Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an appropriate action for the nurse to take?
A. Place the child in Trendelenburg position when performing care.
Placing the child in Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.
B. Use clean technique to change the tracheostomy tube.
Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.
C. Have the child flex his head when securing the ties.
This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.
D. Clean around the stoma with full-strength hydrogen peroxide.
Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.
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. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.
B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.
C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.
D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.
Similar Questions
A nurse is assessing a 24-month-old toddler. Which of the following findings should the nurse report to the provider?
A. Eats a large amount of food one day then very little the next
Eating a large amount of food one day and very little the next is a normal eating pattern for toddlers. They may have days when they eat more and days when they eat less.
B. Holds his breath when having a temper tantrum
This finding should be reported to the provider. Breath-holding spells during temper tantrums can be concerning and may require further evaluation.
C. Sleeps 11 to 12 hr per day
Toddlers typically need about 11-14 hours of sleep per day, so sleeping 11 to 12 hours is within the normal range.
D. Has a vocabulary of 30 words
A vocabulary of 30 words is considered normal for a 24-month-old toddler.
Full Explanation
A. Eating a large amount of food one day and very little the next is a normal eating pattern for toddlers. They may have days when they eat more and days when they eat less.
B. This finding should be reported to the provider. Breath-holding spells during temper tantrums can be concerning and may require further evaluation.
C. Toddlers typically need about 11-14 hours of sleep per day, so sleeping 11 to 12 hours is within the normal range.
D. A vocabulary of 30 words is considered normal for a 24-month-old toddler.
A nurse is preparing a child for a lumbar puncture. In which of the following positions should the child be placed for the procedure?
A. Supine
Placing the child in a supine position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
B. Semi-Fowler's
A semi-Fowler's position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
C. Lateral
Placing the child in a lateral position allows for better access to the spinal canal, which is necessary for a lumbar puncture.
D. Prone
Placing the child in a prone position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
Full Explanation
A. Placing the child in a supine position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
B. A semi-Fowler's position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
C. Correct. Placing the child in a lateral position allows for better access to the spinal canal, which is necessary for a lumbar puncture.
D. Placing the child in a prone position is not the appropriate position for a lumbar puncture. The child should be in a lateral position.
A nurse in a community clinic is reviewing the laboratory results of four clients. The nurse should identify which of the following sexually transmitted infections is nationally notifiable.
A. Gonorrhea
Gonorrhea is a nationally notifiable sexually transmitted infection (STI). This means that healthcare providers are required to report cases of gonorrhea to public health authorities to track and monitor the spread of the disease.
B. Bacterial vaginosis trichomoniasis
Bacterial vaginosis and trichomoniasis are common STIs but are not nationally notifiable.
C. Genital herpes simplex virus
Genital herpes simplex virus is a common STI but is not nationally notifiable.
D. Human papilloma virus
Human papillomavirus (HPV) is a common STI, but it is not nationally notifiable. However, HPV vaccines are recommended to prevent certain strains of the virus that can cause cervical cancer.
Full Explanation
A. Gonorrhea is a nationally notifiable sexually transmitted infection (STI). This means that healthcare providers are required to report cases of gonorrhea to public health authorities to track and monitor the spread of the disease.
B. Bacterial vaginosis and trichomoniasis are common STIs but are not nationally notifiable.
C. Genital herpes simplex virus is a common STI but is not nationally notifiable.
D. Human papillomavirus (HPV) is a common STI, but it is not nationally notifiable.
However, HPV vaccines are recommended to prevent certain strains of the virus that can cause cervical cancer.