Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit.
Which of the following actions should the nurse take?
A. Administer aspirin to the child for fever
because aspirin should not be given to children with chickenpox, as it can cause a serious condition called Reye’s syndrome, which affects the brain and liver. Instead, acetaminophen can be used to reduce fever.
B. Use droplet precautions when caring for the child.
is wrong because droplet precautions are not enough to prevent the spread of chickenpox. Droplet precautions involve wearing a mask and gloves when in close contact with the patient, but they do not prevent the virus from traveling through the air. Airborne precautions, which include a negative air pressure room and wearing a respirator, are needed for chickenpox.
C. Assign the child to a negative air pressure room.
This is because varicella, or chickenpox, is a highly contagious disease caused by the varicellazoster virus (VZV), which can spread through the air or by direct contact with the fluid from the blisters. A negative air pressure room prevents the air from the room from circulating to other areas of the hospital, reducing the risk of transmission to other patients
D. Assess the child for Koplik spots
is wrong because Koplik spots are not a sign of chickenpox, but of measles, another viral infection that causes a rash. Chickenpox causes an itchy rash with small, fluid-filled blisters that crust over.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
This is because varicella, or chickenpox, is a highly contagious disease caused by the varicellazoster virus (VZV), which can spread through the air or by direct contact with the fluid from the blisters. A negative air pressure room prevents the air from the room from circulating to other areas of the hospital, reducing the risk of transmission to other patients and staff.
Choice A is wrong because aspirin should not be given to children with chickenpox, as it can cause a serious condition called Reye’s syndrome, which affects the brain and liver. Instead, acetaminophen can be used to reduce fever.
Choice B is wrong because droplet precautions are not enough to prevent the spread of chickenpox. Droplet precautions involve wearing a mask and gloves when in close contact with the patient, but they do not prevent the virus from traveling through the air. Airborne precautions, which include a negative air pressure room and wearing a respirator, are needed for chickenpox.
Choice D is wrong because Koplik spots are not a sign of chickenpox, but of measles, another viral infection that causes a rash. Chickenpox causes an itchy rash with small, fluid-filled blisters that crust over.
Similar Questions
A nurse in an acute care mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style.
Which of the following actions should the nurse expect from the leader during the session?
A. The leader has group members vote on what they would like to learn about during the session.
A is wrong because having group members vote on what they would like to learn about during the session is an example of a democratic leadership style, not a laissez-faire one. A democratic leader solicits input and feedback from the group, and makes decisions based on consensus and majority rule.
B. The leader lectures about medication adverse effects to the group members.
is wrong because lecturing about medication adverse effects to the group members is an example of an authoritarian leadership style, not a laissez-faire one. An authoritarian leader dictates what the group should do and how they should do it, without considering their opinions or preferences.
C. The leader allows the group to discuss whatever they would like to regarding their medications.
This is because a laissez-faire leadership style is characterized by minimal guidance and direction from the leader, and maximum freedom and autonomy for the followers. The leader does not impose any rules or expectations on the group, and lets them decide how to manage their own learning and behavior.
D. The leader encourages group members to remain silent until questions are called for.
is wrong because encouraging group members to remain silent until questions are called for is an example of a paternalistic leadership style, not a laissez-faire one.
Full Explanation
The leader allows the group to discuss whatever they would like to regarding their medications.
This is because a laissez-faire leadership style is characterized by minimal guidance and direction from the leader, and maximum freedom and autonomy for the followers.
The leader does not impose any rules or expectations on the group, and lets them decide how to manage their own learning and behavior.
Choice A is wrong because having group members vote on what they would like to learn about during the session is an example of a democratic leadership style, not a laissez-faire one.
A democratic leader solicits input and feedback from the group, and makes decisions based on consensus and majority rule.
Choice B is wrong because lecturing about medication adverse effects to the group members is an example of an authoritarian leadership style, not a laissez-faire one.
An authoritarian leader dictates what the group should do and how they should do it, without considering their opinions or preferences.
Choice D is wrong because encouraging group members to remain silent until questions are called for is an example of a paternalistic leadership style, not a laissez-faire one.
A paternalistic leader treats the group as if they are incapable of making their own decisions, and assumes a protective and nurturing role over them.
Normal ranges for leadership styles are not applicable in this context, as different styles may be more or less effective depending on the situation and the goals of the group.
However, some general advantages and disadvantages of each style are:
- Laissez-faire: Advantages - fosters creativity, independence, and self-motivation; Disadvantages - may lead to chaos, confusion, and lack of accountability.
- Democratic: Advantages - promotes participation, collaboration, and satisfaction; Disadvantages - may be time-consuming, inefficient, and conflict-prone.
- Authoritarian: Advantages - provides clarity, direction, and control; Disadvantages - may cause resentment, resistance, and dependency.
- Paternalistic: Advantages - creates trust, loyalty, and commitment; Disadvantages - may inhibit growth, development, and empowerment.
A nurse is teaching a prenatal class about infection prevention at a community center.
Which of the following statements by a client indicates an understanding of the teaching
A. I should take antibiotics when I have a virus
is wrong because antibiotics are not effective against viruses and can cause adverse effects on the fetus. The nurse should teach the client to consult the provider before taking any medication during pregnancy.
B. I can visit my nephew who has chickenpox 5 days after the sores have crusted
This statement indicates an understanding of infection prevention because it demonstrates knowledge about the contagious period of chickenpox. Visiting someone with chickenpox after the sores have crusted is a safe practice, as the person is no longer contagious.
C. I should wash hands for 10 seconds with hot water
wrong because washing hands for 10 seconds with hot water is not sufficient to prevent infection. The nurse should teach the client to wash hands for at least 20 seconds with soap and warm water, especially after working in the garden where soil may contain harmful microorganisms.
D. I can clean my cat’s litter box during my pregnancy.”. Answer and explanation
Cleaning a cat's litter box during pregnancy is generally not recommended due to the risk of toxoplasmosis, a parasitic infection that can be transmitted through cat feces. Pregnant individuals are advised to have someone else handle cat litter or to use gloves and wash their hands thoroughly if they must do it themselves.
Full Explanation
B) I can visit my nephew who has chickenpox 5 days after the sores have crusted.
This statement indicates an understanding of infection prevention because it demonstrates knowledge about the contagious period of chickenpox. Visiting someone with chickenpox after the sores have crusted is a safe practice, as the person is no longer contagious.
The other options represent misconceptions about infection prevention:
A) Taking antibiotics for a viral infection is not effective, as antibiotics are used to treat bacterial infections, not viruses.
C) This statement is identical to option B and is incorrect.
D) Cleaning a cat's litter box during pregnancy is generally not recommended due to the risk of toxoplasmosis, a parasitic infection that can be transmitted through cat feces. Pregnant individuals are advised to have someone else handle cat litter or to use gloves and wash their hands thoroughly if they must do it themselves.
A nurse is caring for an adolescent who has hyperthermia.
Which of the following actions should the nurse take?
A. Cover the adolescent with a thermal blanket
wrong because covering the adolescent with a thermal blanket would increase the body temperature and worsen hyperthermia. The nurse should remove excess clothing and use cooling measures, such as fans, ice packs, or cool fluids.
B. Submerge the adolescent’s feet in ice water
is wrong because submerging the adolescent’s feet in ice water would cause vasoconstriction and shivering, which would reduce heat loss and increase heat production. The nurse should avoid using extreme cold or ice water to cool the body.
C. Initiate seizure precautions
Hyperthermia is a condition in which the body temperature is abnormally high, usually due to exposure to heat, infection, or certain medications. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
D. Administer oral acetaminophen
is wrong because administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
Full Explanation
Hyperthermia is a condition in which the body temperature is abnormally high, usually due to exposure to heat, infection, or certain medications.
Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
Choice A is wrong because covering the adolescent with a thermal blanket would increase the body temperature and worsen hyperthermia. The nurse should remove excess clothing and use cooling measures, such as fans, ice packs, or cool fluids.
Choice B is wrong because submerging the adolescent’s feet in ice water would cause vasoconstriction and shivering, which would reduce heat loss and increase heat production. The nurse should avoid using extreme cold or ice water to cool the body.
Choice D is wrong because administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications.
Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
Normal body temperature ranges from 36.5°C to 37.5°C (97.7°F to 99.5°F). Hyperthermia is defined as a body temperature above 38.5°C (101.3°F).