Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?
A. Beefy, red tongue
B. Productive cough with thick mucus
Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis bacteria. It causes severe coughing spells that can interfere with breathing and produce a characteristic whooping sound when inhaling. The cough may also be accompanied by thick mucus that can be difficult to clear. Therefore, a nurse should expect to see a productive cough with thick mucus as a manifestation of pertussis in a child. The other options are not typical manifestations of pertussis, but rather of other conditions. A beefy, red tongue may indicate vitamin B12 deficiency or pernicious anemia. Facial erythema may indicate fever, allergy, or inflammation. Peeling of the hands and feet may indicate Kawasaki disease, a rare inflammatory disorder that affects the blood vessels.
C. Facial erythema
D. Peeling of the hands and feet
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is B. Productive cough with thick mucus. Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis bacteria. It causes severe coughing spells that can interfere with breathing and produce a characteristic whooping sound when inhaling. The cough may also be accompanied by thick mucus that can be difficult to clear. Therefore, a nurse should expect to see a productive cough with thick mucus as a manifestation of pertussis in a child. The other options are not typical manifestations of pertussis, but rather of other conditions. A beefy, red tongue may indicate vitamin B12 deficiency or pernicious anemia. Facial erythema may indicate fever, allergy, or inflammation. Peeling of the hands and feet may indicate Kawasaki disease, a rare inflammatory disorder that affects the blood vessels.
Similar Questions
A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take?
A. Explain medical terminology using basic, one-syllable words.
While explaining medical terminology using basic, one-syllable words can help in understanding, it is not always practical or necessary. Medical terms often require more than one syllable to convey accurate information.
B. Write the information at an 8th-grade reading level.
Writing the information at an 8th-grade reading level ensures that the brochure is accessible to a broad audience. This readability level is recommended for health education materials to ensure comprehension by the general public.
C. Present information from complex to simple.
Presenting information from complex to simple can confuse readers. It is generally more effective to start with simple concepts and gradually introduce more complex information.
D. Use a 12-point font size
Using a 12-point font size is important for readability, but it is not the most critical factor in ensuring the brochure is understandable. The content’s readability level is more crucial.
Full Explanation
The correct answer is choice b. Write the information at an 8th-grade reading level.
Choice A rationale:
While explaining medical terminology using basic, one-syllable words can help in understanding, it is not always practical or necessary. Medical terms often require more than one syllable to convey accurate information.
Choice B rationale:
Writing the information at an 8th-grade reading level ensures that the brochure is accessible to a broad audience. This readability level is recommended for health education materials to ensure comprehension by the general public.
Choice C rationale:
Presenting information from complex to simple can confuse readers. It is generally more effective to start with simple concepts and gradually introduce more complex information.
Choice D rationale:
Using a 12-point font size is important for readability, but it is not the most critical factor in ensuring the brochure is understandable. The content’s readability level is more crucial.
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
A. Febrile
B. Circulatory overload
C. Acute hemolytic
D. Anaphylactic
Anaphylactic reactions are characterized by urticaria, wheezing, hypotension, and bronchospasm. They are caused by an IgE-mediated hypersensitivity to plasma proteins in the donor blood.
Full Explanation
The correct answer is D. Anaphylactic reactions are characterized by urticaria, wheezing, hypotension, and bronchospasm. They are caused by an IgE-mediated hypersensitivity to plasma proteins in the donor blood.
A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)
A. Plan care for a client who has dysphagia.
Planning care, especially for a client with dysphagia (difficulty swallowing), involves assessment, evaluation, and critical thinking, which are within the scope of practice for licensed nurses, not APs. This task should not be delegated to an AP.
B. Transfer a client who is receiving radiation therapy to radiology.
Transferring a client, especially one undergoing radiation therapy, often involves understanding specific precautions and handling techniques. This task is generally within the scope of APs, provided they have proper training and understand any specific precautions related to the client's condition.
C. Record urine output for a client who has a suprapubic catheter
Recording urine output is ataskthat can be delegated to an assistive personnel under the supervision of a registerednurse, as they do not require nursing judgment or assessment skills.
D. Measure vital signs for a client who requires contact precautions.
Measuring vital signs is a taskthat can be delegated to an assistive personnel under the supervision of a registered nurse, as they do not require nursing judgment or assessment skills.
Full Explanation
A. Planning care, especially for a client with dysphagia (difficulty swallowing), involves assessment, evaluation, and critical thinking, which are within the scope of practice for licensed nurses, not APs. This task should not be delegated to an AP.
B. Transferring a client, especially one undergoing radiation therapy, often involves understanding specific precautions and handling techniques. This task is generally within the scope of APs, provided they have proper training and understand any specific precautions related to the client's condition.
C. Recording urine output is ataskthat can be delegated to an assistive personnel under the supervision of a registerednurse, as they do not require nursing judgment or assessment skills.
D. Measuring vital signs is a taskthat can be delegated to an assistive personnel under the supervision of a registered nurse, as they do not require nursing judgment or assessment skills.