Question 1

Which independent nursing action is appropriate for a 2-month-old infant who is a direct admission to the pediatric unit with a diagnosis of ALTE?&#10;A) Placing the child on contact isolation&#10;B) Drawing blood for arterial blood gases&#10;C) Placing the child on an apnea monitor&#10;D) Placing the child on nasal cannula oxygen&#10;

Accepted Answer

ALTE stands for "apparent life-threatening event" and refers to an episode in which an infant experiences one or more of the following: apnea (cessation of breathing), color change (usually to blue or pale), choking or gagging. Placing the infant on an apnea monitor, which detects episodes of apnea and bradycardia, is an appropriate independent nursing action to closely monitor the infant's breathing and heart rate. Placing a patient on contact isolation or drawing blood for arterial blood gases would require a physician's order. Placing the child on nasal cannula oxygen may or may not be necessary based on the infant's oxygen saturation levels, which would need to be assessed through an arterial blood gas test.

Question 2

The nurse is providing care to an infant who is diagnosed as having Pseudomonas aeruginosa pneumonia.Which respiratory condition should the nurse suspect?&#10;A) Cystic fibrosis&#10;B) Choanal atresia&#10;C) Bronchopulmonary dysplasia&#10;D) Congenital diaphragmatic hernia&#10;

Accepted Answer

Pseudomonas aeruginosa is a common bacterial infection in patients with cystic fibrosis.

Question 3

A pediatric nurse explains discharge instructions to the parents of a child who is postoperative from a tonsillectomy.Which instruction does the nurse stress?&#10;A) Recommend vigorous toothbrushing.&#10;B) Avoid highly seasoned and &#34;sharp&#34; foods.&#10;C) Encourage coughing and clearing the throat.&#10;D) Avoid popsicles the first day postoperative because of aspiration risk.&#10;

Accepted Answer

After a tonsillectomy, the affected area can be sore and sensitive, so avoiding highly seasoned and "sharp" foods will reduce the risk of discomfort and possible harm to the site. The other options are not appropriate or potentially harmful. Vigorous toothbrushing may cause bleeding, coughing may worsen the pain and lead to bleeding, and avoiding popsicles is not necessary as long as they are given slowly and carefully to prevent choking or aspiration.

Question 4

Which should the nurse anticipate when providing care to a child who aspirated a foreign body (FB)?&#10;A) CT scan&#10;B) Chest x-ray&#10;C) Fluoroscopy&#10;D) Bronchoscopy&#10;

Accepted Answer

The best choice for a child who aspirated a foreign body is bronchoscopy, as it allows for visualization and removal of the foreign body. CT scan, chest x-ray, and fluoroscopy may be used in conjunction with bronchoscopy, but alone cannot provide the same level of intervention.

Question 5

The pediatric nurse recognizes that normal breath sounds are equal bilaterally in intensity,rhythm,and pitch.Which respiratory sign may indicate that a child is hypoxic?&#10;A) Stridor&#10;B) Anxiety&#10;C) Rhonchi&#10;D) Crackles&#10;

Accepted Answer

Anxiety can be a sign of hypoxia in children, as the body's response to low oxygen levels can lead to feelings of restlessness or anxiety due to the brain and other organs not receiving enough oxygen.

Question 6

Which data collected during the pediatric respiratory assessment require further action by the nurse? (Select all that apply.)&#10;A) Stridor&#10;B) Strong cry&#10;C) Nasal flaring&#10;D) Substernal retractions&#10;E) Lung sounds clear to auscultation&#10;

Accepted Answer

Stridor, nasal flaring, and substernal retractions indicate respiratory distress and require further assessment and intervention by the nurse. A strong cry and clear lung sounds do not necessarily indicate a problem with the respiratory system.

Question 7

Which nursing actions are essential for safety when providing care to a pediatric patient at risk for respiratory compromise? (Select all that apply.)&#10;A) Identifying distress&#10;B) Documenting the care provided&#10;C) Supporting a compromised airway&#10;D) Keeping the parents abreast of changes&#10;E) Choosing the appropriate method of oxygen&#10;

Accepted Answer

A) Identifying distress is crucial for prompt intervention and prevention of respiratory compromise in pediatric patients.
C) Supporting a compromised airway is essential to maintain oxygenation and prevent further respiratory distress.
E) Choosing the appropriate method of oxygen delivery is important to ensure effective oxygenation and prevent complications. Documenting care and keeping parents informed of changes are important nursing actions but not directly related to preventing respiratory compromise in the pediatric patient.

Question 8

A pediatric nurse is performing a respiratory assessment on an 18-month-old child.The nurse most likely uses which recommended techniques?&#10;A) Assess breath sounds by listening to all lung fields and alternating sides for comparison&#10;B) Assess the resonance of the lungs and underlying organs by using auscultation&#10;C) Assess the child's respiratory status when fully awake and active&#10;D) Assess for normal breath sounds using palpation&#10;

Accepted Answer

The recommended technique for a respiratory assessment on a child is to assess breath sounds by listening to all lung fields and alternating sides for comparison. This allows the nurse to properly evaluate the child's respiratory function and detect any abnormalities or signs of respiratory distress. Palpation may also be used to assess for chest expansion and any areas of tenderness or discomfort, but the primary method of assessment for breath sounds should be through auscultation. It is also important to assess the child's respiratory status in various positions and during different levels of activity, as respiratory distress may become more apparent during periods of increased activity.

Question 9

Which question should the nurse include in the health history to determine the causative factor for the diagnosis of croup?&#10;A) &#34;Does your child have a history of asthma?&#34;&#10;B) &#34;Has your child received the varicella vaccine?&#34;&#10;C) &#34;Has your child recently been diagnosed with the flu?&#34;&#10;D) &#34;Did your child recently receive an immunization for measles,mumps,and rubella?&#34;&#10;

Accepted Answer

Croup is most commonly caused by a viral infection that affects the upper respiratory tract. Therefore, asking if the child has recently been diagnosed with the flu can help determine if this is the causative factor. Other options, such as asthma, vaccine history, and immunizations, may not necessarily be directly related to the development of croup.

Question 10

Which information should the nurse include when teaching information regarding peak flow to a child diagnosed with severe asthma?&#10;A) The test should be conducted at least once a week.&#10;B) The yellow zone is considered the danger zone and indicates the need for immediate intervention.&#10;C) The red zone is a caution zone indicating the need to slow down and have a rescue inhaler available.&#10;D) The green zone indicates the child should continue to take prescribed medication and participate in normal activity.&#10;

Accepted Answer

The green zone on a peak flow meter indicates that the person's asthma is under good control, and they can continue their normal activities and medication regimen. This is a key point in asthma management education. The yellow zone, not the red, is a caution zone indicating that the asthma is getting worse and adjustments in medication may be needed. The red zone indicates a medical emergency requiring immediate action, contrary to the misinformation provided in options B and C. Regular monitoring with a peak flow meter is usually recommended more frequently than once a week, especially for someone with severe asthma, making option A incorrect.

Question 11

On which patient at the greatest risk for croup should the nurse focus information regarding prevention?&#10;A) A 3-year-old preschooler&#10;B) A 6-year-old school-ager&#10;C) A 10-year-old school-ager&#10;D) A 13-year-old adolescent&#10;

Accepted Answer

The answer of On which patient at the greatest risk...

Question 12

Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented?&#10;A) &#34;We'll use pesticides to ensure that our home is free from pests.&#34;&#10;B) &#34;We will replace the carpet in our child's bedroom with tile.&#34;&#10;C) &#34;We're glad the dog can continue to sleep in our child's room.&#34;&#10;D) &#34;We'll be sure to use the fireplace often to keep the house warm in the winter.&#34;&#10;

Accepted Answer

The answer of Which parental statement at the conclusion of...

Question 13

Which prescribed medications should the nurse educate the parents of a child with asthma to administer on a daily basis? (Select all that apply.)&#10;A) Albuterol&#10;B) Ipratropium&#10;C) Theophylline&#10;D) Racemic epinephrine&#10;E) Leukotriene modifiers&#10;

Accepted Answer

The answer of Which prescribed medications should the nurse educate...

Question 14

Which is the priority nursing action for a premature neonate who is experiencing intermittent apnea?&#10;A) Calling a code blue&#10;B) Administering oxygen&#10;C) Performing back blows and chest thrusts&#10;D) Providing stimulation by stroking the back&#10;

Accepted Answer

The answer of Which is the priority nursing action for...

Question 15

Which statement by the nurse accurately describes the difference between the respiratory systems of a child and an adult?&#10;A) The nares in children are larger in size,shallow in depth,underdeveloped,and less easily occluded.&#10;B) The larynx and the glottis are lower in the younger child's neck,which makes the child more prone to aspiration.&#10;C) The epiglottis in the younger child is longer and flaccid,making it more susceptible to swelling that may lead to airway occlusion.&#10;D) There are fewer functional muscles in the neck,and the decreased amount of soft tissue makes the child more susceptible to infection and edema.&#10;

Accepted Answer

The answer of Which statement by the nurse accurately describes...

Question 16

Which nursing action is appropriate for the parents of a 4-month-old infant who died as a result of sudden infant death syndrome (SIDS)?&#10;A) Allowing the parents to hold,touch,and rock the infant&#10;B) Advising the parents that an infant autopsy is not necessary&#10;C) Interviewing the parents to determine the cause of the incident&#10;D) Sheltering the parents from grief by not giving them any personal items of the infant,such as footprints&#10;

Accepted Answer

The answer of Which nursing action is appropriate for the...

Question 17

The mother of a toddler-aged patient states,&#34;My daughter seems to be at an increased risk for complications associated with respiratory infections.&#34; Which response by the nurse is accurate?&#10;A) &#34;You are incorrect in your assessment.&#34;&#10;B) &#34;Younger children do not breathe as deeply as do older children.&#34;&#10;C) &#34;The younger child's airway is smaller and more easily occluded.&#34;&#10;D) &#34;Air passages are more likely to become blocked with mucus because younger children make more mucus than older children.&#34;&#10;

Accepted Answer

The answer of The mother of a toddler-aged patient states,&#34;My...

Question 18

A toddler-aged patient presents to the emergency department with a sore throat and difficulty swallowing.The nurse suspects acute epiglottitis.Which nursing action is avoided on the basis of the current assessment data?

A) Vital signs
B) Throat culture
C) Medical history
D) Auscultation of breath sounds

Accepted Answer

The answer of A toddler-aged patient presents to the emergency...

Question 19

Which action should the nurse include in the plan of care for an infant who is diagnosed with acute respiratory distress?&#10;A) Suctioning the airway&#10;B) Placing in a prone position&#10;C) Daily peak flow readings&#10;D) Implementing breathing exercises&#10;

Accepted Answer

The answer of Which action should the nurse include in...

Question 20

When assisting with the respiratory assessment of a pediatric patient,which should the nurse include to determine oxygenation? (Select all that apply.)&#10;A) Skin&#10;B) Sclera&#10;C) Cornea&#10;D) Nailbeds&#10;E) Mucous membranes&#10;

Accepted Answer

The answer of When assisting with the respiratory assessment of...

Deck 32: Child With a Respiratory Condition