Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
d
A. Factor X
Factor X is a clotting factor involved in the coagulation cascade. It is not directly related to preventing infections. While clotting factors are essential for hemostasis, they do not play a role in infection prevention.
B. Steroids
Steroids can suppress the immune response, making the child more susceptible to infections. Therefore, they are not specifically administered to prevent infections
C. immunizations that the patient is scheduled for
In a child with a sickle cell crisis who is hospitalized, preventing infections is crucial due to the increased risk of infections in this condition. Administering immunizations that the patient is scheduled for can help prevent certain infections. Children with sickle cell disease are at a higher risk of bacterial infections, especially from encapsulated organisms like Streptococcus pneumoniae and Haemophilus influenzae. Vaccines can help protect against these pathogens and reduce the risk of serious infections.
D. PCA Morphine
PCA (patient-controlled analgesia) morphine is used for pain management during a sickle cell crisis. It does not directly prevent infections.
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Full Explanation
A. Factor X is a clotting factor involved in the coagulation cascade. It is not directly related to preventing infections. While clotting factors are essential for hemostasis, they do not play a role in infection prevention.
B. Steroids can suppress the immune response, making the child more susceptible to infections. Therefore, they are not specifically administered to prevent infections
C. In a child with a sickle cell crisis who is hospitalized, preventing infections is crucial due to the increased risk of infections in this condition. Administering immunizations that the patient is scheduled for can help prevent certain infections.
Children with sickle cell disease are at a higher risk of bacterial infections, especially from encapsulated organisms like Streptococcus pneumoniae and Haemophilus influenzae. Vaccines can help protect against these pathogens and reduce the risk of serious infections.
Some of the recommended immunizations for children with sickle cell disease include:
Pneumococcal vaccine: This helps protect against infections caused by Streptococcus pneumoniae, which can cause severe respiratory and bloodstream infections.
Haemophilus influenzae type B (Hib) vaccine: This protects against infections caused by Haemophilus influenzae type B, which can lead to serious illnesses like pneumonia and meningitis.
Meningococcal vaccine: This protects against Neisseria meningitidis, which can cause meningitis and bloodstream infections.
Influenza vaccine: This annual vaccine helps protect against seasonal flu, which can be severe in children with sickle cell disease.
Administering these vaccines according to the recommended schedule helps provide protection against certain infections and can improve outcomes for children with sickle cell disease during hospitalization and beyond. The other options, Factor X, steroids, and PCA morphine, are not specific measures for preventing infections in a child with sickle cell crisis.
D. PCA (patient-controlled analgesia) morphine is used for pain management during a sickle cell crisis. It does not directly prevent infections.
Similar Questions
A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid?
A. Broth
Broth: While broth can be a source of fluids, it does not contain the appropriate balance of electrolytes needed to rehydrate the body effectively. Gastroenteritis can cause significant fluid and electrolyte loss, so an oral rehydration solution (ORS) with the right proportions of salts and sugars is essential to replace these losses adequately.
B. Diluted apple juice
Diluted apple juice: Diluted apple juice may not provide the proper electrolyte balance needed for rehydration in cases of gastroenteritis. In fact, apple juice is not recommended during episodes of acute gastroenteritis, as it can worsen diarrhea due to its high sugar content. This can lead to further dehydration and discomfort.
C. Oral rehydration solution
Oral rehydration solution (ORS): This is the correct answer. Oral rehydration solution is specifically designed to replace lost fluids and electrolytes in cases of gastroenteritis. It contains the right balance of salts and sugars to facilitate effective absorption in the intestines and help rehydrate the body. ORS is the recommended fluid for managing dehydration caused by gastroenteritis in children.
D. Water
Water: While water is essential for hydration, it is not enough to effectively treat dehydration caused by gastroenteritis. Plain water does not contain the necessary electrolytes like sodium, potassium, and chloride, which are lost during episodes of diarrhea and vomiting. Giving water alone may not adequately rehydrate the child and could potentially worsen the dehydration.
Full Explanation
A. Broth: While broth can be a source of fluids, it does not contain the appropriate balance of electrolytes needed to rehydrate the body effectively. Gastroenteritis can cause significant fluid and electrolyte loss, so an oral rehydration solution (ORS) with the right proportions of salts and sugars is essential to replace these losses adequately.
B. Diluted apple juice: Diluted apple juice may not provide the proper electrolyte balance needed for rehydration in cases of gastroenteritis. In fact, apple juice is not recommended during episodes of acute gastroenteritis, as it can worsen diarrhea due to its high sugar content. This can lead to further dehydration and discomfort.
C. Oral rehydration solution (ORS): This is the correct answer. Oral rehydration solution is specifically designed to replace lost fluids and electrolytes in cases of gastroenteritis. It contains the right balance of salts and sugars to facilitate effective absorption in the intestines and help rehydrate the body. ORS is the recommended fluid for managing dehydration caused by gastroenteritis in children.
D. Water: While water is essential for hydration, it is not enough to effectively treat dehydration caused by gastroenteritis. Plain water does not contain the necessary electrolytes like sodium, potassium, and chloride, which are lost during episodes of diarrhea and vomiting. Giving water alone may not adequately rehydrate the child and could potentially worsen the dehydration.
A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?
A. Half-strength orange juice
Half-strength orange juice: Citrus juices, including orange juice, are not recommended for infants under 12 months old. They are acidic and may cause stomach upset or diarrhea.
B. Sterile water
Sterile water: Sterile water does not contain the necessary electrolytes, and offering plain water to an infant after surgery or during an illness can lead to electrolyte imbalances and further dehydration.
C. Half-strength infant formula
Half-strength infant formula: Diluting infant formula can lead to inadequate nutrition for the infant. The baby requires appropriate nutrition to support recovery after surgery, and diluting formula can be harmful.
D. Oral electrolyte solution
An oral electrolyte solution is the best choice as it helps maintain proper hydration and electrolyte balance in the infant's body during the recovery period. If the infant tolerates the oral electrolyte solution well and is not at risk for aspiration, the healthcare provider may gradually advance the diet to include other clear liquids and then slowly reintroduce regular infant formula or breast milk as appropriate. The healthcare provider's instructions should be followed carefully to support the infant's recovery and ensure adequate nutrition.
Full Explanation
For a 6-month-old infant who has undergone the repair of an intussusception, the nurse should select an oral electrolyte solution. This solution is specifically designed to replace lost fluids and electrolytes due to vomiting or diarrhea, which is crucial in preventing dehydration in infants.
Options A, B, and C are not suitable choices for an infant in this situation:
A. Half-strength orange juice: Citrus juices, including orange juice, are not recommended for infants under 12 months old. They are acidic and may cause stomach upset or diarrhea.
B. Sterile water: Sterile water does not contain the necessary electrolytes, and offering plain water to an infant after surgery or during an illness can lead to electrolyte imbalances and further dehydration.
C. Half-strength infant formula: Diluting infant formula can lead to inadequate nutrition for the infant. The baby requires appropriate nutrition to support recovery after surgery, and diluting formula can be harmful.
D. An oral electrolyte solution is the best choice as it helps maintain proper hydration and electrolyte balance in the infant's body during the recovery period. If the infant tolerates the oral electrolyte solution well and is not at risk for aspiration, the healthcare provider may gradually advance the diet to include other clear liquids and then slowly reintroduce regular infant formula or breast milk as appropriate. The healthcare provider's instructions should be followed carefully to support the infant's recovery and ensure adequate nutrition.
A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?
A. Offer the child clear liquids for the first 24 hr.
Option A: Offering the child clear liquids for the first 24 hours is not a typical instruction following a cardiac catheterization. After the procedure, the child may be allowed to resume a regular diet, as tolerated, based on the healthcare provider's orders.
B. Give the child acetaminophen for discomfort.
Option B: This is the correct instruction. After cardiac catheterization, the child may experience some discomfort at the insertion site or the area where the catheter was threaded through the blood vessels. Acetaminophen can be used to manage mild pain or discomfort.
C. Assist the child in taking a tub bath for the first 3 days.
Option C: Taking a tub bath for the first 3 days is not typically mentioned in discharge instructions after a cardiac catheterization. The nurse might advise the parent to avoid submerging the catheter insertion site in water for a specific period and instead use sponge baths until permitted by the healthcare provider.
D. Keep the child home for 1 week.
Option D: Keeping the child home for 1 week is not a standard recommendation for a cardiac catheterization. The recovery period after a cardiac catheterization is usually shorter, and the child can often resume normal activities within a day or two, depending on the specific circumstances of the procedure and the child's condition. The nurse should thoroughly review the specific discharge instructions provided by the healthcare provider and ensure the parent understands the care required at home, including any restrictions on activities or signs of potential complications that require immediate attention.
Full Explanation
Following a cardiac catheterization, the nurse should provide the parent with appropriate discharge instructions to ensure the child's proper recovery. The correct instruction to include is option B: "Give the child acetaminophen for discomfort."
Explanation:
Option A: Offering the child clear liquids for the first 24 hours is not a typical instruction following a cardiac catheterization. After the procedure, the child may be allowed to resume a regular diet, as tolerated, based on the healthcare provider's orders.
Option B: This is the correct instruction. After cardiac catheterization, the child may experience some discomfort at the insertion site or the area where the catheter was threaded through the blood vessels. Acetaminophen can be used to manage mild pain or discomfort.
Option C: Taking a tub bath for the first 3 days is not typically mentioned in discharge instructions after a cardiac catheterization. The nurse might advise the parent to avoid submerging the catheter insertion site in water for a specific period and instead use sponge baths until permitted by the healthcare provider.
Option D: Keeping the child home for 1 week is not a standard recommendation for a cardiac catheterization. The recovery period after a cardiac catheterization is usually shorter, and the child can often resume normal activities within a day or two, depending on the specific circumstances of the procedure and the child's condition.
The nurse should thoroughly review the specific discharge instructions provided by the healthcare provider and ensure the parent understands the care required at home, including any restrictions on activities or signs of potential complications that require immediate attention.