Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following actions should the nurse take?
A. Report the diagnosis to the public health department
Pertussis, also known as whooping cough, is a highly contagious bacterial disease. Health care providers are required to report cases of pertussis to the local health department to help track and control the spread of the disease.
B. Place the child in a protected environment for 48hr
Placing the child in a protected environment for 48 hours is not a standard action for a child with pertussis. The child will need to be isolated until they have completed a full course of antibiotics to prevent spreading the infection.
C. Administer the pertussis vaccine
Administering the pertussis vaccine is not typically done when a child is already infected. The vaccine is used for prevention, not treatment.
D. Restrict oral fluids to 500mL per day
Restricting oral fluids to 500 mL per day is not a standard action for a child with pertussis. Adequate hydration is important for children with respiratory infections.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Pediatrics Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale
Pertussis, also known as whooping cough, is a highly contagious bacterial disease. Health care providers are required to report cases of pertussis to the local health department to help track and control the spread of the disease.
Choice B rationale
Placing the child in a protected environment for 48 hours is not a standard action for a child with pertussis. The child will need to be isolated until they have completed a full course of antibiotics to prevent spreading the infection.
Choice C rationale
Administering the pertussis vaccine is not typically done when a child is already infected. The vaccine is used for prevention, not treatment.
Choice D rationale
Restricting oral fluids to 500 mL per day is not a standard action for a child with pertussis. Adequate hydration is important for children with respiratory infections.
Similar Questions
A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline.
Which of the following findings should the nurse expect?
A. Pinpoint pupils
Pinpoint pupils are not a typical finding in an adolescent who has inhaled gasoline. Pinpoint pupils are more commonly associated with opioid use.
B. Hypothermia
Hypothermia is not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
C. Ataxia
Ataxia, or lack of muscle coordination, can occur after inhaling gasoline. The gasoline vapors can depress the central nervous system, leading to symptoms such as dizziness, confusion, and ataxia.
D. Hyperactive reflexes
Hyperactive reflexes are not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
Full Explanation
Choice A rationale
Pinpoint pupils are not a typical finding in an adolescent who has inhaled gasoline. Pinpoint pupils are more commonly associated with opioid use.
Choice B rationale
Hypothermia is not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
Choice C rationale
Ataxia, or lack of muscle coordination, can occur after inhaling gasoline. The gasoline vapors can depress the central nervous system, leading to symptoms such as dizziness, confusion, and ataxia.
Choice D rationale
Hyperactive reflexes are not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
A nurse is assisting an infant who has respiratory syncytial virus.
For which of the following findings should the nurse intervene?
A. Brisk capillary refill
Brisk capillary refill is a normal finding and does not require intervention.
B. Tachypnea
Tachypnea, or rapid breathing, is a common symptom of respiratory syncytial virus (RSV) infection in infants. It can indicate that the infant is having difficulty breathing and needs immediate intervention.
C. Rhinorrhea
Rhinorrhea, or a runny nose, is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
D. Coughing
Coughing is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
Full Explanation
Choice A rationale
Brisk capillary refill is a normal finding and does not require intervention.
Choice B rationale
Tachypnea, or rapid breathing, is a common symptom of respiratory syncytial virus (RSV) infection in infants. It can indicate that the infant is having difficulty breathing and needs immediate intervention.
Choice C rationale
Rhinorrhea, or a runny nose, is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
Choice D rationale
Coughing is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
A nurse is assessing a toddler who is 8 hr. postoperative following a cardiac catheterization procedure.
Which of the following findings should the nurse report to the provider?
A. Weak pedal pulse distal to the site
A weak pedal pulse distal to the site of a cardiac catheterization procedure could indicate a vascular complication, such as a hematoma or thrombosis, and should be reported to the provider immediately.
B. Blood pressure 102/58mm Hg
A blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not need to be reported to the provider.
C. Bilateral cool extremities
Bilateral cool extremities can be a normal finding in a child who is recovering from anesthesia. However, if coolness is accompanied by other signs of poor perfusion, such as pallor or delayed capillary refill, it should be reported to the provider.
D. Serum glucose 90mg/dL
A serum glucose level of 90 mg/dL is within the normal range for a toddler and does not need to be reported to the provider.
Full Explanation
Choice A rationale
A weak pedal pulse distal to the site of a cardiac catheterization procedure could indicate a vascular complication, such as a hematoma or thrombosis, and should be reported to the provider immediately.
Choice B rationale
A blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not need to be reported to the provider.
Choice C rationale
Bilateral cool extremities can be a normal finding in a child who is recovering from anesthesia. However, if coolness is accompanied by other signs of poor perfusion, such as pallor or delayed capillary refill, it should be reported to the provider.
Choice D rationale
A serum glucose level of 90 mg/dL is within the normal range for a toddler and does not need to be reported to the provider.