Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is transporting a 12-year-old child in a wheelchair. The child begins to experience a tonic-clonic seizure. Which of the following actions should the nurse take?
A. Insert an oral airway for the child.
Insert an oral airway for the child. Inserting an oral airway during a tonic-clonic seizure is not recommended, as it could cause injury to the child or block the airway. During a seizure, the priority is ensuring safety rather than trying to insert devices.
B. Apply soft restraints to the child's wrists.
Apply soft restraints to the child's wrists. Restraints are not recommended during a seizure, as they can increase the risk of injury. Instead, the focus should be on protecting the child from injury and allowing the seizure to run its course.
C. Place a pillow under the child's knees.
Place a pillow under the child's knees. While positioning the child is important, placing a pillow under the knees is not a recommended action. The goal is to move the child to the floor to prevent falls or injury during the seizure.
D. Move the child to the floor
Move the child to the floor. If a child is in a wheelchair and begins to have a seizure, moving them to the floor is the first step to prevent injury. Once the child is on the floor, ensure they are on their side to allow for airway clearance and reduce the risk of aspiration.
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Full Explanation
A. Insert an oral airway for the child. Inserting an oral airway during a tonic-clonic seizure is not recommended, as it could cause injury to the child or block the airway. During a seizure, the priority is ensuring safety rather than trying to insert devices.
B. Apply soft restraints to the child's wrists. Restraints are not recommended during a seizure, as they can increase the risk of injury. Instead, the focus should be on protecting the child from injury and allowing the seizure to run its course.
C. Place a pillow under the child's knees. While positioning the child is important, placing a pillow under the knees is not a recommended action. The goal is to move the child to the floor to prevent falls or injury during the seizure.
D. Move the child to the floor. If a child is in a wheelchair and begins to have a seizure, moving them to the floor is the first step to prevent injury. Once the child is on the floor, ensure they are on their side to allow for airway clearance and reduce the risk of aspiration.
Similar Questions
A nurse is caring for a toddler who had a cleft lip and palate repair and is trying to touch the incision site. Which of the following provider prescriptions is recommended for the toddler?
A. Swaddle the toddler in a blanket.
Swaddle the toddler in a blanket. While swaddling may be comforting, it does not effectively prevent the toddler from reaching the incision site. Elbow restraints are a more appropriate choice for limiting arm movement and protecting the incision site.
B. Place the toddler in bilateral elbow restraints.
Place the toddler in bilateral elbow restraints. Bilateral elbow restraints are commonly used after cleft lip and palate repair to prevent the toddler from touching or disrupting the incision site. These restraints help protect the surgical area while allowing the child to maintain some mobility.
C. Place the child in a mummy restraint.
Place the child in a mummy restraint. A mummy restraint (wrapping the child tightly) may be too restrictive and can cause distress, as it limits the child's ability to move freely. Elbow restraints are typically a better choice to prevent injury to the surgical site while still allowing some movement.
D. Obtain a prescription for lorazepam.
Obtain a prescription for lorazepam. Lorazepam is a sedative and would not be the first-line approach to managing the child's need to prevent touching the incision site. Using physical restraints is a safer and more effective option.
Full Explanation
A. Swaddle the toddler in a blanket. While swaddling may be comforting, it does not effectively prevent the toddler from reaching the incision site. Elbow restraints are a more appropriate choice for limiting arm movement and protecting the incision site.
B. Place the toddler in bilateral elbow restraints. Bilateral elbow restraints are commonly used after cleft lip and palate repair to prevent the toddler from touching or disrupting the incision site. These restraints help protect the surgical area while allowing the child to maintain some mobility.
C. Place the child in a mummy restraint. A mummy restraint (wrapping the child tightly) may be too restrictive and can cause distress, as it limits the child's ability to move freely. Elbow restraints are typically a better choice to prevent injury to the surgical site while still allowing some movement.
D. Obtain a prescription for lorazepam. Lorazepam is a sedative and would not be the first-line approach to managing the child's need to prevent touching the incision site. Using physical restraints is a safer and more effective option.
A nurse is assessing a child who has bacterial pneumonia. Which of the following findings should the nurse identify as a potential risk for aspiration?
A. Elevated temperature
Elevated temperature. An elevated temperature is a common symptom of infection, including bacterial pneumonia, but it is not a direct risk factor for aspiration. The concern for aspiration is more related to a child's ability to protect their airway.
B. Neurological deficit
Neurological deficit. A neurological deficit, such as a decreased level of consciousness or impaired swallowing reflexes, increases the risk of aspiration. A child with neurological impairment may have difficulty swallowing or protecting their airway, making them more prone to inhaling food, fluids, or other substances into the lungs, leading to aspiration pneumonia.
C. Inspiratory wheezing
Inspiratory wheezing. Inspiratory wheezing is more likely to be associated with conditions like asthma or airway obstruction, not specifically with aspiration. It does not directly indicate a risk for aspiration.
D. Rapid respirations
Rapid respirations. Rapid respirations can be a sign of respiratory distress, common in pneumonia, but they do not directly indicate a risk for aspiration. The risk for aspiration is more closely linked to issues with swallowing and airway protection, not just the rate of respiration.
Full Explanation
A. Elevated temperature. An elevated temperature is a common symptom of infection, including bacterial pneumonia, but it is not a direct risk factor for aspiration. The concern for aspiration is more related to a child's ability to protect their airway.
B. Neurological deficit. A neurological deficit, such as a decreased level of consciousness or impaired swallowing reflexes, increases the risk of aspiration. A child with neurological impairment may have difficulty swallowing or protecting their airway, making them more prone to inhaling food, fluids, or other substances into the lungs, leading to aspiration pneumonia.
C. Inspiratory wheezing. Inspiratory wheezing is more likely to be associated with conditions like asthma or airway obstruction, not specifically with aspiration. It does not directly indicate a risk for aspiration.
D. Rapid respirations. Rapid respirations can be a sign of respiratory distress, common in pneumonia, but they do not directly indicate a risk for aspiration. The risk for aspiration is more closely linked to issues with swallowing and airway protection, not just the rate of respiration.
A nurse is providing preoperative teaching for a 9-year-old child who is scheduled for a tonsillectomy. Which of the following actions should the nurse take?
A. Use simple diagrams to explain the procedure.
Use simple diagrams to explain the procedure. Children benefit from visual aids to help them understand medical procedures. Using simple diagrams can help the child visualize what will happen during the tonsillectomy in a non-threatening way and make the process less intimidating.
B. Indicate on a stuffed animal where the procedure will be performed.
Indicate on a stuffed animal where the procedure will be performed. While a stuffed animal might be useful for younger children, a 9-year-old is more likely to benefit from a visual aid that is more aligned with their cognitive and developmental level. Simple diagrams or pictures would be more appropriate for this age group.
C. Provide teaching immediately before the procedure.
Provide teaching immediately before the procedure. It is more effective to provide teaching well before the procedure to allow the child time to process and ask questions. Immediate preoperative teaching might lead to increased anxiety and may not allow enough time for the child to fully understand.
D. Discuss the benefits of the procedure.
Discuss the benefits of the procedure. While it is important to acknowledge the purpose of the procedure, focusing on the benefits alone might not address the child's concerns and anxieties about the procedure. Explaining the procedure in a straightforward and understandable manner, without overemphasizing the benefits, is usually more effective in reducing anxiety.
Full Explanation
A. Use simple diagrams to explain the procedure. Children benefit from visual aids to help them understand medical procedures. Using simple diagrams can help the child visualize what will happen during the tonsillectomy in a non-threatening way and make the process less intimidating.
B. Indicate on a stuffed animal where the procedure will be performed. While a stuffed animal might be useful for younger children, a 9-year-old is more likely to benefit from a visual aid that is more aligned with their cognitive and developmental level. Simple diagrams or pictures would be more appropriate for this age group.
C. Provide teaching immediately before the procedure. It is more effective to provide teaching well before the procedure to allow the child time to process and ask questions. Immediate preoperative teaching might lead to increased anxiety and may not allow enough time for the child to fully understand.
D. Discuss the benefits of the procedure. While it is important to acknowledge the purpose of the procedure, focusing on the benefits alone might not address the child's concerns and anxieties about the procedure. Explaining the procedure in a straightforward and understandable manner, without overemphasizing the benefits, is usually more effective in reducing anxiety.