Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is educating the parents of a pediatric patient who recently had a ventriculoperitoneal (VP) shunt placed to treat hydrocephalus. Which statement by the parents indicates the most critical understanding about care and potential complications?
A. We should limit physical activity and keep the child in bed to prevent dislodging the shunt.
Limiting physical activity and keeping the child in bed is incorrect because children with VP shunts do not need prolonged bed rest. Normal activity is encouraged as long as it is safe; the shunt is designed to withstand routine movement.
B. If the child develops a fever, we can give over-the-counter fever reducers and only call the doctor if it persists more than 3 days.
Managing fever with over-the-counter medications and waiting 3 days to call the provider is incorrect because fever may indicate a shunt infection, which is a medical emergency. Prompt assessment is essential for early intervention.
C. We will need to flush the shunt regularly at home to keep it from clogging.
Flushing the shunt at home is incorrect because VP shunts should never be flushed by caregivers; doing so could cause serious injury or infection. Shunt function is monitored by observing for signs of malfunction, not by manual flushing.
D. We will watch closely for sudden vomiting headache, or changes in behavior and notify the provider immediately if these occur.
Watching for sudden vomiting, headache, or changes in behavior and notifying the provider immediately is correct because these are key signs of shunt malfunction or increased intracranial pressure, which can be life-threatening. Early recognition and prompt medical evaluation are critical for preventing complications such as brain damage or infection.
This question is an excerpt from Nurse Dive's nursing test bank - Ati dmmsn 650 OB/Pediatrics Proctored Exams. Take the full exam now
Full Explanation
A. Limiting physical activity and keeping the child in bed is incorrect because children with VP shunts do not need prolonged bed rest. Normal activity is encouraged as long as it is safe; the shunt is designed to withstand routine movement.
B. Managing fever with over-the-counter medications and waiting 3 days to call the provider is incorrect because fever may indicate a shunt infection, which is a medical emergency. Prompt assessment is essential for early intervention.
C. Flushing the shunt at home is incorrect because VP shunts should never be flushed by caregivers; doing so could cause serious injury or infection. Shunt function is monitored by observing for signs of malfunction, not by manual flushing.
D. Watching for sudden vomiting, headache, or changes in behavior and notifying the provider immediately is correct because these are key signs of shunt malfunction or increased intracranial pressure, which can be life-threatening. Early recognition and prompt medical evaluation are critical for preventing complications such as brain damage or infection.
Similar Questions
The nurse is performing an assessment on a pregnant patient with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?
A. Complaints of feeling hot when the room is cold.
Complaints of feeling hot when the room is cold is incorrect because this is not a typical finding of preeclampsia and may relate to individual comfort or other conditions unrelated to preeclampsia.
B. Edema of the lower extremities.
Edema of the lower extremities is incorrect because mild to moderate edema is common in normal pregnancy and even in preeclampsia, but it is not the most critical sign of a severe complication. Lower extremity edema alone does not indicate a serious or immediate complication.
C. Evidence of bleeding, such as in gums, petechiae, and purpura.
Evidence of bleeding, such as in gums, petechiae, and purpura is correct because these findings suggest thrombocytopenia and a risk for disseminated intravascular coagulation (DIC), a serious complication of severe preeclampsia or HELLP syndrome. Bleeding and clotting abnormalities require immediate attention to prevent maternal and fetal morbidity and mortality.
D. Periods of fetal movement followed by quiet periods.
Periods of fetal movement followed by quiet periods is incorrect because this is a normal fetal behavior. While decreased fetal movement can be concerning, normal intermittent quiet periods are expected and do not indicate preeclampsia complications.
Full Explanation
A. Complaints of feeling hot when the room is cold is incorrect because this is not a typical finding of preeclampsia and may relate to individual comfort or other conditions unrelated to preeclampsia.
B. Edema of the lower extremities is incorrect because mild to moderate edema is common in normal pregnancy and even in preeclampsia, but it is not the most critical sign of a severe complication. Lower extremity edema alone does not indicate a serious or immediate complication.
C. Evidence of bleeding, such as in gums, petechiae, and purpura is correct because these findings suggest thrombocytopenia and a risk for disseminated intravascular coagulation (DIC), a serious complication of severe preeclampsia or HELLP syndrome. Bleeding and clotting abnormalities require immediate attention to prevent maternal and fetal morbidity and mortality.
D. Periods of fetal movement followed by quiet periods is incorrect because this is a normal fetal behavior. While decreased fetal movement can be concerning, normal intermittent quiet periods are expected and do not indicate preeclampsia complications.
A nurse is caring for a toddler who is hospitalized with respiratory syncytial virus (RSV). Which of the following nursing interventions is the priority?
A. Monitor oxygen saturation and apply humidified oxygen if needed
Monitor oxygen saturation and apply humidified oxygen if needed is correct. The priority for a toddler with RSV is maintaining airway patency and adequate oxygenation, as RSV can cause bronchiolitis, airway inflammation, and hypoxemia. Using the Airway, Breathing, Circulation (ABC) framework, oxygenation takes precedence over other interventions. Continuous monitoring of oxygen saturation and providing humidified oxygen as needed helps prevent respiratory distress or failure.
B. Place the child on contact and droplet precautions
Place the child on contact and droplet precautions is important for infection control, but it is not the priority over ensuring adequate oxygenation. Precautions prevent spread of RSV but do not immediately address the child’s respiratory status.
C. Administer prescribed antipyretics for a temperature of 38.5°C (101.3°F)
Administer prescribed antipyretics for a temperature of 38.5°C (101.3°F) is appropriate to manage fever, but reducing fever does not take priority over maintaining oxygenation, which is essential for survival.
D. Encourage the child to drink small, frequent amounts of fluids
Encourage the child to drink small, frequent amounts of fluids is important to prevent dehydration, especially with fever or difficulty feeding, but fluid intake is secondary to airway and breathing needs.
Full Explanation
A. Monitor oxygen saturation and apply humidified oxygen if needed is correct. The priority for a toddler with RSV is maintaining airway patency and adequate oxygenation, as RSV can cause bronchiolitis, airway inflammation, and hypoxemia. Using the Airway, Breathing, Circulation (ABC) framework, oxygenation takes precedence over other interventions. Continuous monitoring of oxygen saturation and providing humidified oxygen as needed helps prevent respiratory distress or failure.
B. Place the child on contact and droplet precautions is important for infection control, but it is not the priority over ensuring adequate oxygenation. Precautions prevent spread of RSV but do not immediately address the child’s respiratory status.
C. Administer prescribed antipyretics for a temperature of 38.5°C (101.3°F) is appropriate to manage fever, but reducing fever does not take priority over maintaining oxygenation, which is essential for survival.
D. Encourage the child to drink small, frequent amounts of fluids is important to prevent dehydration, especially with fever or difficulty feeding, but fluid intake is secondary to airway and breathing needs.
A 22 kg patient has an ordered for cefazolin 500 mg IV every 6 hours. The safe dose is 50 mg/kg/day. Is the ordered dose safe for the patient?
Full Explanation
Given:
- Patient weight = 22 kg
- Ordered dose = 500 mg IV every 6 hours (4 doses/day)
- Safe dose = 50 mg/kg/day
Step 1: Calculate the maximum safe daily dose
Maximum safe dose = 50 mg/kg/day × 22 kg
50 × 22 = 1100 mg/day
Step 2: Calculate the ordered daily dose
Ordered dose = 500 mg per dose × 4 doses/day
500 × 4 = 2000 mg/day
Step 3: Compare the ordered dose with the maximum safe dose
- Maximum safe dose = 1100 mg/day
- Ordered dose = 2000 mg/day
2000 mg/day > 1100 mg/day → not safe