Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this infant? (Select All that Apply.)
A. Maintain a thermoneutral environment
Maintain a thermoneutral environment: Helps prevent temperature fluctuations that can stress the heart post-surgery.
B. Accurately measure all intake and output
Accurately measure all intake and output: Ensures fluid balance is carefully monitored to prevent fluid overload or dehydration.
C. Provide for several periods of uninterrupted rest
Provide for several periods of uninterrupted rest: Reduces metabolic demand, aiding in recovery and healing.
D. Incentive spirometer 10 times every hour
Incentive spirometer 10 times every hour: Inappropriate for infants following cardiac surgery, as they are unable to effectively use an incentive spirometer.
E. Encourage periods of bonding
Encourage periods of bonding: Supports emotional well-being and aids in the infant's overall recovery and development.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 209 Reproductive Health Proctored Exam. Take the full exam now
Full Explanation
A. Maintain a thermoneutral environment: Helps prevent temperature fluctuations that can stress the heart post-surgery.
B. Accurately measure all intake and output: Ensures fluid balance is carefully monitored to prevent fluid overload or dehydration.
C. Provide for several periods of uninterrupted rest: Reduces metabolic demand, aiding in recovery and healing.
D. Incentive spirometer 10 times every hour: Inappropriate for infants following cardiac surgery, as they are unable to effectively use an incentive spirometer.
E. Encourage periods of bonding: Supports emotional well-being and aids in the infant's overall recovery and development.
Similar Questions
Which three (3) assessment findings indicate that the breastfeeding client has achieved a proper latch?
A. Rhythmic suckling
Rhythmic suckling. Indicates the infant is effectively extracting milk.
B. A slurping sound as the infant sucks
A slurping sound as the infant sucks. This suggests poor latch and possible ingestion of air.
C. Tongue down with lips flanged
Tongue down with lips flanged. Shows that the infant's tongue is extended over the lower gum and lips are flared outward, creating a seal.
D. Dimpling of the infant's cheeks while sucking
Dimpling of the infant's cheeks while sucking. Indicates improper latch and poor seal around the breast.
E. Audible swallowing
Audible swallowing. Indicates milk transfer is occurring as the infant swallows.
Full Explanation
A. Rhythmic suckling. Indicates the infant is effectively extracting milk.
B. A slurping sound as the infant sucks. This suggests poor latch and possible ingestion of air.
C. Tongue down with lips flanged. Shows that the infant's tongue is extended over the lower gum and lips are flared outward, creating a seal.
D. Dimpling of the infant's cheeks while sucking. Indicates improper latch and poor seal around the breast.
E. Audible swallowing. Indicates milk transfer is occurring as the infant swallows.
When teaching a menopausal woman who chooses not to use hormone therapy what self-care measure is most important to include?
A. Limit alcohol and caffeine intake
Limit alcohol and caffeine intake. This is important for bone health and overall well-being during menopause, especially since alcohol and caffeine can affect bone density.
B. Decreasing the intake of dairy products
Decreasing the intake of dairy products. While calcium intake is important, decreasing dairy intake is not a recommended strategy during menopause unless there are specific dietary restrictions or intolerances.
C. Performing regular weight-bearing exercises
Performing regular weight-bearing exercises. This is important for maintaining bone density but may not be the most important measure compared to limiting alcohol and caffeine intake.
D. Taking vitamin E and B complex vitamin supplements
Taking vitamin E and B complex vitamin supplements. While vitamins are important, they are not as critical as lifestyle measures like limiting alcohol and caffeine.
Full Explanation
A. Limit alcohol and caffeine intake. This is important for bone health and overall well-being during menopause, especially since alcohol and caffeine can affect bone density.
B. Decreasing the intake of dairy products. While calcium intake is important, decreasing dairy intake is not a recommended strategy during menopause unless there are specific dietary restrictions or intolerances.
C. Performing regular weight-bearing exercises. This is important for maintaining bone density but may not be the most important measure compared to limiting alcohol and caffeine intake.
D. Taking vitamin E and B complex vitamin supplements. While vitamins are important, they are not as critical as lifestyle measures like limiting alcohol and caffeine.
The nurse places an infant with a tracheoesophageal fistula under a radiant warmer with the infant's head elevated at a 45-degree angle. Which statement by the mother indicates an understanding of the most important reason for this position?
A. This position prevents stomach juice from going into the lungs
This position prevents stomach juice from going into the lungs. Elevating the head helps prevent reflux of stomach contents into the trachea and lungs, which can lead to aspiration pneumonia.
B. This position allows food to be easily digested by the stomach
This position allows food to be easily digested by the stomach. The position primarily focuses on respiratory protection, not digestion.
C. This position helps my baby breathe better by opening the lungs
This position helps my baby breathe better by opening the lungs. While elevation can aid breathing, it's primarily to prevent aspiration rather than improving respiratory function.
D. This position keeps pressure off the stomach
This position keeps pressure off the stomach. It's not primarily about relieving pressure but rather preventing aspiration.
Full Explanation
A. This position prevents stomach juice from going into the lungs. Elevating the head helps prevent reflux of stomach contents into the trachea and lungs, which can lead to aspiration pneumonia.
B. This position allows food to be easily digested by the stomach. The position primarily focuses on respiratory protection, not digestion.
C. This position helps my baby breathe better by opening the lungs. While elevation can aid breathing, it's primarily to prevent aspiration rather than improving respiratory function.
D. This position keeps pressure off the stomach. It's not primarily about relieving pressure but rather preventing aspiration.