Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an adolescent who is postoperative following epidural anesthesia. Which of the following findings should the nurse expect?
A. Hypertension
"Hypertension" Epidural anesthesia typically causes hypotension, not hypertension, due to vasodilation and decreased sympathetic nervous system activity.
B. Mild sedation
"Mild sedation" While some systemic absorption of anesthetics may occur, epidural anesthesia primarily affects sensory and motor function rather than causing significant sedation.
C. Urinary retention
"Urinary retention" Epidural anesthesia can inhibit bladder sensation and detrusor muscle function, leading to urinary retention. The nurse should monitor urine output and assess for bladder distention.
D. Respiratory depression
"Respiratory depression" While respiratory depression can occur with high doses of opioids administered through an epidural, it is not a common expected effect of epidural anesthesia alone.
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. "Hypertension" Epidural anesthesia typically causes hypotension, not hypertension, due to vasodilation and decreased sympathetic nervous system activity.
B. "Mild sedation" While some systemic absorption of anesthetics may occur, epidural anesthesia primarily affects sensory and motor function rather than causing significant sedation.
C. "Urinary retention" Epidural anesthesia can inhibit bladder sensation and detrusor muscle function, leading to urinary retention. The nurse should monitor urine output and assess for bladder distention.
D. "Respiratory depression" While respiratory depression can occur with high doses of opioids administered through an epidural, it is not a common expected effect of epidural anesthesia alone.
Similar Questions
A nurse is caring for a pediatric client receiving radiation therapy to the abdominal area. Which of the following statements by the nurse promotes proper skin integrity for the client?
A. "Do not wash the area with strong soaps and do not rub the area dry, just pat it dry."
"Do not wash the area with strong soaps and do not rub the area dry, just pat it dry." Radiation therapy can cause skin irritation and dryness. Using mild soap, lukewarm water, and gently patting the area dry helps prevent further irritation and promotes skin integrity.
B. "Apply some triple antibiotic ointment to help the dryness and itching."
"Apply some triple antibiotic ointment to help the dryness and itching." Antibiotic ointments are not recommended unless there is an infection. Instead, radiation patients should use gentle, fragrance-free moisturizers as directed by their provider.
C. "You should get an abdominal binder and try to keep the area covered."
"You should get an abdominal binder and try to keep the area covered." Tight or restrictive clothing can further irritate the skin and increase the risk of breakdown in the radiation-exposed area.
D. "You need to keep the area exposed to air and direct sunshine."
"You need to keep the area exposed to air and direct sunshine." Direct sun exposure can worsen radiation burns and should be avoided. The skin in the treated area is more sensitive to UV rays and at a higher risk for damage.
Full Explanation
A. "Do not wash the area with strong soaps and do not rub the area dry, just pat it dry." Radiation therapy can cause skin irritation and dryness. Using mild soap, lukewarm water, and gently patting the area dry helps prevent further irritation and promotes skin integrity.
B. "Apply some triple antibiotic ointment to help the dryness and itching." Antibiotic ointments are not recommended unless there is an infection. Instead, radiation patients should use gentle, fragrance-free moisturizers as directed by their provider.
C. "You should get an abdominal binder and try to keep the area covered." Tight or restrictive clothing can further irritate the skin and increase the risk of breakdown in the radiation-exposed area.
D. "You need to keep the area exposed to air and direct sunshine." Direct sun exposure can worsen radiation burns and should be avoided. The skin in the treated area is more sensitive to UV rays and at a higher risk for damage.
A nurse is teaching an adolescent how to manage his cystic fibrosis. Which of the following statements by the adolescent indicates an understanding of the teaching?
A. "I will be excused from physical education class."
"I will be excused from physical education class." Exercise is encouraged for children with cystic fibrosis (CF) because it helps clear mucus from the lungs and improves overall lung function.
B. "I will increase my intake of vitamin D."
"I will increase my intake of vitamin D." People with CF have difficulty absorbing fat-soluble vitamins (A, D, E, and K) due to pancreatic insufficiency. Vitamin D supplementation is essential to prevent deficiencies and support bone health.
C. "I will limit my calcium intake to prevent kidney stones."
"I will limit my calcium intake to prevent kidney stones." CF patients are at risk for osteoporosis due to malabsorption of calcium and vitamin D, so they should increase, not limit, their calcium intake.
D. "I will take fewer enzymes when I eat high-fat foods."
"I will take fewer enzymes when I eat high-fat foods." CF patients require pancreatic enzyme replacement therapy (PERT) with every meal and snack to aid digestion. More enzymes, not fewer, are needed for high-fat meals to properly digest and absorb nutrients.
Full Explanation
A. "I will be excused from physical education class." Exercise is encouraged for children with cystic fibrosis (CF) because it helps clear mucus from the lungs and improves overall lung function.
B. "I will increase my intake of vitamin D." People with CF have difficulty absorbing fat-soluble vitamins (A, D, E, and K) due to pancreatic insufficiency. Vitamin D supplementation is essential to prevent deficiencies and support bone health.
C. "I will limit my calcium intake to prevent kidney stones." CF patients are at risk for osteoporosis due to malabsorption of calcium and vitamin D, so they should increase, not limit, their calcium intake.
D. "I will take fewer enzymes when I eat high-fat foods." CF patients require pancreatic enzyme replacement therapy (PERT) with every meal and snack to aid digestion. More enzymes, not fewer, are needed for high-fat meals to properly digest and absorb nutrients.
A nurse is preparing to obtain a urine specimen from a 5-month-old infant using a urine collection bag. Which of the following actions should the nurse take?
A. Attach the bag first to the perineum, then to the skin above the urethra.
"Attach the bag first to the perineum, then to the skin above the urethra." Proper technique involves first securing the collection bag to the perineum to ensure a snug fit, then pressing it firmly to the surrounding skin to prevent leaks.
B. Remove the bag 1 hr after the infant voids.
"Remove the bag 1 hr after the infant voids." The bag should be removed as soon as sufficient urine is collected to avoid contamination or leakage.
C. Place absorbent cotton balls inside the bag.
"Place absorbent cotton balls inside the bag." Absorbent materials would absorb the urine, making it difficult to retrieve an adequate sample for testing.
D. Apply petroleum jelly to the perineum before applying the bag.
"Apply petroleum jelly to the perineum before applying the bag." Petroleum jelly could prevent the bag from adhering properly, leading to leakage or contamination.
Full Explanation
A. "Attach the bag first to the perineum, then to the skin above the urethra." Proper technique involves first securing the collection bag to the perineum to ensure a snug fit, then pressing it firmly to the surrounding skin to prevent leaks.
B. "Remove the bag 1 hr after the infant voids." The bag should be removed as soon as sufficient urine is collected to avoid contamination or leakage.
C. "Place absorbent cotton balls inside the bag." Absorbent materials would absorb the urine, making it difficult to retrieve an adequate sample for testing.
D. "Apply petroleum jelly to the perineum before applying the bag." Petroleum jelly could prevent the bag from adhering properly, leading to leakage or contamination.