Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for a 10-month-old infant diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should be included in the child's care? (Select all that apply.).
A. Institute cluster care to encourage adequate rest.
Institute cluster care to encourage adequate rest. This is a correct choice. Cluster care involves grouping nursing interventions together to minimize disruptions to the child's rest. Adequate rest is crucial for the healing process in infants with respiratory syncytial virus (RSV) bronchiolitis.
B. Administer cough syrup.
Administer cough syrup. This choice is incorrect for RSV bronchiolitis. Cough syrup is not recommended for infants with bronchiolitis. RSV primarily affects the lower respiratory tract and can cause airway inflammation, making cough syrup potentially ineffective and unnecessary.
C. Administer antibiotics.
Administer antibiotics. This choice is incorrect for RSV bronchiolitis. RSV is a viral infection, and antibiotics are ineffective against viruses. Antibiotics should only be used when there is a bacterial infection or a clear indication.
D. Encourage infant to drink 8 ounces of formula every 4 hours.
Encourage infant to drink 8 ounces of formula every 4 hours. This choice is not the best approach for managing RSV bronchiolitis. Infants with RSV may experience decreased appetite due to respiratory distress. Smaller, more frequent feedings are often recommended to prevent overfeeding and aspiration.
E. Place on noninvasive oxygen monitoring.
Place on noninvasive oxygen monitoring. This is a correct choice. RSV bronchiolitis can cause respiratory distress and compromise oxygenation. Noninvasive oxygen monitoring helps assess the child's oxygen levels and aids in determining the need for supplemental oxygen therapy.
This question is an excerpt from Nurse Dive's nursing test bank - Pediatrics Midterm V1 2023 Test 3 Proctored Exam. Take the full exam now
Full Explanation
The correct answers are choices A and E: Institute cluster care to encourage adequate rest and Place on noninvasive oxygen monitoring.
Choice A rationale:
Institute cluster care to encourage adequate rest. This is a correct choice. Cluster care involves grouping nursing interventions together to minimize disruptions to the child's rest. Adequate rest is crucial for the healing process in infants with respiratory syncytial virus (RSV) bronchiolitis.
Choice B rationale:
Administer cough syrup. This choice is incorrect for RSV bronchiolitis. Cough syrup is not recommended for infants with bronchiolitis. RSV primarily affects the lower respiratory tract and can cause airway inflammation, making cough syrup potentially ineffective and unnecessary.
Choice C rationale:
Administer antibiotics. This choice is incorrect for RSV bronchiolitis. RSV is a viral infection, and antibiotics are ineffective against viruses. Antibiotics should only be used when there is a bacterial infection or a clear indication.
Choice D rationale:
Encourage infant to drink 8 ounces of formula every 4 hours. This choice is not the best approach for managing RSV bronchiolitis. Infants with RSV may experience decreased appetite due to respiratory distress. Smaller, more frequent feedings are often recommended to prevent overfeeding and aspiration.
Choice E rationale:
Place on noninvasive oxygen monitoring. This is a correct choice. RSV bronchiolitis can cause respiratory distress and compromise oxygenation. Noninvasive oxygen monitoring helps assess the child's oxygen levels and aids in determining the need for supplemental oxygen therapy.
Similar Questions
What is the initial goal for the treatment of secondary hypertension?
A. Administration of digoxin.
Administration of digoxin. Administering digoxin is not the initial goal for the treatment of secondary hypertension. Digoxin is a medication commonly used to treat heart failure and certain arrhythmias, but it is not a primary intervention for hypertension. The rationale for this choice being incorrect lies in the fact that digoxin primarily affects the heart's contractility and is not a preferred option for managing high blood pressure.
B. Weight control and diet.
Weight control and diet. Weight control and dietary modifications are important aspects of managing hypertension, both primary and secondary. However, they are not the initial goal for the treatment of secondary hypertension. While these lifestyle modifications can contribute to blood pressure reduction, the primary focus in secondary hypertension is to identify and address the underlying condition causing the high blood pressure.
C. Treating the underlying disease.
Treating the underlying disease. Correct Answer. The initial goal for the treatment of secondary hypertension is to address the underlying disease or condition that is causing the elevated blood pressure. Unlike primary hypertension, which often lacks a specific underlying cause, secondary hypertension results from an identifiable condition such as kidney disease, hormonal disorders, or certain medications. Treating the root cause can lead to blood pressure normalization.
D. Administration of B-adrenergic receptor blockers.
Administration of β-adrenergic receptor blockers. Administering β-adrenergic receptor blockers is not typically the initial goal for the treatment of secondary hypertension. While these medications can lower blood pressure by blocking the effects of adrenaline and reducing heart rate, they are not the first-line approach for addressing the underlying cause of secondary hypertension.
Full Explanation
The correct answer is choice C. Treating the underlying disease.
Choice A rationale:
Administration of digoxin. Administering digoxin is not the initial goal for the treatment of secondary hypertension. Digoxin is a medication commonly used to treat heart failure and certain arrhythmias, but it is not a primary intervention for hypertension. The rationale for this choice being incorrect lies in the fact that digoxin primarily affects the heart's contractility and is not a preferred option for managing high blood pressure.
Choice B rationale:
Weight control and diet. Weight control and dietary modifications are important aspects of managing hypertension, both primary and secondary. However, they are not the initial goal for the treatment of secondary hypertension. While these lifestyle modifications can contribute to blood pressure reduction, the primary focus in secondary hypertension is to identify and address the underlying condition causing the high blood pressure.
Choice C rationale:
Treating the underlying disease. Correct Answer. The initial goal for the treatment of secondary hypertension is to address the underlying disease or condition that is causing the elevated blood pressure. Unlike primary hypertension, which often lacks a specific underlying cause, secondary hypertension results from an identifiable condition such as kidney disease, hormonal disorders, or certain medications. Treating the root cause can lead to blood pressure normalization.
Choice D rationale:
Administration of β-adrenergic receptor blockers. Administering β-adrenergic receptor blockers is not typically the initial goal for the treatment of secondary hypertension. While these medications can lower blood pressure by blocking the effects of adrenaline and reducing heart rate, they are not the first-line approach for addressing the underlying cause of secondary hypertension.
What is an important nursing consideration when suctioning a young child who has had heart surgery?
A. Expect symptoms of respiratory distress when suctioning.
Expect symptoms of respiratory distress when suctioning. While respiratory distress can occur during and after suctioning, it is not the main nursing consideration. The primary goal is to minimize any potential complications and ensure the child's safety during the procedure, which can be achieved by following appropriate guidelines.
B. Administer supplemental oxygen before and after suctioning.
Administer supplemental oxygen before and after suctioning. Correct Answer. Administering supplemental oxygen before and after suctioning is crucial to maintain adequate oxygenation during and after the procedure. Suctioning can temporarily decrease oxygen levels and cause desaturation, especially in a child who has undergone heart surgery. Providing supplemental oxygen helps prevent hypoxia and supports respiratory function.
C. Perform suctioning at least every hour.
Perform suctioning at least every hour. Frequent suctioning at least every hour is not a standard nursing practice, especially for a child who has had heart surgery. Suctioning should only be performed as needed based on the child's clinical condition, and excessive suctioning can irritate the airway and lead to complications.
D. Suction for no longer than 30 seconds at a time.
Suction for no longer than 30 seconds at a time. While limiting the duration of suctioning is important to prevent hypoxia and trauma to the airway, the specific duration of 30 seconds is not a universal rule. Suctioning should be performed for the shortest effective duration to minimize the risk of complications, but the optimal time can vary based on the child's condition and the type of suctioning being used.
Full Explanation
The correct answer is choice B. Administer supplemental oxygen before and after suctioning.
Choice A rationale:
Expect symptoms of respiratory distress when suctioning. While respiratory distress can occur during and after suctioning, it is not the main nursing consideration. The primary goal is to minimize any potential complications and ensure the child's safety during the procedure, which can be achieved by following appropriate guidelines.
Choice B rationale:
Administer supplemental oxygen before and after suctioning. Correct Answer. Administering supplemental oxygen before and after suctioning is crucial to maintain adequate oxygenation during and after the procedure. Suctioning can temporarily decrease oxygen levels and cause desaturation, especially in a child who has undergone heart surgery. Providing supplemental oxygen helps prevent hypoxia and supports respiratory function.
Choice C rationale:
Perform suctioning at least every hour. Frequent suctioning at least every hour is not a standard nursing practice, especially for a child who has had heart surgery. Suctioning should only be performed as needed based on the child's clinical condition, and excessive suctioning can irritate the airway and lead to complications.
Choice D rationale:
Suction for no longer than 30 seconds at a time. While limiting the duration of suctioning is important to prevent hypoxia and trauma to the airway, the specific duration of 30 seconds is not a universal rule. Suctioning should be performed for the shortest effective duration to minimize the risk of complications, but the optimal time can vary based on the child's condition and the type of suctioning being used.
A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, what medication should the nurse prepare for immediate administration?
A. Diphenhydramine.
Diphenhydramine. Diphenhydramine is an antihistamine commonly used to relieve allergic symptoms such as itching, rash, and runny nose. While it can be part of the treatment for anaphylactic reactions, it is not the medication of choice for immediate administration in the case of a severe anaphylactic reaction like the one described in the scenario.
B. Epinephrine.
Epinephrine. Correct Answer. In cases of severe anaphylactic reactions, epinephrine (adrenaline) is the medication of choice for immediate administration. Epinephrine acts rapidly to reverse life-threatening symptoms, such as airway constriction, low blood pressure, and hives. It works by dilating airways, increasing heart rate, and improving blood pressure.
C. Dopamine.
Dopamine. Dopamine is a medication used to increase blood pressure and cardiac output in certain critical situations. However, it is not the first-line treatment for anaphylactic reactions. Epinephrine's effects on airway and cardiovascular function make it the preferred choice in this context.
D. Calcium chloride.
Calcium chloride. Calcium chloride is not the appropriate medication for treating anaphylactic reactions. Its main medical uses include treating hypocalcemia (low blood calcium levels) and certain cardiac arrhythmias. It does not address the primary symptoms and physiological changes associated with anaphylaxis.
Full Explanation
The correct answer is choice B. Epinephrine.
Choice A rationale:
Diphenhydramine. Diphenhydramine is an antihistamine commonly used to relieve allergic symptoms such as itching, rash, and runny nose. While it can be part of the treatment for anaphylactic reactions, it is not the medication of choice for immediate administration in the case of a severe anaphylactic reaction like the one described in the scenario.
Choice B rationale:
Epinephrine. Correct Answer. In cases of severe anaphylactic reactions, epinephrine (adrenaline) is the medication of choice for immediate administration. Epinephrine acts rapidly to reverse life-threatening symptoms, such as airway constriction, low blood pressure, and hives. It works by dilating airways, increasing heart rate, and improving blood pressure.
Choice C rationale:
Dopamine. Dopamine is a medication used to increase blood pressure and cardiac output in certain critical situations. However, it is not the first-line treatment for anaphylactic reactions. Epinephrine's effects on airway and cardiovascular function make it the preferred choice in this context.
Choice D rationale:
Calcium chloride. Calcium chloride is not the appropriate medication for treating anaphylactic reactions. Its main medical uses include treating hypocalcemia (low blood calcium levels) and certain cardiac arrhythmias. It does not address the primary symptoms and physiological changes associated with anaphylaxis.