Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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.
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. 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.
Similar Questions
A nurse is preparing to administer ondansetron 0.15 mg/kg IV to a child who is receiving chemotherapy and weighs 29.4 kg. Available is ondansetron 4 mg/2 mL solution. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the dose of ondansetron for a child who is receiving chemotherapy, the nurse needs to use the following formula:
Dose (mL) = (Dose ordered in mg / Dose available in mg) x Volume available in mL
In this case, the dose ordered in mg is 0.15 mg/kg x 29.4 kg, which equals 4.41 mg. The dose available in mg is 4 mg, and the volume available in mL is 2 mL. Therefore, the dose in mL is:
Dose (mL) = (4.41 mg / 4 mg) x 2 mL Dose (mL) = 2.205 mL
The nurse should round the answer to the nearest tenth, so the final answer is 2.2 mL. The nurse should administer 2.2 mL of ondansetron IV to the child who is receiving chemotherapy.
A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing, and urticaria after receiving an IV medication. Which of the following actions should the nurse take first?
A. Administer methylprednisolone.
Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severeanaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.
B. Administer oxygen.
Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,low blood pressure, and hives.
C. Administer epinephrine.
This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.
D. Administer a nebulized bronchodilator.
Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first- line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing theallergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.
Full Explanation
A. Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severe
anaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.
B. Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,
low blood pressure, and hives.
C. This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.
D. Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first-line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing the
allergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.
A nurse is teaching the guardian of a 5-year-old child who has encopresis about the management of the condition. Which of the following statements by the guardian indicates an understanding of the teaching?
A. "I will have my child try to defecate 15 minutes after each meal."
This statement demonstrates an understanding of a helpful strategy for managing encopresis. Having the child try to defecate 15 minutes after each meal can take advantage of the body's natural reflexes and increase the likelihood of regular bowel movements.
B. "I will limit my child's fluid intake."
Limiting fluid intake is not a recommended strategy for managing encopresis. Maintaining proper hydration is important for overall health.
C. "I will have my child sit on the toilet for 20 minutes at a time."
Having the child sit on the toilet for extended periods of time may lead to frustration and aversion to toilet training. It is not a recommended approach.
D. "I will increase my child's dairy intake."
Increasing dairy intake is not a specific strategy for managing encopresis. In fact, some dairy products can contribute to constipation in some individuals. A balanced diet with an appropriate amount of fiber is important for bowel regularity.
Full Explanation
A. This statement demonstrates an understanding of a helpful strategy for managing encopresis. Having the child try to defecate 15 minutes after each meal can take advantage of the body's natural reflexes and increase the likelihood of regular bowel movements.
B. Limiting fluid intake is not a recommended strategy for managing encopresis.
Maintaining proper hydration is important for overall health.
C. Having the child sit on the toilet for extended periods of time may lead to frustration and aversion to toilet training. It is not a recommended approach.
D. Increasing dairy intake is not a specific strategy for managing encopresis. In fact, some dairy products can contribute to constipation in some individuals. A balanced diet with an appropriate amount of fiber is important for bowel regularity.