promote trust and emotional security help the child participate more effectively in the interview.
Rationale:
A. Documentation after the interview should focus on objective findings and the child’s exact words rather than subjective interpretation. Recording subjective information can introduce bias and may weaken the legal value of the documentation. Accurate documentation should be factual, precise, and completed promptly, but the nurse should avoid relying on subjective statements.
B. Encouraging the parent to remain with the child is inappropriate when physical maltreatment is suspected because the caregiver may be the source of abuse or may influence the child’s responses. The child should be interviewed separately in a safe environment where they can speak freely without fear of intimidation or pressure. Privacy helps improve the reliability of the information obtained.
C. Conducting the interview in a semi-private room is not appropriate because confidentiality and safety are essential during abuse assessment. A fully private setting is necessary to protect the child’s emotional well-being and to allow open communication without interruptions or exposure to others. Semi-private spaces may increase anxiety and limit disclosure.
D. Allowing the child to have their favorite stuffed animal provides comfort, reduces anxiety, and helps establish a sense of safety during the interview. Familiar objects can be especially reassuring for preschool children in stressful healthcare situations. This supports therapeutic communication and helps the child feel more secure while discussing sensitive experiences.