Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a school-age child who is 1hr postoperative following a tonsillectomy. Which of the following actions should the nurse take? (Select all that apply.)
A. Maintain the child in a supine position.
Maintaining the child in a supine position is incorrect because it increases the risk of aspiration if bleeding or emesis occurs. The preferred position is side-lying or prone with the head slightly turned to facilitate drainage and prevent airway obstruction. Supine positioning can compromise airway safety in this postoperative period.
B. Observe the child for frequent swallowing.
Observing the child for frequent swallowing is important because it may indicate occult bleeding from the surgical site. Blood trickling into the throat can be swallowed rather than visible externally, and repeated swallowing is an early sign of hemorrhage. Prompt recognition allows for immediate intervention to prevent significant blood loss.
C. Discourage the child from coughing.
Discouraging the child from coughing is appropriate because coughing can disrupt the surgical site and increase the risk of bleeding. It can also cause irritation and pain in the throat, potentially leading to complications. Minimizing throat irritation helps protect the surgical area during healing.
D. Provide cranberry juice to the child.
Providing cranberry juice is inappropriate because acidic or red-colored liquids can irritate the throat and may be mistaken for blood if vomiting occurs. Fluids should be cool, clear, and non-irritating, such as water or apple juice. Acidic beverages may also increase discomfort at the surgical site.
E. Administer an analgesic to the child on a scheduled basis.
Administering analgesics on a scheduled basis is appropriate because it helps maintain consistent pain control and promotes comfort, hydration, and recovery. Adequate pain management encourages the child to drink fluids, reducing the risk of dehydration. It also helps minimize agitation that could disrupt the surgical site.
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
Postoperative care following a tonsillectomy in a school-age child focuses on airway protection, bleeding prevention, pain control, and promoting safe recovery. The immediate postoperative period carries a high risk for hemorrhage due to the vascular nature of the surgical site. Children may not always verbalize bleeding, so nurses must rely on subtle clinical indicators. Maintaining airway safety and minimizing irritation to the surgical site are critical priorities in care.
Rationale:
A. Maintaining the child in a supine position is incorrect because it increases the risk of aspiration if bleeding or emesis occurs. The preferred position is side-lying or prone with the head slightly turned to facilitate drainage and prevent airway obstruction. Supine positioning can compromise airway safety in this postoperative period.
B. Observing the child for frequent swallowing is important because it may indicate occult bleeding from the surgical site. Blood trickling into the throat can be swallowed rather than visible externally, and repeated swallowing is an early sign of hemorrhage. Prompt recognition allows for immediate intervention to prevent significant blood loss.
C. Discouraging the child from coughing is appropriate because coughing can disrupt the surgical site and increase the risk of bleeding. It can also cause irritation and pain in the throat, potentially leading to complications. Minimizing throat irritation helps protect the surgical area during healing.
D. Providing cranberry juice is inappropriate because acidic or red-colored liquids can irritate the throat and may be mistaken for blood if vomiting occurs. Fluids should be cool, clear, and non-irritating, such as water or apple juice. Acidic beverages may also increase discomfort at the surgical site.
E. Administering analgesics on a scheduled basis is appropriate because it helps maintain consistent pain control and promotes comfort, hydration, and recovery. Adequate pain management encourages the child to drink fluids, reducing the risk of dehydration. It also helps minimize agitation that could disrupt the surgical site.
Similar Questions
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 place hairbrushes, combs, and hair accessories in boiling water for 10 minutes."
Placing hairbrushes, combs, and hair accessories in boiling water for 10 minutes is an appropriate method to kill lice and nits on personal items. High heat effectively destroys parasites and prevents reinfestation when items are reused. This demonstrates correct understanding of environmental decontamination for pediculosis.
B. "I will seal nonwashable items in a plastic bag for 1 week."
Sealing nonwashable items in a plastic bag for 1 week is incorrect because lice cannot survive more than 1 to 2 days without a human host. Recommended quarantine for nonwashable items is typically about 48 hours to 2 days, not a full week. Prolonged sealing is unnecessary and reflects incorrect timing.
C. "I will use the medicated shampoo on my child's hair daily for 3 days."
Using medicated shampoo daily for 3 days is incorrect because most pediculicide treatments are applied once and then repeated only if needed after 7 to 10 days. Overuse can cause scalp irritation and does not improve effectiveness. Proper timing is essential to target newly hatched lice after the initial treatment.
D. "I will wash my child's clothing and bedding using a double rinse."
Washing clothing and bedding using a double rinse is unnecessary because lice are primarily transmitted through direct head contact rather than fabrics. Standard washing in hot water and drying on high heat is sufficient to eliminate lice. A double rinse does not provide added benefit in preventing reinfestation.
Full Explanation
Pediculosis (head lice infestation) is a common parasitic condition in school-age children caused by Pediculus humanus capitis. Transmission occurs through direct head-to-head contact and, less commonly, through contaminated personal items. Management involves pharmacologic treatment of the scalp and environmental decontamination of items that may harbor lice or nits. Effective eradication requires breaking the cycle of reinfestation through proper hygiene and cleaning measures.
Rationale:
A. Placing hairbrushes, combs, and hair accessories in boiling water for 10 minutes is an appropriate method to kill lice and nits on personal items. High heat effectively destroys parasites and prevents reinfestation when items are reused. This demonstrates correct understanding of environmental decontamination for pediculosis.
B. Sealing nonwashable items in a plastic bag for 1 week is incorrect because lice cannot survive more than 1 to 2 days without a human host. Recommended quarantine for nonwashable items is typically about 48 hours to 2 days, not a full week. Prolonged sealing is unnecessary and reflects incorrect timing.
C. Using medicated shampoo daily for 3 days is incorrect because most pediculicide treatments are applied once and then repeated only if needed after 7 to 10 days. Overuse can cause scalp irritation and does not improve effectiveness. Proper timing is essential to target newly hatched lice after the initial treatment.
D. Washing clothing and bedding using a double rinse is unnecessary because lice are primarily transmitted through direct head contact rather than fabrics. Standard washing in hot water and drying on high heat is sufficient to eliminate lice. A double rinse does not provide added benefit in preventing reinfestation.
A nurse in the emergency department is caring for a preschooler who has acetaminophen toxicity. The nurse should expect the provider to prescribe which of the following medications?
A. Acetylcysteine
Acetylcysteine is the antidote for acetaminophen toxicity because it replenishes glutathione stores in the liver, allowing detoxification of harmful metabolites. It is most effective when given early but can still provide benefit even after several hours post-ingestion. Administration helps prevent or reduce hepatic damage and is the standard treatment in overdose cases.
B. Disulfiram
Disulfiram is used in the management of alcohol use disorder by producing unpleasant effects when alcohol is consumed. It has no role in treating acetaminophen toxicity or reversing liver damage. Its mechanism does not address glutathione depletion or hepatotoxic metabolites.
C. Deferoxamine
Deferoxamine is a chelating agent used to treat iron toxicity by binding excess iron and promoting its excretion. It is not effective in acetaminophen poisoning because it does not interact with acetaminophen metabolites or liver injury pathways. Therefore, it is not indicated in this situation.
D. Naloxone
Naloxone is an opioid antagonist used to reverse opioid overdose by displacing opioids from receptor sites in the central nervous system. It has no effect on acetaminophen metabolism or liver toxicity. Its use is limited to opioid-related respiratory depression and not hepatotoxic overdoses.
Full Explanation
Acetaminophen toxicity occurs when excessive doses lead to depletion of glutathione stores in the liver, resulting in accumulation of a toxic metabolite, NAPQI, that causes hepatocellular injury and potentially acute liver failure. Early recognition and treatment are essential to prevent irreversible damage. Management includes gastrointestinal decontamination in some cases and administration of an antidote that restores glutathione levels. Nursing care focuses on timely intervention and monitoring of liver function.
Rationale:
A. Acetylcysteine is the antidote for acetaminophen toxicity because it replenishes glutathione stores in the liver, allowing detoxification of harmful metabolites. It is most effective when given early but can still provide benefit even after several hours post-ingestion. Administration helps prevent or reduce hepatic damage and is the standard treatment in overdose cases.
B. Disulfiram is used in the management of alcohol use disorder by producing unpleasant effects when alcohol is consumed. It has no role in treating acetaminophen toxicity or reversing liver damage. Its mechanism does not address glutathione depletion or hepatotoxic metabolites.
C. Deferoxamine is a chelating agent used to treat iron toxicity by binding excess iron and promoting its excretion. It is not effective in acetaminophen poisoning because it does not interact with acetaminophen metabolites or liver injury pathways. Therefore, it is not indicated in this situation.
D. Naloxone is an opioid antagonist used to reverse opioid overdose by displacing opioids from receptor sites in the central nervous system. It has no effect on acetaminophen metabolism or liver toxicity. Its use is limited to opioid-related respiratory depression and not hepatotoxic overdoses.
A nurse is providing teaching to a parent about sudden unexpected infant death (SUID). Which of the following statements should the nurse include?
A. "Use bumper pads around the interior of your infant's crib."
Using bumper pads around the crib is unsafe because they increase the risk of suffocation, entrapment, and impaired airflow. Soft bedding items are strongly discouraged in infant sleep environments. The crib should remain free of loose or padded materials to ensure safe sleep.
B. "Share a bedroom with your infant for the first 6 months."
Sharing a bedroom with the infant for the first 6 months is recommended because it allows the caregiver to closely monitor the infant during sleep while maintaining a separate safe sleep surface. Room-sharing has been shown to reduce the risk of SUID by facilitating early recognition of distress and promoting safer sleep practices.
C. "Place your infant on a soft crib mattress after they are 4 months old."
Placing the infant on a soft crib mattress after 4 months is unsafe because soft sleep surfaces increase the risk of suffocation and airway obstruction. Infants should always sleep on a firm, flat mattress covered with a fitted sheet regardless of age. Soft bedding remains a risk factor throughout infancy.
D. "Cover your infant with a nonflammable blanket at bedtime."
Covering the infant with a nonflammable blanket at bedtime is not recommended because any loose bedding can increase the risk of suffocation or overheating. Instead, wearable sleep sacks or appropriate clothing should be used to keep the infant warm safely without loose coverings in the crib.
Full Explanation
Sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), is associated with unsafe sleep environments and certain modifiable risk factors. Prevention focuses on safe sleep practices such as supine positioning, firm sleep surfaces, and avoiding soft bedding or overheating. Room-sharing without bed-sharing is recommended because it allows close monitoring of the infant while maintaining a separate safe sleep surface. Parental education is essential to reduce risk.
Rationale:
A. Using bumper pads around the crib is unsafe because they increase the risk of suffocation, entrapment, and impaired airflow. Soft bedding items are strongly discouraged in infant sleep environments. The crib should remain free of loose or padded materials to ensure safe sleep.
B. Sharing a bedroom with the infant for the first 6 months is recommended because it allows the caregiver to closely monitor the infant during sleep while maintaining a separate safe sleep surface. Room-sharing has been shown to reduce the risk of SUID by facilitating early recognition of distress and promoting safer sleep practices.
C. Placing the infant on a soft crib mattress after 4 months is unsafe because soft sleep surfaces increase the risk of suffocation and airway obstruction. Infants should always sleep on a firm, flat mattress covered with a fitted sheet regardless of age. Soft bedding remains a risk factor throughout infancy.
D. Covering the infant with a nonflammable blanket at bedtime is not recommended because any loose bedding can increase the risk of suffocation or overheating. Instead, wearable sleep sacks or appropriate clothing should be used to keep the infant warm safely without loose coverings in the crib.