Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a parent of a toddler how to prepare for the arrival of their newborn sibling. Which of the following statements by the parent indicates to the nurse an understanding of the teaching?
A. "I will start sending my toddler to daycare once the baby is born."
"I will start sending my toddler to daycare once the baby is born." Introducing major changes, like starting daycare, immediately after a new sibling's arrival may cause stress and feelings of rejection. If a change is necessary, it should be introduced well before the baby arrives to allow the toddler time to adjust.
B. "I will anticipate that my toddler might demand to have their pacifier again once their sibling is born."
"I will anticipate that my toddler might demand to have their pacifier again once their sibling is born." Regression is a common response in toddlers when a new sibling arrives. They may return to earlier behaviors such as wanting a pacifier, asking to be bottle-fed, or having potty-training setbacks. Parents should offer reassurance and patience rather than discouraging these behaviors.
C. "I will tell my toddler now about the date their sibling will arrive."
"I will tell my toddler now about the date their sibling will arrive." Toddlers have a limited understanding of time, so telling them too early can lead to confusion and anxiety. Instead, parents should introduce the idea gradually and use tangible events (e.g., "When the leaves start falling, the baby will be here").
D. "I will tell my toddler the baby will be their new playmate."
"I will tell my toddler the baby will be their new playmate." A newborn will not be an immediate playmate, and telling a toddler this may lead to disappointment or frustration. Instead, parents should explain that newborns need a lot of care but will grow and play later.
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. "I will start sending my toddler to daycare once the baby is born." Introducing major changes, like starting daycare, immediately after a new sibling's arrival may cause stress and feelings of rejection. If a change is necessary, it should be introduced well before the baby arrives to allow the toddler time to adjust.
B. "I will anticipate that my toddler might demand to have their pacifier again once their sibling is born." Regression is a common response in toddlers when a new sibling arrives. They may return to earlier behaviors such as wanting a pacifier, asking to be bottle-fed, or having potty-training setbacks. Parents should offer reassurance and patience rather than discouraging these behaviors.
C. "I will tell my toddler now about the date their sibling will arrive." Toddlers have a limited understanding of time, so telling them too early can lead to confusion and anxiety. Instead, parents should introduce the idea gradually and use tangible events (e.g., "When the leaves start falling, the baby will be here").
D. "I will tell my toddler the baby will be their new playmate." A newborn will not be an immediate playmate, and telling a toddler this may lead to disappointment or frustration. Instead, parents should explain that newborns need a lot of care but will grow and play later.
Similar Questions
A nurse is providing teaching about home care to a parent of a 3-year-old child who has a fever. Which of the following instructions should the nurse include in the teaching?
A. Apply a light blanket if the child begins to shiver.
"Apply a light blanket if the child begins to shiver." Shivering can increase body temperature, so a light blanket can provide comfort while preventing excessive heat retention. Over-bundling should be avoided.
B. Wake the child every 4 hr during the night to drink 118.3 mL (4 oz) of apple juice.
"Wake the child every 4 hr during the night to drink 118.3 mL (4 oz) of apple juice." Encouraging fluid intake is important, but waking a sleeping child is unnecessary unless there are concerns about dehydration. Instead, fluids should be offered frequently while the child is awake.
C. Take the child's temperature every 10 min after administering acetaminophen.
"Take the child's temperature every 10 min after administering acetaminophen." Checking the temperature this frequently is not necessary and could cause unnecessary stress for the child. Acetaminophen typically takes 30–60 minutes to take effect, so temperature checks should be spaced appropriately.
D. Place ice packs on the child's armpits and groin.
"Place ice packs on the child's armpits and groin." Using ice packs can cause shivering, which increases body temperature. Instead, cooling measures like a lukewarm sponge bath or removing excess clothing are preferred.
Full Explanation
A. "Apply a light blanket if the child begins to shiver." Shivering can increase body temperature, so a light blanket can provide comfort while preventing excessive heat retention. Over-bundling should be avoided.
B. "Wake the child every 4 hr during the night to drink 118.3 mL (4 oz) of apple juice." Encouraging fluid intake is important, but waking a sleeping child is unnecessary unless there are concerns about dehydration. Instead, fluids should be offered frequently while the child is awake.
C. "Take the child's temperature every 10 min after administering acetaminophen." Checking the temperature this frequently is not necessary and could cause unnecessary stress for the child. Acetaminophen typically takes 30–60 minutes to take effect, so temperature checks should be spaced appropriately.
D. "Place ice packs on the child's armpits and groin." Using ice packs can cause shivering, which increases body temperature. Instead, cooling measures like a lukewarm sponge bath or removing excess clothing are preferred.
A nurse is caring for a school-age child following a femoral venous cardiac catheterization. Which of the following actions should the nurse take?
A. Perform a sterile dressing change 8 hr after the procedure.
"Perform a sterile dressing change 8 hr after the procedure." The initial dressing should be left in place for at least 24 hours, and any dressing changes should be performed per facility protocol.
B. Keep the affected extremity straight for 4 hr.
"Keep the affected extremity straight for 4 hr." After a femoral venous cardiac catheterization, the child should keep the affected extremity straight for about 4 to 6 hours to prevent bleeding or hematoma formation at the insertion site.
C. Assess the pulses above the catheterization site.
"Assess the pulses above the catheterization site." The pulses below the site (distal pulses) should be assessed, not above. This is important to check for adequate circulation and potential complications such as clot formation or arterial obstruction.
D. Maintain NPO status for 24 hr following the procedure.
"Maintain NPO status for 24 hr following the procedure." The child should typically resume oral intake as soon as they are fully awake and able to tolerate fluids, usually within a few hours post-procedure.
Full Explanation
A. "Perform a sterile dressing change 8 hr after the procedure." The initial dressing should be left in place for at least 24 hours, and any dressing changes should be performed per facility protocol.
B. "Keep the affected extremity straight for 4 hr." After a femoral venous cardiac catheterization, the child should keep the affected extremity straight for about 4 to 6 hours to prevent bleeding or hematoma formation at the insertion site.
C. "Assess the pulses above the catheterization site." The pulses below the site (distal pulses) should be assessed, not above. This is important to check for adequate circulation and potential complications such as clot formation or arterial obstruction.
D. "Maintain NPO status for 24 hr following the procedure." The child should typically resume oral intake as soon as they are fully awake and able to tolerate fluids, usually within a few hours post-procedure.
A nurse is caring for an adolescent who is scheduled for insertion of an intrauterine device. Which of the following actions should the nurse take?
A. Encourage the adolescent to wait to ask questions about the device until after its insertion.
"Encourage the adolescent to wait to ask questions about the device until after its insertion." The adolescent should be encouraged to ask questions before the procedure to ensure informed consent and understanding.
B. Call the adolescent's guardian to obtain verbal consent prior to the procedure.
"Call the adolescent's guardian to obtain verbal consent prior to the procedure." In many areas, adolescents can provide consent for reproductive health services, including contraception, without parental consent.
C. Reschedule the procedure until the client's guardian provides written consent.
"Reschedule the procedure until the client's guardian provides written consent." Most states and healthcare policies allow minors to consent to birth control procedures without requiring parental involvement.
D. Witness the adolescent's signature on the consent form.
"Witness the adolescent's signature on the consent form." The nurse should witness and document the adolescent’s informed consent, as they have the right to make decisions regarding their reproductive health.
Full Explanation
A. "Encourage the adolescent to wait to ask questions about the device until after its insertion." The adolescent should be encouraged to ask questions before the procedure to ensure informed consent and understanding.
B. "Call the adolescent's guardian to obtain verbal consent prior to the procedure." In many areas, adolescents can provide consent for reproductive health services, including contraception, without parental consent.
C. "Reschedule the procedure until the client's guardian provides written consent." Most states and healthcare policies allow minors to consent to birth control procedures without requiring parental involvement.
D. "Witness the adolescent's signature on the consent form." The nurse should witness and document the adolescent’s informed consent, as they have the right to make decisions regarding their reproductive health.