Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a school-age child who has pertussis. Which of the following actions should the nurse take?
A. Place the child in a protected environment for 48 hr.
Placing the child in a protected environment for 48 hours is not a necessary measure for managing pertussis. Pertussis is transmitted through respiratory droplets, and standard precautions are typically sufficient.
B. Administer the pertussis vaccine.
Administering the pertussis vaccine is a preventive measure, but it is not a treatment for an active infection. In this case, the child already has pertussis, so administering the vaccine will not address the current illness.
C. Restrict oral fluids to 500 mL per day.
Restricting oral fluids to 500 mL per day is not a recommended intervention for pertussis. Maintaining hydration is important, and fluid intake should be based on the child's needs.
D. Report the diagnosis to the public health department.
This is the correct action. Reporting the diagnosis of pertussis to the public health department is a crucial step in preventing the spread of the disease. It allows for contact tracing and appropriate public health measures to be implemented to limit furthertransmission.
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. Placing the child in a protected environment for 48 hours is not a necessary measure for managing pertussis. Pertussis is transmitted through respiratory droplets, and standard precautions are typically sufficient.
B. Administering the pertussis vaccine is a preventive measure, but it is not a treatment for an active infection. In this case, the child already has pertussis, so administering the vaccine will not address the current illness.
C. Restricting oral fluids to 500 mL per day is not a recommended intervention for pertussis. Maintaining hydration is important, and fluid intake should be based on the child's needs.
D. This is the correct action. Reporting the diagnosis of pertussis to the public health department is a crucial step in preventing the spread of the disease. It allows for contact tracing and appropriate public health measures to be implemented to limit further
transmission.
Similar Questions
A nurse is providing teaching to the parents of a child who has varicella about the management of the disease. Which of the following instructions should the nurse include in the teaching?
A. Keep the child away from others until the skin is clear of scabs.
This is the correct instruction. Varicella (chickenpox) is highly contagious. The child should be kept away from others until all lesions are crusted over and no new lesions have formed for at least 24 hours. This typically indicates that the child is no longer contagious.
B. Apply calamine lotion to vesicles on the child's skin.
Applying calamine lotion can help alleviate itching and discomfort associated with the vesicles. This is a supportive measure but does not address the contagious nature of the disease.
C. Dress the child in warm clothing to promote healing of vesicles.
Dressing the child in warm clothing is not specific to the management of varicella. It is important to keep the child comfortable, but this instruction does not address the contagious period.
D. Avoid giving the child a bath while vesicles are present.
It is generally safe to give the child a bath during varicella. Warm baths with mild soap can help soothe itching. However, the child should be dried gently to avoid breaking open any vesicles.
Full Explanation
A. This is the correct instruction. Varicella (chickenpox) is highly contagious. The child should be kept away from others until all lesions are crusted over and no new lesions have formed for at least 24 hours. This typically indicates that the child is no longer contagious.
B. Applying calamine lotion can help alleviate itching and discomfort associated with the vesicles. This is a supportive measure but does not address the contagious nature of the disease.
C. Dressing the child in warm clothing is not specific to the management of varicella. It is important to keep the child comfortable, but this instruction does not address the
contagious period.
D. It is generally safe to give the child a bath during varicella. Warm baths with mild soap can help soothe itching. However, the child should be dried gently to avoid breaking open any vesicles.
A nurse is reviewing the laboratory results of a preschooler who has gastroenteritis and notes the client's potassium level is 3.2 mEq/L. Which of the following assessment findings should the nurse expect?
A. Oliguria
Oliguria (decreased urine output) is not typically associated with hypokalemia. It can be a symptom of other electrolyte imbalances or kidney dysfunction.
B. Hypertension
Hypertension (high blood pressure) is not a typical finding in a child with hypokalemia. Low potassium levels are more likely to be associated with cardiac dysrhythmias and hypotension.
C. Hyperactive bowel sounds
Hyperactive bowel sounds are not directly related to hypokalemia. They can occur in various gastrointestinal conditions, but they are not a specific indicator of potassium levels.
D. Hyporeflexia
This is the correct answer. Hypokalemia (low potassium levels) can lead to decreased neuromuscular excitability, which can result in hyporeflexia (reduced reflexes). This is an important neurological sign associated with low potassium levels.
Full Explanation
A. Oliguria (decreased urine output) is not typically associated with hypokalemia. It can be a symptom of other electrolyte imbalances or kidney dysfunction.
B. Hypertension (high blood pressure) is not a typical finding in a child with hypokalemia. Low potassium levels are more likely to be associated with cardiac dysrhythmias and hypotension.
C. Hyperactive bowel sounds are not directly related to hypokalemia. They can occur in various gastrointestinal conditions, but they are not a specific indicator of potassium
levels.
D. This is the correct answer. Hypokalemia (low potassium levels) can lead to decreased neuromuscular excitability, which can result in hyporeflexia (reduced reflexes). This is an important neurological sign associated with low potassium levels.
A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?
A. "Your child's feet should be 3 to 6 inches off the ground when seated on the bicycle."
"Your child's feet should be 3 to 6 inches off the ground when seated on the bicycle." This instruction is not related to safety. Proper seat height is important for comfort and efficiency but does not directly impact safety.
B. "Your child should keep the bicycle at least 3 feet from the curb while riding in the street."
This is the correct instruction. Maintaining a distance of at least 3 feet from the curb while riding in the street allows space for maneuvering and helps prevent collisions with obstacles or parked cars.
C. "Your child should walk the bicycle through intersections."
"Your child should walk the bicycle through intersections." This is a good safety practice. Walking the bicycle through intersections reduces the risk of accidents with other vehicles.
D. "Your child should ride the bicycle against the flow of traffic."
"Your child should ride the bicycle against the flow of traffic." This is incorrect.Children should ride their bicycles in the same direction as traffic. Riding against traffic increases the risk of accidents.
Full Explanation
A. "Your child's feet should be 3 to 6 inches off the ground when seated on the bicycle." This instruction is not related to safety. Proper seat height is important for comfort and efficiency but does not directly impact safety.
B. This is the correct instruction. Maintaining a distance of at least 3 feet from the curb while riding in the street allows space for maneuvering and helps prevent collisions with obstacles or parked cars.
C. "Your child should walk the bicycle through intersections." This is a good safety practice. Walking the bicycle through intersections reduces the risk of accidents with other vehicles.
D. "Your child should ride the bicycle against the flow of traffic." This is incorrect.
Children should ride their bicycles in the same direction as traffic. Riding against traffic increases the risk of accidents.