Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?
A. Test the urine for protein
Test the urine for protein.Explanation: Testing urine for protein is not a priority nursing intervention in the preoperative period for an infant with hydrocephalus. The focus is on preventing complications related to immobility and positioning.
B. Reposition the infant frequently.
Reposition the infant frequently. Explanation:Repositioning the infant frequently is a crucial intervention to prevent complications such as pressure ulcers (bedsores). Infants with hydrocephalus may be at an increased risk of skin breakdown due to prolonged immobility and pressure on specific areas. Repositioning helps distribute pressure, improves circulation, and reduces the risk of skin breakdown.
C. Assess blood pressure every 15 minutes
Assess blood pressure every 15 minutes. Explanation: While monitoring blood pressure is important in certain situations, it is not typically the priority for an infant with hydrocephalus in the preoperative period. The focus is on preventing skin breakdown through repositioning.
D. Provide a stimulating environment
Provide a stimulating environment. Explanation: While providing a stimulating environment can be beneficial for infant development, it is not the priority in the preoperative period for an infant with hydrocephalus. The primary concern is addressing potential complications related to immobility, such as skin breakdown.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Paediatric Assessment Proctored Exam 2022. Take the full exam now
Full Explanation
A. Test the urine for protein.
Explanation: Testing urine for protein is not a priority nursing intervention in the preoperative period for an infant with hydrocephalus. The focus is on preventing complications related to immobility and positioning.
B. Reposition the infant frequently.
Explanation:
Repositioning the infant frequently is a crucial intervention to prevent complications such as pressure ulcers (bedsores). Infants with hydrocephalus may be at an increased risk of skin breakdown due to prolonged immobility and pressure on specific areas. Repositioning helps distribute pressure, improves circulation, and reduces the risk of skin breakdown.
C. Assess blood pressure every 15 minutes.
Explanation: While monitoring blood pressure is important in certain situations, it is not typically the priority for an infant with hydrocephalus in the preoperative period. The focus is on preventing skin breakdown through repositioning.
D. Provide a stimulating environment.
Explanation: While providing a stimulating environment can be beneficial for infant development, it is not the priority in the preoperative period for an infant with hydrocephalus. The primary concern is addressing potential complications related to immobility, such as skin breakdown.
Similar Questions
A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of following information should the nurse include in the discharge instructions? (Select all that apply.)
A. Stopping the medication when the child feels better
Stopping the medication when the child feels better: Antibiotics should be taken for the full prescribed course, even if the child starts feeling better. Stopping prematurely can lead to incomplete eradication of the infection and potential antibiotic resistance.
B. Written information about the medication
Written information about the medication: Providing written information about the medication helps reinforce verbal instructions and serves as a reference for the parents or caregivers.
C. The reason why the child is taking the medication
The reason why the child is taking the medication: It is essential to explain to parents or caregivers the purpose of the medication, such as treating a specific infection. Understanding the reason for the medication promotes compliance.
D. Using a kitchen spoon to administer the medication
Using a kitchen spoon can result in inaccurate dosing. The nurse should recommend using an appropriate measuring device, such as a calibrated oral syringe or a dosing spoon, to ensure accurate dosage administration.
E. The adverse effects of the medication
Educating parents or caregivers about potential adverse effects helps them monitor for any signs of complications and seek medical attention if needed.
Full Explanation
A. Stopping the medication when the child feels better: Antibiotics should be taken for the full prescribed course, even if the child starts feeling better. Stopping prematurely can lead to incomplete eradication of the infection and potential antibiotic resistance.
B. Written information about the medication: Providing written information about the medication helps reinforce verbal instructions and serves as a reference for the parents or caregivers.
C. The reason why the child is taking the medication: It is essential to explain to parents or caregivers the purpose of the medication, such as treating a specific infection. Understanding the reason for the medication promotes compliance.
D. Using a kitchen spoon to administer the medication: Using a kitchen spoon can result in inaccurate dosing. The nurse should recommend using an appropriate measuring device, such as a calibrated oral syringe or a dosing spoon, to ensure accurate dosage administration.
E. The adverse effects of the medication: Educating parents or caregivers about potential adverse effects helps them monitor for any signs of complications and seek medical attention if needed.
A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?
A. "Newborns are abdominal breathers."
"Newborns are abdominal breathers." Explanation: While it is true that newborns primarily use their diaphragms for breathing (abdominal breathing), this statement does not specifically address why the respiratory rate should be counted for a full minute.
B. "Activity will increase the respiratory rate."
"Activity will increase the respiratory rate." Explanation: This statement acknowledges that activity can influence the respiratory rate but does not specifically address the need to count for a full minute to capture the irregular patterns.
C. "Newborns do not expand their lungs fully with each respiration."
"Newborns do not expand their lungs fully with each respiration." Explanation: This statement highlights a characteristic of newborn respiratory physiology but does not specifically explain the importance of counting the respiratory rate for a full minute.
D. "The rate and rhythm of breath are irregular in newborns."
"The rate and rhythm of breath are irregular in newborns." Explanation: Newborns often have irregular breathing patterns, and counting the respiratory rate for a full minute helps capture the variations in rate and rhythm accurately. Newborns may experience periods of rapid breathing followed by periods of slower breathing, and their respiratory patterns can be influenced by sleep-wake cycles, feeding, and other factors. Counting for a full minute provides a more comprehensive and representative assessment of the newborn's respiratory status.
Full Explanation
A. "Newborns are abdominal breathers."
Explanation: While it is true that newborns primarily use their diaphragms for breathing (abdominal breathing), this statement does not specifically address why the respiratory rate should be counted for a full minute.
B. "Activity will increase the respiratory rate."
Explanation: This statement acknowledges that activity can influence the respiratory rate but does not specifically address the need to count for a full minute to capture the irregular patterns.
C. "Newborns do not expand their lungs fully with each respiration."
Explanation: This statement highlights a characteristic of newborn respiratory physiology but does not specifically explain the importance of counting the respiratory rate for a full minute.
D. "The rate and rhythm of breath are irregular in newborns."
Explanation:
Newborns often have irregular breathing patterns, and counting the respiratory rate for a full minute helps capture the variations in rate and rhythm accurately. Newborns may experience periods of rapid breathing followed by periods of slower breathing, and their respiratory patterns can be influenced by sleep-wake cycles, feeding, and other factors. Counting for a full minute provides a more comprehensive and representative assessment of the newborn's respiratory status.
A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering?
A. Meningococcal polysaccharide vaccine
Meningococcal polysaccharide vaccine Explanation: Meningococcal vaccine is recommended for adolescents, particularly before starting college, as it helps protect against meningococcal disease. The conjugate form of the vaccine is usually preferred over the polysaccharide form.
B. Pneumococcal polysacchande vaccine
Pneumococcal polysaccharide vaccine Explanation: Pneumococcal vaccine is generally recommended for older adults and individuals with specific medical conditions, but it may not be part of routine immunizations for healthy adolescents.
C. Influenza vaccine
Influenza vaccine Explanation:Influenza vaccine is recommended annually for adolescents as part of routine immunizations. It helps protect against the seasonal flu, which can cause significant illness and complications.
D. Bacille Calmette-Guerin (BCG) vaccine
Bacille Calmette-Guerin (BCG) vaccine Explanation: BCG vaccine is primarily used in some countries to prevent tuberculosis. It is not routinely administered in the United States as part of standard immunization schedules for adolescents.
Full Explanation
A. Meningococcal polysaccharide vaccine
Explanation: Meningococcal vaccine is recommended for adolescents, particularly before starting college, as it helps protect against meningococcal disease. The conjugate form of the vaccine is usually preferred over the polysaccharide form.
B. Pneumococcal polysaccharide vaccine
Explanation: Pneumococcal vaccine is generally recommended for older adults and individuals with specific medical conditions, but it may not be part of routine immunizations for healthy adolescents.
C. Influenza vaccine
Explanation:
Influenza vaccine is recommended annually for adolescents as part of routine immunizations. It helps protect against the seasonal flu, which can cause significant illness and complications.
D. Bacille Calmette-Guerin (BCG) vaccine
Explanation: BCG vaccine is primarily used in some countries to prevent tuberculosis. It is not routinely administered in the United States as part of standard immunization schedules for adolescents.