Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching an adolescent how to manage his cystic fibrosis. Which of the following statements by the adolescent indicates an understanding of the teaching?
A. "I will be excused from physical education class."
"I will be excused from physical education class." Exercise is encouraged for children with cystic fibrosis (CF) because it helps clear mucus from the lungs and improves overall lung function.
B. "I will increase my intake of vitamin D."
"I will increase my intake of vitamin D." People with CF have difficulty absorbing fat-soluble vitamins (A, D, E, and K) due to pancreatic insufficiency. Vitamin D supplementation is essential to prevent deficiencies and support bone health.
C. "I will limit my calcium intake to prevent kidney stones."
"I will limit my calcium intake to prevent kidney stones." CF patients are at risk for osteoporosis due to malabsorption of calcium and vitamin D, so they should increase, not limit, their calcium intake.
D. "I will take fewer enzymes when I eat high-fat foods."
"I will take fewer enzymes when I eat high-fat foods." CF patients require pancreatic enzyme replacement therapy (PERT) with every meal and snack to aid digestion. More enzymes, not fewer, are needed for high-fat meals to properly digest and absorb nutrients.
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 be excused from physical education class." Exercise is encouraged for children with cystic fibrosis (CF) because it helps clear mucus from the lungs and improves overall lung function.
B. "I will increase my intake of vitamin D." People with CF have difficulty absorbing fat-soluble vitamins (A, D, E, and K) due to pancreatic insufficiency. Vitamin D supplementation is essential to prevent deficiencies and support bone health.
C. "I will limit my calcium intake to prevent kidney stones." CF patients are at risk for osteoporosis due to malabsorption of calcium and vitamin D, so they should increase, not limit, their calcium intake.
D. "I will take fewer enzymes when I eat high-fat foods." CF patients require pancreatic enzyme replacement therapy (PERT) with every meal and snack to aid digestion. More enzymes, not fewer, are needed for high-fat meals to properly digest and absorb nutrients.
Similar Questions
A nurse is preparing to obtain a urine specimen from a 5-month-old infant using a urine collection bag. Which of the following actions should the nurse take?
A. Attach the bag first to the perineum, then to the skin above the urethra.
"Attach the bag first to the perineum, then to the skin above the urethra." Proper technique involves first securing the collection bag to the perineum to ensure a snug fit, then pressing it firmly to the surrounding skin to prevent leaks.
B. Remove the bag 1 hr after the infant voids.
"Remove the bag 1 hr after the infant voids." The bag should be removed as soon as sufficient urine is collected to avoid contamination or leakage.
C. Place absorbent cotton balls inside the bag.
"Place absorbent cotton balls inside the bag." Absorbent materials would absorb the urine, making it difficult to retrieve an adequate sample for testing.
D. Apply petroleum jelly to the perineum before applying the bag.
"Apply petroleum jelly to the perineum before applying the bag." Petroleum jelly could prevent the bag from adhering properly, leading to leakage or contamination.
Full Explanation
A. "Attach the bag first to the perineum, then to the skin above the urethra." Proper technique involves first securing the collection bag to the perineum to ensure a snug fit, then pressing it firmly to the surrounding skin to prevent leaks.
B. "Remove the bag 1 hr after the infant voids." The bag should be removed as soon as sufficient urine is collected to avoid contamination or leakage.
C. "Place absorbent cotton balls inside the bag." Absorbent materials would absorb the urine, making it difficult to retrieve an adequate sample for testing.
D. "Apply petroleum jelly to the perineum before applying the bag." Petroleum jelly could prevent the bag from adhering properly, leading to leakage or contamination.
A nurse is caring for a preschooler who has a gastrostomy tube. Which of the following actions should the nurse take?
A. Use barrier ointments around the site.
"Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. Cleanse the tube site with hydrogen peroxide.
"Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. Maintain tension between the tubing and the site.
"Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. Place a transparent occlusive dressing over the site.
"Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.
Full Explanation
A. "Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. "Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. "Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. "Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.
A nurse is planning care for a school-age child who has acute glomerulonephritis. Which of the following interventions should the nurse include?
A. Monitor blood pressure every 4 hr.
"Monitor blood pressure every 4 hr." Acute glomerulonephritis can cause hypertension due to fluid retention and impaired kidney function. Regular monitoring is essential to detect and manage hypertension early.
B. Increase fluid consumption.
"Increase fluid consumption." Fluid intake is often restricted to prevent fluid overload, especially if there is hypertension, edema, or decreased urine output.
C. Implement a protein-restricted diet.
"Implement a protein-restricted diet." A protein-restricted diet is not necessary unless the child has severe renal impairment. In most cases, moderate protein intake is recommended.
D. Collect and strain all urine for sediment.
"Collect and strain all urine for sediment." While hematuria (blood in urine) is common in acute glomerulonephritis, straining urine for sediment is not a standard intervention for this condition.
Full Explanation
A. "Monitor blood pressure every 4 hr." Acute glomerulonephritis can cause hypertension due to fluid retention and impaired kidney function. Regular monitoring is essential to detect and manage hypertension early.
B. "Increase fluid consumption." Fluid intake is often restricted to prevent fluid overload, especially if there is hypertension, edema, or decreased urine output.
C. "Implement a protein-restricted diet." A protein-restricted diet is not necessary unless the child has severe renal impairment. In most cases, moderate protein intake is recommended.
D. "Collect and strain all urine for sediment." While hematuria (blood in urine) is common in acute glomerulonephritis, straining urine for sediment is not a standard intervention for this condition.