Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a school-age child who has acute glomerulonephritis. Which of the following interventions should the nurse include?
A. Monitor blood pressure every 4 hr.
"Monitor blood pressure every 4 hr." Acute glomerulonephritis can cause hypertension due to fluid retention and impaired kidney function. Regular monitoring is essential to detect and manage hypertension early.
B. Increase fluid consumption.
"Increase fluid consumption." Fluid intake is often restricted to prevent fluid overload, especially if there is hypertension, edema, or decreased urine output.
C. Implement a protein-restricted diet.
"Implement a protein-restricted diet." A protein-restricted diet is not necessary unless the child has severe renal impairment. In most cases, moderate protein intake is recommended.
D. Collect and strain all urine for sediment.
"Collect and strain all urine for sediment." While hematuria (blood in urine) is common in acute glomerulonephritis, straining urine for sediment is not a standard intervention for this condition.
This question is an excerpt from Nurse Dive's nursing test bank - Ati rn paediatrics nursing proctored exam 2023. Take the full exam now
Full Explanation
A. "Monitor blood pressure every 4 hr." Acute glomerulonephritis can cause hypertension due to fluid retention and impaired kidney function. Regular monitoring is essential to detect and manage hypertension early.
B. "Increase fluid consumption." Fluid intake is often restricted to prevent fluid overload, especially if there is hypertension, edema, or decreased urine output.
C. "Implement a protein-restricted diet." A protein-restricted diet is not necessary unless the child has severe renal impairment. In most cases, moderate protein intake is recommended.
D. "Collect and strain all urine for sediment." While hematuria (blood in urine) is common in acute glomerulonephritis, straining urine for sediment is not a standard intervention for this condition.
Similar Questions
A school nurse is providing teaching to the guardian of a child who has pediculosis. Which of the following statements by the guardian indicates an understanding of the teaching?
A. "I will seal nonwashable items in a plastic bag for 1 week."
"I will seal nonwashable items in a plastic bag for 1 week." Nonwashable items (e.g., stuffed animals, pillows) should be sealed in a plastic bag for at least 2 weeks, not just 1 week, to ensure all lice and nits die.
B. "I will place hairbrushes, combs, and hair accessories in boiling water for 10 minutes."
"I will place hairbrushes, combs, and hair accessories in boiling water for 10 minutes." Boiling these items in water for at least 5–10 minutes effectively kills lice and nits.
C. "I will wash my child's clothing and bedding using a double rinse."
"I will wash my child's clothing and bedding using a double rinse." Clothing and bedding should be washed in hot water (at least 130°F or 54°C) and dried on high heat, but a double rinse is not necessary.
D. "I will use the medicated shampoo on my child's hair daily for 3 days."
"I will use the medicated shampoo on my child's hair daily for 3 days." Medicated lice shampoos should be used once, followed by a repeat application in 7–10 days if needed. Daily use is not recommended due to potential toxicity and irritation.
Full Explanation
A. "I will seal nonwashable items in a plastic bag for 1 week." Nonwashable items (e.g., stuffed animals, pillows) should be sealed in a plastic bag for at least 2 weeks, not just 1 week, to ensure all lice and nits die.
B. "I will place hairbrushes, combs, and hair accessories in boiling water for 10 minutes." Boiling these items in water for at least 5–10 minutes effectively kills lice and nits.
C. "I will wash my child's clothing and bedding using a double rinse." Clothing and bedding should be washed in hot water (at least 130°F or 54°C) and dried on high heat, but a double rinse is not necessary.
D. "I will use the medicated shampoo on my child's hair daily for 3 days." Medicated lice shampoos should be used once, followed by a repeat application in 7–10 days if needed. Daily use is not recommended due to potential toxicity and irritation.
A nurse is providing teaching to the guardian of an infant who has heart failure. Which of the following instructions should the nurse include?
A. Place the infant in a supine position.
"Place the infant in a supine position." Infants with heart failure often have difficulty breathing, so placing them in a semi-upright position (e.g., in a car seat or with the head elevated) can help with breathing and reduce cardiac workload.
B. Allow the infant to sleep through night feedings.
"Allow the infant to sleep through night feedings." Infants with heart failure have increased metabolic demands and may fatigue easily during feedings. Small, frequent feedings (including nighttime feedings) are important to ensure adequate nutrition.
C. Minimize the infant's environmental stimuli.
"Minimize the infant's environmental stimuli." Excessive stimulation can increase the infant’s metabolic and oxygen demands, worsening heart failure symptoms. Keeping the environment calm and quiet helps reduce stress on the heart.
D. Bathe the infant every day.
"Bathe the infant every day." While hygiene is important, daily baths can be too exhausting for an infant with heart failure. Instead, bathing should be limited to as needed (e.g., sponge baths) to prevent excessive fatigue.
Full Explanation
A. "Place the infant in a supine position." Infants with heart failure often have difficulty breathing, so placing them in a semi-upright position (e.g., in a car seat or with the head elevated) can help with breathing and reduce cardiac workload.
B. "Allow the infant to sleep through night feedings." Infants with heart failure have increased metabolic demands and may fatigue easily during feedings. Small, frequent feedings (including nighttime feedings) are important to ensure adequate nutrition.
C. "Minimize the infant's environmental stimuli." Excessive stimulation can increase the infant’s metabolic and oxygen demands, worsening heart failure symptoms. Keeping the environment calm and quiet helps reduce stress on the heart.
D. "Bathe the infant every day." While hygiene is important, daily baths can be too exhausting for an infant with heart failure. Instead, bathing should be limited to as needed (e.g., sponge baths) to prevent excessive fatigue.
A nurse is assessing a 12-year-old child who has asthma and states, "I am frustrated about not being able to participate in sports." Which of the following responses should the nurse make?
A. "You should consider finding other hobbies to participate in instead of sports."
"You should consider finding other hobbies to participate in instead of sports." Avoiding sports altogether is not necessary for children with asthma. Many children with well-managed asthma can safely participate in sports with proper precautions.
B. "You shouldn't feel frustrated, because you can find other options for exercise."
"You shouldn't feel frustrated, because you can find other options for exercise." This response dismisses the child's feelings instead of acknowledging them and providing a solution.
C. "You will be able to exercise if you use your peak expiratory flow meter twice per day."
"You will be able to exercise if you use your peak expiratory flow meter twice per day." While monitoring peak expiratory flow (PEF) is important for asthma management, it does not directly enable participation in sports.
D. "You can participate in sports if you use your rescue inhaler before practice or games."
"You can participate in sports if you use your rescue inhaler before practice or games." Using a short-acting bronchodilator (such as albuterol) before exercise is a common strategy to prevent exercise-induced bronchoconstriction, allowing children with asthma to safely participate in sports.
Full Explanation
A. "You should consider finding other hobbies to participate in instead of sports." Avoiding sports altogether is not necessary for children with asthma. Many children with well-managed asthma can safely participate in sports with proper precautions.
B. "You shouldn't feel frustrated, because you can find other options for exercise." This response dismisses the child's feelings instead of acknowledging them and providing a solution.
C. "You will be able to exercise if you use your peak expiratory flow meter twice per day." While monitoring peak expiratory flow (PEF) is important for asthma management, it does not directly enable participation in sports.
D. "You can participate in sports if you use your rescue inhaler before practice or games." Using a short-acting bronchodilator (such as albuterol) before exercise is a common strategy to prevent exercise-induced bronchoconstriction, allowing children with asthma to safely participate in sports.