Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an 8-month-old infant who has received a bolus of IV fluid for hypovolemic shock. Which of the following findings indicates the treatment was effective?
A. Temperature 38.6° C (101.5° F)
"Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. Sunken anterior fontanel
"Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. Tachycardia
"Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. Capillary refill is 2 seconds
"Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
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. "Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. "Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. "Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
Similar Questions
A nurse is performing a dressing change for a child and notices that the gauze dressing is adhering to the wound bed. Which of the following actions should the nurse take?
A. Apply firm pressure to the wound base while removing the gauze dressing.
"Apply firm pressure to the wound base while removing the gauze dressing." Applying firm pressure can cause pain and damage the wound bed, delaying healing and increasing the risk of bleeding.
B. Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing.
"Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing." Hydrogen peroxide can damage healthy tissue and delay wound healing. It is not recommended for routine wound care.
C. Continue to remove the gauze dressing by pulling it parallel to the skin.
"Continue to remove the gauze dressing by pulling it parallel to the skin." Removing a dry gauze dressing without moistening it can cause trauma to the wound bed, increasing pain and impeding healing.
D. Saturate the gauze dressing with sterile saline solution prior to removing it.
"Saturate the gauze dressing with sterile saline solution prior to removing it." Moistening the dressing with sterile saline reduces trauma to the wound, prevents tissue damage, and minimizes pain. This method is preferred for atraumatic dressing removal.
Full Explanation
A. "Apply firm pressure to the wound base while removing the gauze dressing." Applying firm pressure can cause pain and damage the wound bed, delaying healing and increasing the risk of bleeding.
B. "Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing." Hydrogen peroxide can damage healthy tissue and delay wound healing. It is not recommended for routine wound care.
C. "Continue to remove the gauze dressing by pulling it parallel to the skin." Removing a dry gauze dressing without moistening it can cause trauma to the wound bed, increasing pain and impeding healing.
D. "Saturate the gauze dressing with sterile saline solution prior to removing it." Moistening the dressing with sterile saline reduces trauma to the wound, prevents tissue damage, and minimizes pain. This method is preferred for atraumatic dressing removal.
A nurse is assessing a school-age child who is receiving IV fluids to treat dehydration. Which of the following findings should indicate to the nurse that the fluid replacement therapy has been effective?
A. Capillary refill less than 2 seconds
"Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.
B. Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)
"Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.
C. Voiding less than 1 mL/kg/hr
"Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.
D. Tachycardia
"Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.
Full Explanation
A. "Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.
B. "Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.
C. "Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.
D. "Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.
A nurse in a clinic is assessing an infant who has diarrhea, is lethargic, and has dry skin. Which of the following findings indicates moderate dehydration?
A. Decreased respiratory rate
"Decreased respiratory rate." Moderate dehydration typically causes tachypnea (increased respiratory rate), not a decreased respiratory rate. This is the body's response to metabolic acidosis caused by fluid loss.
B. Bulging anterior fontanel
"Bulging anterior fontanel." A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel due to fluid loss.
C. Mottled skin
"Mottled skin." Mottled skin can be a sign of severe dehydration or shock, but it is not a definitive indicator of moderate dehydration.
D. Capillary refill 3 seconds
"Capillary refill 3 seconds." A capillary refill time of 2–3 seconds is indicative of moderate dehydration. In severe dehydration, capillary refill would be greater than 4 seconds.
Full Explanation
A. "Decreased respiratory rate." Moderate dehydration typically causes tachypnea (increased respiratory rate), not a decreased respiratory rate. This is the body's response to metabolic acidosis caused by fluid loss.
B. "Bulging anterior fontanel." A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel due to fluid loss.
C. "Mottled skin." Mottled skin can be a sign of severe dehydration or shock, but it is not a definitive indicator of moderate dehydration.
D. "Capillary refill 3 seconds." A capillary refill time of 2–3 seconds is indicative of moderate dehydration. In severe dehydration, capillary refill would be greater than 4 seconds.