Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the insertion of an IV catheter. Which of the following actions should the nurse plan to take?
A. Avoid removing the cream prior to the procedure.
The cream should be removed after it has been on the skin for the recommended amount of time. It is typically wiped off before the procedure.
B. Gently rub the cream into the skin.
Correct. To ensure proper absorption, the cream should be gently rubbed into the skin.This helps the medication to penetrate the skin and provide local anesthesia.
C. Wash the site with alcohol prior to applying the cream.
Washing the site with alcohol before applying the cream is not necessary and may cause unnecessary skin irritation.
D. Apply the cream 1 hr before the procedure.
Lidocaine and prilocaine cream typically requires about 30 minutes to take effect. It does not need to be applied 1 hour before the procedure.
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. The cream should be removed after it has been on the skin for the recommended amount of time. It is typically wiped off before the procedure.
B. The medication should applied repeatedly to provide analgesia
C. Washing the site with alcohol before applying the cream is not necessary and may cause unnecessary skin irritation.
D. Lidocaine and prilocaine cream typically require about 60 minutes to take effect.
Similar Questions
A nurse in an emergency department is caring for a preschool-age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?
A. Hyperpyrexia
Hyperpyrexia, or extremely high fever, is a potential complication of acuteacetylsalicylic acid (aspirin) poisoning. It can occur due to the toxic effects of salicylates on the hypothalamus, which regulates body temperature.
B. Polyuria
Polyuria (excessive urination) is not a typical finding associated with acute acetylsalicylic acid poisoning.
C. Jaundice
Jaundice (yellowing of the skin and eyes) is not a typical finding associated with acute acetylsalicylic acid poisoning.
D. Neck vein distention
Neck vein distention is not a typical finding associated with acute acetylsalicylic acid poisoning. It may be a sign of increased central venous pressure, which is not directly related to salicylate toxicity.
Full Explanation
A. Hyperpyrexia, or extremely high fever, is a potential complication of acute
acetylsalicylic acid (aspirin) poisoning. It can occur due to the toxic effects of salicylates on the hypothalamus, which regulates body temperature.
B. Polyuria (excessive urination) is not a typical finding associated with acute acetylsalicylic acid poisoning.
C. Jaundice (yellowing of the skin and eyes) is not a typical finding associated with acute acetylsalicylic acid poisoning.
D. Neck vein distention is not a typical finding associated with acute acetylsalicylic acid poisoning. It may be a sign of increased central venous pressure, which is not directly related to salicylate toxicity.
A school nurse is assessing a 7-year-old student. The nurse should identify which of the following findings as a potential indicator of physical abuse?
A. Abrasions on the knees
Abrasions on the knees may be common in active children and may not necessarily indicate physical abuse.
B. Front deciduous teeth missing
Front deciduous teeth missing is a normal occurrence as children lose their baby teeth and grow permanent teeth. It is not indicative of physical abuse.
C. Weight in 45th percentile
Weight in the 45th percentile indicates that the child's weight falls within the average range for their age. This finding is not indicative of physical abuse.
D. Bruising around the wrists
Bruising around the wrists can be a concerning sign, especially if it suggests that the child has been restrained or grabbed forcefully. This finding raises suspicion of physical abuse and should be further assessed and reported if necessary.
Full Explanation
A. Abrasions on the knees may be common in active children and may not necessarily indicate physical abuse.
B. Front deciduous teeth missing is a normal occurrence as children lose their baby teeth and grow permanent teeth. It is not indicative of physical abuse.
C. Weight in the 45th percentile indicates that the child's weight falls within the average range for their age. This finding is not indicative of physical abuse.
D. Bruising around the wrists can be a concerning sign, especially if it suggests that the child has been restrained or grabbed forcefully. This finding raises suspicion of physical abuse and should be further assessed and reported if necessary.
A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?
A. Tighten the screws on the halo device one-quarter turn every 48 hr.
Tightening the screws on the halo device is not within the nurse's scope of practice.This should be done by a qualified healthcare provider.
B. Assess the pin sites for infection once every other day.
Assessing the pin sites for signs of infection is an important nursing responsibility. Infection at the pin sites can lead to serious complications.
C. Encourage flexion and extension of the neck.
Encouraging flexion and extension of the neck is contraindicated for a client with a halo vest in place. The device is designed to immobilize the cervical spine, and anymovement of the neck should be strictly controlled.
D. Reposition the client using a turning sheet.
Repositioning the client using a turning sheet is an appropriate nursing intervention.However, the primary concern in this scenario is the assessment of pin sites for signs of infection.
Full Explanation
- A: Tighten the screws on the halo device one-quarter turn every 48 hr.
- Rationale: This action is incorrect because the screws on a halo device should not be adjusted by the nurse. The screws are typically set and secured by a healthcare provider, and any adjustments can compromise the integrity of the device and the stability of the cervical spine.
- B: Assess the pin sites for infection once every other day.
- Rationale: While it is important to monitor the pin sites for signs of infection, doing so once every other day may not be sufficient. Pin sites should be assessed at least once per shift to ensure early detection and management of any potential infection.
- C: Encourage flexion and extension of the neck.
- Rationale: This action is contraindicated for a client with a halo vest. The purpose of the halo vest is to immobilize the cervical spine to promote healing. Encouraging neck movement could cause further injury or delay healing.
- D: Reposition the client using a turning sheet.
- Rationale: This is the correct action. Using a turning sheet helps to reposition the client safely and effectively without exerting unnecessary pressure on the cervical spine. It also aids in preventing pressure ulcers and promotes comfort for the client.