Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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.
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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.
Similar Questions
Which statement made by a pregnant patient indicates teaching was effective related to an elevated alpha fetoprotein (AFP) level?
A. The elevated AFP means may baby may have Down Syndrome
The elevated AFP means my baby may have Down Syndrome. AFP is not typically elevated in Down Syndrome; other tests like nuchal translucency or cell-free DNA are used for that.
B. The elevated AFP means my baby may have spina bifida
The elevated AFP means my baby may have spina bifida. AFP screening is used to detect neural tube defects like spina bifida. An elevated AFP level suggests a higher risk for such conditions.
C. The elevated AFP means my baby has Down syndrome
The elevated AFP means my baby has Down syndrome. This is incorrect; AFP is not a marker for Down Syndrome.
D. The elevated APR means my baby has spina bifida
The elevated AFP means my baby has spina bifida. This is correct, but option B is a more precise statement of understanding.
Full Explanation
A. The elevated AFP means my baby may have Down Syndrome. AFP is not typically elevated in Down Syndrome; other tests like nuchal translucency or cell-free DNA are used for that.
B. The elevated AFP means my baby may have spina bifida. AFP screening is used to detect neural tube defects like spina bifida. An elevated AFP level suggests a higher risk for such conditions.
C. The elevated AFP means my baby has Down syndrome. This is incorrect; AFP is not a marker for Down Syndrome.
D. The elevated AFP means my baby has spina bifida. This is correct, but option B is a more precise statement of understanding.
Which assessment findings would alert the nurse to an infant or child in heart failure? (Select All that Apply.)
A. Tachypnea
Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales
Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses
Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous
Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding
Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down
Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.
Full Explanation
A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.
A nurse is caring for a client having a biophysical profile. The client asks what the test is for. What should the nurse include in the response? (Select All that Apply.)
A. Fetal breathing
Fetal breathing. The biophysical profile assesses fetal breathing movements as one of the components indicating fetal well-being.
B. Fetal neck translucency
Fetal neck translucency. This is not part of the biophysical profile; it is typically assessed during first-trimester screening for chromosomal abnormalities.
C. Fetal motion
Fetal motion. Fetal movements are another component of the biophysical profile, reflecting the fetal central nervous system integrity and oxygenation.
D. Amniotic fluid volume
Amniotic fluid volume. The assessment of amniotic fluid volume is crucial in determining fetal well-being and adequate fetal renal function.
E. Fetal gender
Fetal gender. Gender is not assessed as part of the biophysical profile; the test focuses on fetal physiological parameters related to well-being.
Full Explanation
A. Fetal breathing. The biophysical profile assesses fetal breathing movements as one of the components indicating fetal well-being.
B. Fetal neck translucency. This is not part of the biophysical profile; it is typically assessed during first-trimester screening for chromosomal abnormalities.
C. Fetal motion. Fetal movements are another component of the biophysical profile, reflecting the fetal central nervous system integrity and oxygenation.
D. Amniotic fluid volume. The assessment of amniotic fluid volume is crucial in determining fetal well-being and adequate fetal renal function.
E. Fetal gender. Gender is not assessed as part of the biophysical profile; the test focuses on fetal physiological parameters related to well-being.