Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Auscultate the abdomen for at least 1 min if bowel sounds are absent.
Auscultate the abdomen for at least 1 min if bowel sounds are absent. This is an appropriate action. Absence of bowel sounds can indicate a serious condition, so the nurse should auscultate for at least 1 minute to confirm their absence. However, it is generally recommended to listen for up to 5 minutes before concluding that bowel sounds are absent.
B. Use the bell stethoscope to auscultate breath sounds.
Use the bell stethoscope to auscultate breath sounds. The diaphragm of the stethoscope, not the bell, is typically used to auscultate breath sounds because it is better at picking up higher-pitched sounds like those of the lungs.
C. Check visual acuity by using the tumbling E eyechart.
Check visual acuity by using the tumbling E eyechart. The tumbling E chart is appropriate for pre-schoolers who may not know the alphabet. This chart helps assess visual acuity in young children by having them identify the direction of the E's legs.
D. Place hand on the preschooler's abdomen to determine respiratory rate.
Place hand on the pre-schooler’s abdomen to determine respiratory rate. Placing a hand on the abdomen can help in counting the respiratory rate in infants and very young children who are diaphragmatic breathers, but for pre-schoolers, it is typically easier and more accurate to count respirations by observing the chest rise.
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Full Explanation
A. Auscultate the abdomen for at least 1 min if bowel sounds are absent. This is an appropriate action. Absence of bowel sounds can indicate a serious condition, so the nurse should auscultate for at least 1 minute to confirm their absence. However, it is generally recommended to listen for up to 5 minutes before concluding that bowel sounds are absent.
B. Use the bell stethoscope to auscultate breath sounds. The diaphragm of the stethoscope, not the bell, is typically used to auscultate breath sounds because it is better at picking up higher-pitched sounds like those of the lungs.
C. Check visual acuity by using the tumbling E eyechart. The tumbling E chart is appropriate for pre-schoolers who may not know the alphabet. This chart helps assess visual acuity in young children by having them identify the direction of the E's legs.
D. Place hand on the pre-schooler’s abdomen to determine respiratory rate. Placing a hand on the abdomen can help in counting the respiratory rate in infants and very young children who are diaphragmatic breathers, but for pre-schoolers, it is typically easier and more accurate to count respirations by observing the chest rise.
Similar Questions
A nurse is caring for a child on a pediatric unit who is at the end-of-life stage. Which of the following actions should the nurse take to help the sibling cope with the child's diagnosis?
A. Consult the Child Life Specialist to speak with the sibling.
Consult the Child Life Specialist to speak with the sibling. Child Life Specialists are trained to help children and their families cope with illness, hospitalization, and the end-of-life process. This is an appropriate and supportive action.
B. Discourage the sibling from talking about their feelings with the child.
Discourage the sibling from talking about their feelings with the child. Discouraging the sibling from expressing their feelings can be harmful and inhibit healthy emotional processing. Open communication should be encouraged.
C. Limit the amount of time the sibling spends at the hospital.
Limit the amount of time the sibling spends at the hospital. Limiting time at the hospital might make the sibling feel excluded or increase feelings of fear and anxiety. Involvement and presence can be beneficial for coping.
D. Have the sibling leave the room during the child's care.
Have the sibling leave the room during the child's care. Excluding the sibling during care can increase feelings of anxiety and helplessness. Involvement in appropriate aspects of care can be helpful for the sibling's coping process.
Full Explanation
A. Consult the Child Life Specialist to speak with the sibling. Child Life Specialists are trained to help children and their families cope with illness, hospitalization, and the end-of-life process. This is an appropriate and supportive action.
B. Discourage the sibling from talking about their feelings with the child. Discouraging the sibling from expressing their feelings can be harmful and inhibit healthy emotional processing. Open communication should be encouraged.
C. Limit the amount of time the sibling spends at the hospital. Limiting time at the hospital might make the sibling feel excluded or increase feelings of fear and anxiety. Involvement and presence can be beneficial for coping.
D. Have the sibling leave the room during the child's care. Excluding the sibling during care can increase feelings of anxiety and helplessness. Involvement in appropriate aspects of care can be helpful for the sibling's coping process.
A nurse in a pediatric clinic is planning care for four children. The nurse should anticipate a provider's prescription for an auditory evaluation for which of the following children?
A. A 3-year-old child with a newly applied cast for a fractured arm who stutters
A 3-year-old child with a newly applied cast for a fractured arm who stutters: Stuttering in a 3-year-old is not an immediate indicator for an auditory evaluation unless accompanied by other signs of hearing issues.
B. A 3-month-old infant discharged two days ago after hospitalization for bacterial meningitis
A 3-month-old infant discharged two days ago after hospitalization for bacterial meningitis: Bacterial meningitis can lead to hearing loss, so an auditory evaluation is appropriate for this infant to assess for any hearing impairment resulting from the infection.
C. A 24-month-old toddler who recently completed a course of erythromycin for treatment of pertussis
A 24-month-old toddler who recently completed a course of erythromycin for treatment of pertussis: Erythromycin use is not typically associated with hearing loss. The focus should be on monitoring recovery from pertussis.
D. A 6-month-old infant who is experiencing loose stools and is babbling loudly
A 6-month-old infant who is experiencing loose stools and is babbling loudly: Loose stools and babbling are not related to hearing issues and do not indicate the need for an auditory evaluation.
Full Explanation
A. A 3-year-old child with a newly applied cast for a fractured arm who stutters: Stuttering in a 3-year-old is not an immediate indicator for an auditory evaluation unless accompanied by other signs of hearing issues.
B. A 3-month-old infant discharged two days ago after hospitalization for bacterial meningitis: Bacterial meningitis can lead to hearing loss, so an auditory evaluation is appropriate for this infant to assess for any hearing impairment resulting from the infection.
C. A 24-month-old toddler who recently completed a course of erythromycin for treatment of pertussis: Erythromycin use is not typically associated with hearing loss. The focus should be on monitoring recovery from pertussis.
D. A 6-month-old infant who is experiencing loose stools and is babbling loudly: Loose stools and babbling are not related to hearing issues and do not indicate the need for an auditory evaluation.
A nurse in a pediatric clinic is assessing a 6-month-old infant. Which of the following findings should the nurse identify as an indication of a visual Impairment?
A. The infant reacts to bright light.
The infant reacts to bright light. Reacting to bright light is a normal response and indicates that the infant can see. This does not indicate a visual impairment.
B. The infant's corneal light reflex is symmetrical.
The infant's corneal light reflex is symmetrical. A symmetrical corneal light reflex indicates proper eye alignment and does not suggest a visual impairment.
C. The infant does not fixate and follow an object.
The infant does not fixate and follow an object. By 6 months, an infant should be able to fixate on and follow an object. Failure to do so can be an indication of a visual impairment.
D. The infant's red reflex is present bilaterally.
The infant's red reflex is present bilaterally. A normal red reflex in both eyes indicates that the eyes are clear and healthy. Absence of the red reflex could suggest a problem, but its presence does not indicate impairment.
Full Explanation
A. The infant reacts to bright light. Reacting to bright light is a normal response and indicates that the infant can see. This does not indicate a visual impairment.
B. The infant's corneal light reflex is symmetrical. A symmetrical corneal light reflex indicates proper eye alignment and does not suggest a visual impairment.
C. The infant does not fixate and follow an object. By 6 months, an infant should be able to fixate on and follow an object. Failure to do so can be an indication of a visual impairment.
D. The infant's red reflex is present bilaterally. A normal red reflex in both eyes indicates that the eyes are clear and healthy. Absence of the red reflex could suggest a problem, but its presence does not indicate impairment.