Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse should identify which of the following findings as an indication of the therapy has been effective?
A. Increased urine output
Increased urine output is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
B. increase expectoration
Increased expectoration, or coughing up and spitting out mucus, is a sign that chest physiotherapy is effective. The goal of chest physiotherapy is to help clear the thick, sticky mucus from the lungs of children with cystic fibrosis. Reduced pain is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
C. reduced pain
D. increased heart rate .
An increased heart rate is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Pediatrics Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale
Increased urine output is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
Choice B rationale
Increased expectoration, or coughing up and spitting out mucus, is a sign that chest physiotherapy is effective. The goal of chest physiotherapy is to help clear the thick, sticky mucus from the lungs of children with cystic fibrosis.
Reduced pain is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
Choice D rationale
An increased heart rate is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
Similar Questions
A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full thickness burn to 10% of this body.
Which of the following findings should the nurse report to the provider?
A. Increased restlessness
Increased restlessness in a toddler with a full-thickness burn may indicate hypoxia, pain, or shock. These conditions require immediate medical attention to prevent further complications and ensure proper management of the burn injury.
B. Respiratory rate 25/min
A respiratory rate of 25 breaths per minute is within the normal range for a toddler. It does not require immediate reporting to the provider.
C. Bowel sounds 20/min
Bowel sounds of 20/min are within the normal range (5-30 sounds per minute). This finding does not indicate any gastrointestinal complications that need to be reported to the provider.
D. Urinary output 35 mL/hr
A urinary output of 35 mL/hr is lower than the expected urine output for a toddler. In a child of this weight, the expected urine output is typically higher. This finding may indicate decreased renal perfusion, which should be reported to the provider for further evaluation.
Full Explanation
The correct answer is Choice A.
Choice A rationale: Increased restlessness in a toddler with a full-thickness burn may indicate hypoxia, pain, or shock. These conditions require immediate medical attention to prevent further complications and ensure proper management of the burn injury.
Choice B rationale: A respiratory rate of 25/min is within the normal range for toddlers (20-30 breaths per minute). This finding does not indicate an immediate concern that requires reporting to the provider.
Choice C rationale: Bowel sounds of 20/min are within the normal range (5-30 sounds per minute). This finding does not indicate any gastrointestinal complications that need to be reported to the provider.
Choice D rationale: Urinary output of 35 mL/hr is within the normal range for toddlers (1-2 mL/kg/hr). This finding indicates adequate kidney function and hydration status, so it does not require immediate reporting.
A nurse in an emergency department is caring for a child who experienced a submersion injury.
Which of the following is the priority action for the nurse to take?
A. Assist with intubation
Assisting with intubation is the priority action. A submersion injury can cause respiratory distress or failure, and ensuring a clear airway is critical. Intubation is often necessary to maintain oxygenation and prevent complications like hypoxia or aspiration.
B. Obtain an ABG sample
Obtaining an ABG sample is important to assess the child’s oxygenation and acid-base balance, but it is not the priority action. Ensuring the airway is clear and secured takes precedence over diagnostic tests.
C. Administer an IV bolus
Administering an IV bolus might be necessary for fluid resuscitation if the child is experiencing shock, but establishing and maintaining the airway is the first critical step in managing submersion injuries.
D. Apply warming blankets
Applying warming blankets can be important to prevent hypothermia, especially if the child has been in cold water. However, addressing airway and breathing issues is the top priority before initiating warming measures.
Full Explanation
The correct answer is Choice A.
Choice A rationale: Assisting with intubation is the priority action. A submersion injury can cause respiratory distress or failure, and ensuring a clear airway is critical. Intubation is often necessary to maintain oxygenation and prevent complications like hypoxia or aspiration.
Choice B rationale: Obtaining an ABG sample is important to assess the child’s oxygenation and acid-base balance, but it is not the priority action. Ensuring the airway is clear and secured takes precedence over diagnostic tests.
Choice C rationale: Administering an IV bolus might be necessary for fluid resuscitation if the child is experiencing shock, but establishing and maintaining the airway is the first critical step in managing submersion injuries.
Choice D rationale: Applying warming blankets can be important to prevent hypothermia, especially if the child has been in cold water. However, addressing airway and breathing issues is the top priority before initiating warming measures.
A nurse is assessing a toddler who has a history of lead poisoning.
Which of the following actions should the nurse take?
A. Obtain a stool specimen for lead levels
Obtaining a stool specimen for lead levels is not the appropriate action in this scenario. Lead poisoning is typically assessed through blood lead levels, not stool specimens. Stool specimens are more commonly used for assessing gastrointestinal issues or infections rather than lead levels.
B. Initiate a low-iron diet for lead absorption
Initiating a low-iron diet for lead absorption is not recommended. Iron deficiency can actually increase lead absorption in the body, so reducing iron intake could potentially exacerbate the issue. Instead, ensuring an adequate intake of iron-rich foods may be beneficial for overall health but is not a primary intervention for lead poisoning.
C. Perform developmental testing for delays
Lead poisoning can lead to cognitive, behavioral, and developmental impairments, making developmental testing crucial for assessing potential delays and planning interventions. Developmental testing allows healthcare providers to identify any areas of concern early on, enabling them to implement appropriate interventions to support the child's development and mitigate the effects of lead poisoning.
D. Inspect the skin for discoloration
Inspecting the skin for discoloration is not a relevant action for assessing lead poisoning. While lead poisoning can manifest in various symptoms, skin discoloration is not typically associated with lead exposure. Other signs and symptoms such as cognitive, behavioral, and developmental impairments are more indicative of lead poisoning.
Full Explanation
Question 1: The correct answer is Choice c. Perform developmental testing for delays.
Lead poisoning can lead to cognitive, behavioral, and developmental impairments, making developmental testing crucial for assessing potential delays and planning interventions. Developmental testing allows healthcare providers to identify any areas of concern early on, enabling them to implement appropriate interventions to support the child's development and mitigate the effects of lead poisoning.
Choice A rationale: Obtaining a stool specimen for lead levels is not the appropriate action in this scenario. Lead poisoning is typically assessed through blood lead levels, not stool specimens. Stool specimens are more commonly used for assessing gastrointestinal issues or infections rather than lead levels.
Choice B rationale: Initiating a low-iron diet for lead absorption is not recommended. Iron deficiency can actually increase lead absorption in the body, so reducing iron intake could potentially exacerbate the issue. Instead, ensuring an adequate intake of iron-rich foods may be beneficial for overall health but is not a primary intervention for lead poisoning.
Choice D rationale: Inspecting the skin for discoloration is not a relevant action for assessing lead poisoning. While lead poisoning can manifest in various symptoms, skin discoloration is not typically associated with lead exposure. Other signs and symptoms such as cognitive, behavioral, and developmental impairments are more indicative of lead poisoning.