Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full-thickness burn to 10% of his body. Which of the following findings should the nurse report to the provider?
A. Increased restlessness
Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate 25/min
Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds 20/min
Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output 35 mL/hr
Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.
This question is an excerpt from Nurse Dive's nursing test bank - RN Nursing Care of Children 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
A. Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.
Similar Questions
A nurse is assessing a child who has heart failure. Which of the following findings is a clinical manifestation associated with this diagnosis?
A. Tremors
Tremors are not a typical clinical manifestation of heart failure. They may be associated with conditions like hyperthyroidism or certain medications.
B. Bradycardia
Bradycardia (slow heart rate) is not a typical finding in heart failure. In fact, tachycardia (fast heart rate) is more commonly associated with this condition.
C. Increased appetite
Increased appetite is not a typical clinical manifestation of heart failure. Children with heart failure may actually experience poor appetite due to decreased cardiac output.
D. Tachypnea
Tachypnea (rapid breathing) is a common clinical manifestation of heartfailure. It can occur as the body tries to compensate for the decreased cardiac output by increasing respiratory rate in an effort to maintain oxygenation.
Full Explanation
A. Tremors are not a typical clinical manifestation of heart failure. They may be associated with conditions like hyperthyroidism or certain medications.
B. Bradycardia (slow heart rate) is not a typical finding in heart failure. In fact, tachycardia (fast heart rate) is more commonly associated with this condition.
C. Increased appetite is not a typical clinical manifestation of heart failure. Children with heart failure may actually experience poor appetite due to decreased cardiac output.
D. Correct. Tachypnea (rapid breathing) is a common clinical manifestation of heart
failure. It can occur as the body tries to compensate for the decreased cardiac output by increasing respiratory rate in an effort to maintain oxygenation.
A nurse is teaching a parent about home interventions for a preschooler who is experiencing night terrors. Which of the following instructions should the nurse include in the teaching?
A. "Allow your child to watch an animated movie right before bedtime."
Allowing the child to watch an animated movie right before bedtime can be stimulating and may not be conducive to a calm and restful sleep environment.
B. "Avoid allowing your child to sleep in your bed."
This is correct. Allowing the child to sleep in the parent's bed may reinforce the night terrors. It's important for the child to learn to self-soothe and feel secure in their own sleeping environment.
C. "Wake your child up during the night terror."
It is not recommended to wake a child during a night terror. This can be disorienting and may not be effective in preventing future night terrors.
D. "Wait until your child indicates that he is tired before putting him to bed."
Waiting until the child indicates tiredness before putting them to bed may result in over-tiredness, which can sometimes contribute to night terrors. Establishing a consistent bedtime routine can be beneficial.
Full Explanation
A. Allowing the child to watch an animated movie right before bedtime can be stimulating and may not be conducive to a calm and restful sleep environment.
B. This is correct. Allowing the child to sleep in the parent's bed may reinforce the night terrors. It's important for the child to learn to self-soothe and feel secure in their own sleeping environment.
C. It is not recommended to wake a child during a night terror. This can be disorienting and may not be effective in preventing future night terrors.
D. Waiting until the child indicates tiredness before putting them to bed may result in over-tiredness, which can sometimes contribute to night terrors. Establishing a consistent bedtime routine can be beneficial.
A nurse is planning care for an adolescent following the repair of the Meckel diverticulum. Which of the following actions should the nurse include in the plan of care?
A. Teach the client about ostomy care.
Teaching the client about ostomy care is unnecessary because surgical repair of Meckel diverticulum does not typically require an ostomy.
B. Administer total parenteral nutrition.
Administering total parenteral nutrition (TPN) is not routinely required postoperatively unless there are significant complications affecting digestion.
C. Initiate long-term antibiotic therapy.
Initiating long-term antibiotic therapy is not standard post-surgical care for Meckel diverticulum repair; antibiotics are usually given short-term to prevent infection.
D. Maintain an NG tube for decompression.
Maintaining an NG tube for decompression is appropriate because postoperative bowel rest is needed to prevent distension and reduce the risk of complications such as ileus.
Full Explanation
A. Teaching the client about ostomy care is unnecessary because surgical repair of Meckel diverticulum does not typically require an ostomy.
B. Administering total parenteral nutrition (TPN) is not routinely required postoperatively unless there are significant complications affecting digestion.
C. Initiating long-term antibiotic therapy is not standard post-surgical care for Meckel diverticulum repair; antibiotics are usually given short-term to prevent infection.
D. Maintaining an NG tube for decompression is appropriate because postoperative bowel rest is needed to prevent distension and reduce the risk of complications such as ileus.