Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur.
This finding is associated with which congenital heart defect?
A. Pulmonary stenosis
This is wrong because pulmonary stenosis is a narrowing of the pulmonary valve or artery that obstructs blood flow to the lungs. It causes a systolic ejection murmur that is best heard at the upper left sternal border.
B. Patent ductus arteriosus
This is because a patent ductus arteriosus is a congenital heart defect that involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. This causes a continuous machinery-like murmur that can be heard on auscultation.
C. Ventricular septal defect
This is wrong because ventricular septal defect is a hole in the wall between the ventricles that allows blood to flow from the left to the right side of the heart. It causes a loud, harsh holosystolic murmur that is best heard at the left lower sternal border.
D. Coarctation of the aorta
This is wrong because coarctation of the aorta is a narrowing of the aorta that reduces blood flow to the lower body. It causes a systolic murmur that radiates to the back and weak or absent femoral pulses.
This question is an excerpt from Nurse Dive's nursing test bank - OB Pediatric Cumulative Exam Test 4 V 1 2023 Proctored Exam. Take the full exam now
Full Explanation
This is because a patent ductus arteriosus is a congenital heart defect that involves a defect in which the fetal shunt between the aorta and the pulmonary artery fails to close. This causes a continuous machinery-like murmur that can be heard on auscultation.
Choice A is wrong because pulmonary stenosis is a narrowing of the pulmonary valve or artery that obstructs blood flow to the lungs. It causes a systolic ejection murmur that is best heard at the upper left sternal border.
Choice C is wrong because the ventricular septal defect is a hole in the wall between the ventricles that allows blood to flow from the left to the right side of the heart. It causes a loud, harsh holosystolic murmur that is best heard at the left lower sternal border.
Choice D is wrong because coarctation of the aorta is a narrowing of the aorta that reduces blood flow to the lower body. It causes a systolic murmur that radiates to the back and weak or absent femoral pulses.
Similar Questions
A parent asks the nurse why self-monitoring of blood glucose is being recommended for her child with diabetes.
The nurse should base the explanation on what information?
A. It is a less expensive method of testing
This is wrong because it is not a less expensive method of testing. Self-monitoring of blood glucose requires a glucose meter, test strips, lancets, and a logbook, which can be costly for some families.
B. It is not as accurate as laboratory testing
This is wrong because it is not less accurate than laboratory testing. Self-monitoring of blood glucose can provide accurate and reliable results if done correctly and regularly. Laboratory testing is usually done periodically to measure the average blood sugar level over the past 2 to 3 months (hemoglobin A1c).
C. Children need to learn to manage their diabetes
This is because self-monitoring of blood glucose allows children to learn how their blood sugar levels change in response to different factors such as food, exercise, stress, and medication. It also helps them to adjust their insulin doses and dietary intake accordingly. Self-monitoring of blood glucose can improve glycemic control and reduce the risk of complications.
D. The parents are better able to manage the disease
This is wrong because it implies that the parents are not involved in the child’s diabetes management. Parents should still provide support and guidance to their children with diabetes, especially when they are young or newly diagnosed. Parents should also monitor their child’s blood glucose levels and help them with insulin administration if needed.
Full Explanation
This is because self-monitoring of blood glucose allows children to learn how their blood sugar levels change in response to different factors such as food, exercise, stress, and medication.
It also helps them to adjust their insulin doses and dietary intake accordingly. Self-monitoring of blood glucose can improve glycemic control and reduce the risk of complications.
Choice A is wrong because it is not a less expensive method of testing.
Self-monitoring of blood glucose requires a glucose meter, test strips, lancets, and a logbook, which can be costly for some families.
Choice B is wrong because it is not less accurate than laboratory testing.
Self-monitoring of blood glucose can provide accurate and reliable results if done correctly and regularly.
Laboratory testing is usually done periodically to measure the average blood sugar level over the past 2 to 3 months (hemoglobin A1c).
Choice D is wrong because it implies that the parents are not involved in the child’s diabetes management.
Parents should still provide support and guidance to their children with diabetes, especially when they are young or newly diagnosed. Parents should also monitor their child’s blood glucose levels and help them with insulin administration if needed.
The nurse observes some children in the playroom.
Which play situation exhibits the characteristics of parallel play?
A. Kimberly and Amanda sharing clay to each make things
This is wrong because Kimberly and Amanda sharing clay to each make things is an example of cooperative play, which involves sharing, taking turns, and following rules. Cooperative play is typical for school-age children.
B. Brian playing with his truck next to Kristina playing with her truck.
Brian playing with his truck next to Kristina playing with her truck. This is because parallel play is when children play side by side with similar toys but do not interact with each other. Parallel play is typical for toddlers and preschoolers.
C. Adam playing a board game with Kyle, Steven, and Erich
This is wrong because Adam playing a board game with Kyle, Steven, and Erich is also an example of cooperative play, as they are playing by the same rules and interacting with each other.
D. Danielle playing with a music box on her mother’s lap
This is wrong because Danielle playing with a music box on her mother’s lap is an example of solitary play, which is when a child plays alone and does not seek contact with others. Solitary play is typical for infants.
E. Danielle playing with a music box on her mother’s lap.
Full Explanation
Brian playing with his truck next to Kristina playing with her truck. This is because parallel play is when children play side by side with similar toys but do not interact with each other. Parallel play is typical for toddlers and preschoolers.
Choice A is wrong because Kimberly and Amanda sharing clay to each make things is an example of cooperative play, which involves sharing, taking turns, and following
rules. Cooperative play is typical for school-age children.
Choice C is wrong because Adam playing a board game with Kyle, Steven, and Erich is also an example of cooperative play, as they are playing by the same rules and interacting with each other.
Choice D is wrong because Danielle playing with a music box on her mother’s lap is an example of solitary play, which is when a child plays alone and does not seek contact with others. Solitary play is typical for infants.
Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure?
A. Weigh the infant every day on the same scale at the same time.
This is wrong because weighing the infant every day on the same scale at the same time is a way to monitor fluid balance, not an intervention to treat excess fluid volume.
B. Notify the physician when weight gain exceeds more than 20 g/day.
This is wrong because notifying the physician when weight gain exceeds more than 20 g/day is also a monitoring measure, not an intervention. Moreover, weight gain may not accurately reflect fluid volume status in some patients with heart failure due to poor nutrition and decreased appetite.
C. Put the infant in a car seat to minimize movement.
This is wrong because putting the infant in a car seat to minimize movement may worsen respiratory distress and increase the workload of the heart. The infant should be positioned in a semi-Fowler’s or Fowler’s position to facilitate breathing and reduce venous return.
D. Administer digoxin as ordered by the physician.
Digoxin is a medication that helps improve the pumping function of the heart and reduces fluid retention in the lungs and other tissues. It is commonly used to treat congestive heart failure in infants.
Full Explanation
Digoxin is a medication that helps improve the pumping function of the heart and reduces fluid retention in the lungs and other tissues. It is commonly used to treat congestive heart failure in infants.
Choice A is wrong because weighing the infant every day on the same scale at the same time is a way to monitor fluid balance, not an intervention to treat excess fluid volume.
Choice B is wrong because notifying the physician when weight gain exceeds more than 20 g/day is also a monitoring measure, not an intervention. Moreover, weight gain may not accurately reflect fluid volume status in some patients with heart failure due to poor nutrition and decreased appetite.
Choice C is wrong because putting the infant in a car seat to minimize movement may worsen the respiratory distress and increase the workload of the heart. The infant should be positioned in a semi-Fowler’s or Fowler’s position to facilitate breathing and reduce venous return.