Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an infant who has gastroenteritis.
Which of the following assessment findings should the nurse report to the provider?
A. Sunken fontanels and dry mucous membranes
These are signs of severe dehydration in an infant, which can be life-threatening and should be reported to the provider immediately. The infant may need intravenous fluids and electrolytes to restore hydration and prevent complications.
B. Temperature 38° C (100.4° F) and pulse rate 124/min.
A temperature of 38° C (100.4° F) and pulse rate of 124/min are not abnormal for an infant and do not indicate severe dehydration. These are common findings in an infant who has gastroenteritis, which is an inflammation of the stomach and intestines caused by a virus, bacteria, or parasite.
C. Decreased appetite and irritability.
Decreased appetite and irritability are also common findings in an infant who has gastroenteritis, but they do not indicate severe dehydration. The nurse should encourage oral rehydration with fluids such as breast milk, formula, or oral electrolyte solution.
D. Pale and a 24-hr fluid deficit of 30 mL.
Pale skin and a 24-hr fluid deficit of 30 mL are not signs of severe dehydration in an infant.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
These are signs of severe dehydration in an infant, which can be life-threatening and should be reported to the provider immediately. The infant may need intravenous fluids and electrolytes to restore hydration and prevent complications.
Choice B is wrong because a temperature of 38° C (100.4° F) and pulse rate of 124/min are not abnormal for an infant and do not indicate severe dehydration. These are common findings in an infant who has gastroenteritis, which is an inflammation of the stomach and intestines caused by a virus, bacteria, or parasite.
Choice C is wrong because decreased appetite and irritability are also common findings in an infant who has gastroenteritis, but they do not indicate severe dehydration. The nurse should encourage oral rehydration with fluids such as breast milk, formula, or oral electrolyte solution.
Choice D is wrong because pale skin and a 24-hr fluid deficit of 30 mL are not signs of severe dehydration in an infant.
A fluid deficit of 30 mL is less than 1 oz and is not significant for an infant who weighs about 10 kg (22 lbs). A fluid deficit of more than 10% of body weight would indicate severe dehydration.
Normal ranges for vital signs in infants are as follows:
- Temperature: 36.5° C to 37.5° C (97.7° F to 99.5° F)
- Pulse rate: 100 to 160/min
- Respiratory rate: 30 to 60/min
- Blood pressure: 65/41 to 100/50 mm Hg
Normal ranges for fluid intake and output in infants are as follows:
- Fluid intake: 100 to 150 mL/kg/day
- Fluid output: 1 to 2 mL/kg/hr
Similar Questions
A hospice nurse is visiting with the son of a client who has terminal cancer.
The son reports sleeping very little during the past week due to caring for his mother.
Which of the following responses should the nurse make?
A. I can give you information about respite care if you are interested
I can give you information about respite care if you are interested.” Respite care is a service that provides short-term inpatient care for terminally-ill patients at a professional care facility, such as a hospital, hospice inpatient care facility, or nursing home. It is meant to relieve caregiver stress and offer them rest and time away from caregiving duties. Respite care is covered by Medicare for up to five consecutive days and no more than one respite period in a single billing period. The nurse should offer this option to the son who is experiencing sleep deprivation due to caring for his mother.
B. You should consider taking a sleeping pill before bed each night
because it suggests that the son should rely on medication to cope with his situation, which may not be appropriate or effective. Sleeping pills may have side effects or interactions with other drugs, and they do not address the underlying cause of the son’s stress and fatigue.
C. I am sure you’re doing a great job taking care of your mother
because it does not acknowledge the son’s need for support or assistance. It may sound like an empty compliment or a dismissal of the son’s concerns. The nurse should express empathy and compassion, but also provide information and resources that can help the son.
D. It is always difficult caring for someone who is terminally ill
because it does not offer any solution or guidance to the son. It may also sound like a cliché or a generalization that does not reflect the son’s unique experience. The nurse should avoid making assumptions or judgments about the son’s feelings or situation, and instead focus on his needs and preferences.
Full Explanation
The correct answer is choice A. “I can give you information about respite care if you are interested.” Respite care is a service that provides short-term inpatient care for terminally-ill patients at a professional care facility, such as a hospital, hospice inpatient care facility, or nursing home. It is meant to relieve caregiver stress and offer them rest and time away from caregiving duties. Respite care is covered by Medicare for up to five consecutive days and no more than one respite period in a single billing period.
The nurse should offer this option to the son who is experiencing sleep deprivation due to caring for his mother.
Choice B is wrong because it suggests that the son should rely on medication to cope with his situation, which may not be appropriate or effective.
Sleeping pills may have side effects or interactions with other drugs, and they do not address the underlying cause of the son’s stress and fatigue.
Choice C is wrong because it does not acknowledge the son’s need for support or assistance.
It may sound like an empty compliment or a dismissal of the son’s concerns.
The nurse should express empathy and compassion, but also provide information and resources that can help the son.
Choice D is wrong because it does not offer any solution or guidance to the son.
It may also sound like a cliché or a generalization that does not reflect the son’s unique experience.
The nurse should avoid making assumptions or judgments about the son’s feelings or situation, and instead focus on his needs and preferences.
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department.
Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
A. Engage the panic alarm
Engaging the panic alarm is not the first action to take when interacting with an agitated client. The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures. Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.
B. Use a face shield with a mask when providing care to the client.
Using a face shield with a mask when providing care to the client is not relevant to the situation. This is a personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation. Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.
C. Tell the client, “You seem to be very upset.”
Tell the client, “You seem to be very upset.”. This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically. It also shows empathy and respect for the client’s perspective.
D. Initiate seclusion protocol.
Initiating seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly. Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.
Full Explanation
Tell the client, “You seem to be very upset.”.
This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically. It also shows empathy and respect for the client’s perspective.
Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.
The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.
Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.
Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.
This is a personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.
Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.
Choice D is wrong because initiating seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.
Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.
It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.
Secluding an agitated client may escalate their behavior and violate their rights.
Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.
However, some tools that can be used to assess agitation include the Richmond AgitationSedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).
A nurse is providing teaching to a client who has a new prescription for enoxaparin.
Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
A. Naproxen sodium.
the nurse should instruct the client to avoid taking pain relievers such as naproxen sodiumwhile on enoxaparin
B. Ibuprofen.
the nurse should instruct the client to avoid taking pain relievers such as ibuprofenwhile on enoxaparin
C. Acetaminophen.
is a pain reliever that does not affect blood clotting and can be taken safely with enoxaparin. However, the client should follow the directions on the box to make sure they do not take more than the recommended amount of acetaminophen, as it can cause liver damage in high doses.
D. Aspirin.
the nurse should instruct the client to avoid taking pain relievers such as aspirinwhile on enoxaparin
E. undefined
Full Explanation
Enoxaparin is a blood thinner that helps prevent the formation of blood clots in people who have certain medical conditions or who are undergoing certain procedures. Enoxaparin can increase the risk of bleeding, especially if taken with other medications that affect blood clotting, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin.
Therefore, the nurse should instruct the client to avoid taking pain relievers such as naproxen sodium (choice A), ibuprofen (choice B), or aspirin (choice D) while on enoxaparin. These pain relievers can make the client more likely to bleed when on enoxaparin. Acetaminophen (choice C) is a pain reliever that does not affect blood clotting and can be taken safely with enoxaparin. However, the client should follow the directions on the box to make sure they do not take more than the recommended amount of acetaminophen, as it can cause liver damage in high doses.