Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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.
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. "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.
Similar Questions
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.
A nurse is caring for an 8-month-old infant who has received a bolus of IV fluid for hypovolemic shock. Which of the following findings indicates the treatment was effective?
A. Temperature 38.6° C (101.5° F)
"Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. Sunken anterior fontanel
"Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. Tachycardia
"Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. Capillary refill is 2 seconds
"Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
Full Explanation
A. "Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. "Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. "Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
A nurse is performing a dressing change for a child and notices that the gauze dressing is adhering to the wound bed. Which of the following actions should the nurse take?
A. Apply firm pressure to the wound base while removing the gauze dressing.
"Apply firm pressure to the wound base while removing the gauze dressing." Applying firm pressure can cause pain and damage the wound bed, delaying healing and increasing the risk of bleeding.
B. Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing.
"Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing." Hydrogen peroxide can damage healthy tissue and delay wound healing. It is not recommended for routine wound care.
C. Continue to remove the gauze dressing by pulling it parallel to the skin.
"Continue to remove the gauze dressing by pulling it parallel to the skin." Removing a dry gauze dressing without moistening it can cause trauma to the wound bed, increasing pain and impeding healing.
D. Saturate the gauze dressing with sterile saline solution prior to removing it.
"Saturate the gauze dressing with sterile saline solution prior to removing it." Moistening the dressing with sterile saline reduces trauma to the wound, prevents tissue damage, and minimizes pain. This method is preferred for atraumatic dressing removal.
Full Explanation
A. "Apply firm pressure to the wound base while removing the gauze dressing." Applying firm pressure can cause pain and damage the wound bed, delaying healing and increasing the risk of bleeding.
B. "Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing." Hydrogen peroxide can damage healthy tissue and delay wound healing. It is not recommended for routine wound care.
C. "Continue to remove the gauze dressing by pulling it parallel to the skin." Removing a dry gauze dressing without moistening it can cause trauma to the wound bed, increasing pain and impeding healing.
D. "Saturate the gauze dressing with sterile saline solution prior to removing it." Moistening the dressing with sterile saline reduces trauma to the wound, prevents tissue damage, and minimizes pain. This method is preferred for atraumatic dressing removal.