Deck 15: Oxygenation

Question 1

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma.Which action by the newly licensed nurse requires immediate intervention?

A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler.
B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.
C) The newly licensed nurse is observed assessing the client's thoracic wall, skin, and nail beds.
D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.

Answer 1

The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.

Question 2

The nurse is providing care to a client who has a tracheostomy.The nurse will monitor the client for complications related to the loss of which protective mechanism?

A) The ability to cough
B) Filtration and humidification of inspired air
C) Decrease in oxygen-carrying capacity of the trachea
D) The sneeze reflex initiated by irritants in the nasal passages

Answer 2

Filtration and humidification of inspired air

Question 3

The nurse is reviewing the results of laboratory tests conducted on a client admitted with a respiratory disorder.Which laboratory finding would be most significant for this client?

A) Hemoglobin level 12 mg/dL
B) Oxygen saturation 96%
C) Serum sodium 140 mg/dL
D) Blood pH 7.32

Answer 3

Blood pH 7.32

Question 4

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD).Which clinical manifestations indicate the client's perfusion is affected? Select all that apply.

A) Bounding pulse
B) Pink nail beds
C) Acrocyanosis
D) Confusion
E) Wheezing

Question 5

The nurse is providing care to clients on a medical-surgical unit.Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply.

A) Encouraging deep breathing exercises
B) Assisting with positioning
C) Providing suctioning
D) Prescribing bronchodilators
E) Monitoring activity intolerance

Question 6

A client with chronic obstructive pulmonary disease (COPD)is prescribed oxygen 24% 2 L/min.Which is the best method to administer oxygen to this client?

A) Face mask
B) Nasal cannula
C) Nonrebreather mask
D) Venturi mask

Question 7

When auscultating the lungs of a client experiences dyspnea,the nurse hears a low-pitched sound that is continuous throughout inspiration.What does this lung sound indicate to the nurse?

A) Narrow bronchi
B) Narrow trachea passages
C) Blocked large airway passages
D) Inflamed pleural surfaces

Question 8

The nurse is providing care to a client experiencing the acid-base balance of respiratory acidosis.Which effects does the nurse anticipate based on this diagnosis? Select all that apply.

A) Increased CO₂
B) Vasoconstriction
C) Decreased O₂
D) Decreased intracranial pressure (ICP)
E) Increased pulse rate

Question 9

The nurse is providing care to a client with an infected leg wound.The client is exhibiting symptoms of a systemic infection and is receiving intravenous antibiotics.The client states to the nurse,"I am having trouble breathing." Based on this data,which does the nurse suspect the client is experiencing?

A) Allergic response from antibiotic therapy
B) Deep vein thrombosis
C) Acute respiratory distress syndrome
D) Anemia

Question 10

The nurse is providing care for a client admitted during an acute exacerbation of asthma.Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client?

A) Inhaled short-acting beta-agonists
B) Oral corticosteroids
C) Inhaled long-acting beta-agonists
D) Oral anticholinergics

Question 11

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%.Which nursing diagnosis is a priority for this client?

A) Risk for Infection
B) Impaired Spontaneous Ventilation
C) Risk for Acute Confusion
D) Decreased Cardiac Output

Question 12

The nurse is providing care to a client on a medical-surgical unit.The client's arterial blood gas analysis is as follows: PaO₂ of 82,PaCO₂ of 49,HCO₃ of 26,and pH of 7.55.Which acid-base imbalance is this client experiencing based on this data?

A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic alkalosis
D) Metabolic acidosis

Question 13

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance.Which action by the nurse is the most appropriate?

A) Encourage strenuous activity.
B) Consult a dietitian for low-calorie meals.
C) Consult physical therapy for endurance and musculoskeletal function.
D) Encourage dependence with activities of daily living.

Question 14

While performing nasotracheal suctioning,the nurse notes the older adult client is moving the head around and pulling at the nurse's hand to remove the suction catheter.Which actions by the nurse are appropriate? Select all that apply.

A) Remove the suction catheter
B) Lower the head of the bed
C) Hyperinflate the client's lungs
D) Apply restraints to the client's arms and legs
E) Hyperoxygenate the client

Question 15

The nurse is providing care to a client admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS).When educating the client's family on the disease progress,in which order will the nurse present the material?

A) Initiation of ARDS
B) Onset of pulmonary edema
C) End-stage ARDS
D) Alveolar collapse

Question 16

The nurse is providing care to a client who is diagnosed with acute respiratory distress syndrome (ARDS).Which clinical manifestation does the nurse anticipate for this client who is experiencing hypoxia as a result of the ARDS diagnosis?

A) Fluid imbalance
B) Hypertension
C) Bradycardia
D) Dyspnea

Question 17

A client with acute respiratory distress syndrome (ARDS)is being weaned from ventilatory support.Which nursing actions are appropriate for this client? Select all that apply.

A) Increase percentage of oxygen being provided through the ventilator.
B) Place in the Fowler position.
C) Provide morning care during the weaning procedures.
D) Begin weaning procedures in the morning.
E) Medicate with morphine for pain as needed.

Question 18

The nurse assigned to the newborn nursery is conducting shift assessments.While assessing one newborn,the nurse notes the respiratory rate is 52 breaths per minute.Which action by the nurse is appropriate?

A) Notify the healthcare provider of this assessment finding.
B) Obtain an arterial blood gas for further respiratory assessment.
C) Begin monitoring the respiratory rate every 5 minutes.
D) Continue to monitor the newborn per facility policy.

Question 19

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD).The client is admitted to the intensive care unit with a pneumothroax.Which interventions are appropriate for this client? Select all that apply.

A) Elevate head of the bed
B) Administer a high rate of oxygen by nasal cannula
C) Prepare for a chest tube insertion
D) Administer prescribed antihypertensive medications
E) Administer intravenous caffeine per order

Question 20

The nursing student is conducting an assessment for a client on a medical-surgical unit.Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.

A) Excessive rapid breathing
B) Chest pain
C) Rapid breathing at rest
D) Shallow breathing
E) Cyanosis

Question 21

The nurse is providing care to a client diagnosed with chronic obstruction pulmonary disease (COPD)after years of experiencing emphysema.Which clinical manifestation does the nurse anticipate when assessing this client?

A) Tachycardia
B) Cough
C) Barrel chest
D) Wheezing

Question 22

The nurse working on a pediatric unit is caring for a client newly diagnosed with asthma.Which assessment data indicates exhaustion and the need for immediate intervention? Select all that apply.

A) Shallow respirations
B) Slightly diminished breath sounds
C) Decreased wheezing
D) Increased crackles
E) Increased respiratory rate

Question 23

The nurse is providing care to an infant in the emergency department (ED).Initial assessment indicates that the infant is experiencing an asthma attack.The infant is unresponsive to medication and a chest x-ray reveals a foreign body partially obstructing the airway.While placing an oxygen mask on the infant,the nurse notes a total obstruction of the airway.Which nursing action is appropriate?

A) Attempt to clear the obstruction by delivering back blows and chest thrusts.
B) Attempt to clear the obstruction by delivering back blows.
C) Attempt to clear the obstruction by delivering back blows and abdominal thrusts.
D) Attempt to clear the obstruction by delivering abdominal thrusts.

Question 24

The nurse caring for a client admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS).Which early clinical manifestation would indicate the development of ARDS?

A) Intercostal retractions
B) Cyanosis
C) Tachypnea
D) Tachycardia

Question 25

A nurse is teaching environmental control to the parents of a child with asthma.Which statement by the parents indicates effective teaching?

A) "We'll be sure to use the fireplace often to keep the house warm in the winter."
B) "We will replace the carpet in our child's bedroom with tile."
C) "We'll keep the plants in our child's room dusted."
D) "We're glad the dog can continue to sleep in our child's room."

Question 26

The nurse caring for a newborn on a ventilator for acute respiratory distress syndrome (ARDS)informs the parents that the newborn is improving.Which data supports the nurse's assessment of the newborn's condition?

A) Increased PCO₂
B) Oxygen saturation of 92%
C) Pulmonary vascular resistance increases
D) Less than 1 mL/kg/hour urine output

Question 27

Friends of a client hospitalized with asthma would like to bring the client a gift.Which gift would the nurse recommend for this client?

A) A basket of flowers
B) A stuffed animal
C) Fruit and candy
D) A book

Question 28

The nurse is planning care for a young adolescent client diagnosed with asthma.Which evidence-based age-appropriate interventions will the nurse include in the plan of care? Select all that apply.

A) Referring to a peer-lead support group
B) Teaching the parents how to administer maintenance medication prior to teaching the client
C) Assessing peer-support when planning care
D) Collaborating with teachers for support in the school setting
E) Telling the client to avoid medication while at school

Question 29

Which assessment finding supports the nurse's suspicion that a client is experiencing chronic obstructive pulmonary disease (COPD)?

A) Dysrhythmias
B) Cyanotic nail beds
C) Clubbing of the fingers
D) Cough in the morning producing clear sputum

Question 30

The nurse is reviewing discharge instructions with a client who is newly diagnosed with asthma.Which client statement indicates a need for further teaching?

A) "I need to rinse my mouth after every use of my inhaler."
B) "I need to take my Singulair at least 1 hour before I eat."
C) "I can resume my ephedra when I return home."
D) "Because I am on theophylline, I will need to have therapeutic blood levels drawn."

Question 31

A client admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS).The nurse anticipates the healthcare provider will prescribe which course of action with regard to oxygen therapy?

A) Oxygen via a nasal cannula
B) Mechanical ventilation
C) Oxygen via a facial mask
D) Oxygen via a venturi mask

Question 32

The nurse instructs a client with asthma on bronchodilator therapy.Which statement indicates client understanding?

A) "The medication widens the airways because it acts on the parasympathetic nervous system."
B) "The medication widens the airways because it stimulates the fight-or-flight response of the nervous system."
C) "The medication widens the airways because it decreases the production of histamine that narrows the airways."
D) "The medication widens the airways because it decreases the production of mucous that narrows the airways."

Question 33

The nurse is providing care to a client admitted after experiencing an acute asthma attack.Which assessment findings indicate the need for immediate intervention by the nurse? Select all that apply.

A) Retractions and fatigue
B) Tachycardia and tachypnea
C) Inaudible breath sounds
D) Diffuse wheezing and the use of accessory muscles when inhaling
E) Reduced wheezing and an ineffective cough

Question 34

The nurse is providing care to a newly diagnosed with asthma.When developing the client's plan of care,which intervention would be most appropriate to promote airway clearance?

A) Provide adequate rest periods.
B) Reduce excessive stimuli.
C) Assist with activities of daily living
D) Place in Fowler position.

Question 35

A client asks why asthma medication is needed even though the client's last attack was several months ago.Which response by the nurse is appropriate?

A) "The medication needs to be taken or your lungs will be severely damaged and we will not be able to prevent an acute attack."
B) "The medication needs to be taken indefinitely according to your doctor, so you should discuss this with him."
C) "The medication is still needed to decrease inflammation in your airways and help prevent an attack."
D) "The medication needs to be taken for at least a year; then, if you have not had an acute attack, you can stop it."

Question 36

The nurse in the intensive care unit (ICU)is caring for a client diagnosed with acute respiratory distress syndrome (ARDS).Vital signs prior to endotracheal intubation: HR 108 bpm,RR 32 bpm,BP 88/58 mmHg,and oxygen saturation 82%.The client is intubated and placed on mechanical ventilation with positive pressure ventilation.Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation?

A) Blood pressure 90/60 mmHg
B) Urine output 25mL/hr
C) Heart rate 110 bpm
D) Oxygen saturation 90%

Question 37

An older adult client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration.Based on this data,which nursing diagnosis is the most appropriate?

A) Ineffective Airway Clearance
B) Impaired Tissue Perfusion
C) Ineffective Breathing Pattern
D) Activity Intolerance

Question 38

A client receiving treatment for acute respiratory distress syndrome (ARDS)is demonstrating anxiety and fear of having to stay on the ventilator indefinitely.Which interventions by the nurse are appropriate? Select all that apply.

A) Explain about care areas specifically designed for long-term ventilatory support.
B) Dim the lights and reduce distracting noise, such as the television.
C) Instruct that intubation and ventilation are temporary measures.
D) Encourage family visits and participation in care.
E) Remain with the client as much as possible.

Question 39

The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS).Which conditions will the nurse include in the teaching session? Select all that apply.

A) Septic shock
B) Viral pneumonia
C) Aspirin overdose
D) Head injury
E) Angioplasty

Question 40

The nurse is instructing a client who is prescribed ipratropium bromide (Atrovent)for asthma.Which should be included in this client's teaching? Select all that apply.

A) Take no more than the prescribed number of doses each day.
B) Rinse the mouth after taking this medication.
C) Take on an empty stomach.
D) Take with meals or a full glass of water.
E) Use hard candy or drink extra fluids to help with a dry mouth.

Question 41

The nurse is planning care for a child with respiratory syncytial virus (RSV)bronchiolitis with the nursing diagnosis of Impaired Gas Exchange.Which interventions should be included in the child's plan of care? Select all that apply.

A) Weigh daily.
B) Monitor vital signs and pulse oximetry.
C) Administer oxygen as prescribed.
D) Weigh diapers.
E) Provide frequent rest periods.

Question 42

The clinic nurse is educating a group of new moms on the risk factors and prevention of respiratory syncytial virus (RSV).The nurse is aware that which action is the best way to prevent RSV?

A) Hand washing
B) Monitoring temperature
C) Administering antibiotics
D) Limiting fluid intake

Question 43

An infant with respiratory syncytial virus (RSV)bronchiolitis is prescribed intubation to maintain an adequate airway.Who will the nurse collaborate with to maintain the endotracheal tube and ventilation? Select all that apply.

A) An advanced practice nurse
B) A dietitian
C) The primary healthcare provider
D) A respiratory therapist
E) A play therapist

Question 44

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD).Which observation would indicate that care provided to this client has been effective?

A) Client conducts morning care and ambulates in room while maintaining an oxygen saturation of 92% on room air per oximetry reading.
B) Client needs assistance with morning care and meals due to shortness of breath.
C) Client states family members are discussing admission to a nursing home for continuing care.
D) Client leaves hospital unit to smoke outside 4 times a day.

Question 45

The nurse on the medical unit is admitting a client with chronic obstructive pulmonary disease (COPD).Which prescription does the nurse anticipate to decrease this client's risk for developing a respiratory infection?

A) A broad-spectrum antibiotic
B) A bronchodilator
C) A corticosteroid
D) An influenza vaccine

Question 46

The nurse is providing care to a client recently diagnosed with chronic obstructive pulmonary disease (COPD).The client's family ask how their loved on got this disease.Which risk factors for COPD will the nurse include in the teaching session?

A) Asthma and bronchitis
B) Asthma and emphysema
C) Bronchitis and emphysema
D) Emphysema and atelectasis

Question 47

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD).When planning care for this client,which interventions are appropriate to enhance the client's breathing pattern? Select all that apply.

A) Provide adequate rest periods.
B) Assist with ADLs.
C) Educate on relaxation techniques.
D) Educate on pursed-lip breathing.
E) Administer a cough suppressant.

Question 48

A client diagnosed with chronic obstructive pulmonary disease (COPD)has a pulse oximetry reading of 93%,increased red blood and white blood cell count,temperature of 101°F,pulse 100 bpm,respirations 35 bpm,and a chest x-ray that showed a flattened diaphragm with infiltrates.Based on this data,which prescription does the nurse question for this client?

A) Antibiotic therapy
B) Nonsteroidal anti-inflammatory agents
C) Oxygen by nasal cannula at 3-4 liters/minute
D) Bronchodilators such as an adrenergic stimulating drugs or anticholinergic agents

Question 49

Which interventions would be the most beneficial for the nurse to discuss with the parents of a child who has had repeated admissions for respiratory syncytial virus (RSV)bronchiolitis? Select all that apply.

A) Do not smoke, and avoid all secondhand smoke around the child.
B) Practice frequent hand washing.
C) Encourage physical activity and play.
D) Consider alternatives to sending the child to daycare.
E) Ensure an adequate nutritional intake.

Question 50

The nurse assesses fatigue in an infant with acute bronchiolitis due to respiratory syncytial virus (RSV).Which nursing diagnosis would be most appropriate for the infant?

A) Acute Pain
B) Ineffective Tissue Perfusion
C) Activity Intolerance
D) Decreased Cardiac Output

Question 51

The nurse is providing care for a client diagnosed with chronic obstructive pulmonary disease (COPD.Which interventions are appropriate in order to control the client's breathing pattern? Select all that apply.

A) Instruct in pursed-lip breathing.
B) Teach visualization and meditation.
C) Deep breathing and coughing every hour.
D) Instruct in abdominal breathing.
E) Provide oxygen 2 liters nasal cannula.

Question 52

The nurse observes a toddler-age client,admitted with possible respiratory syncytial virus (RSV)bronchiolitis,grunting with expiration.Which action by the nurse is appropriate?

A) Assist the child to clear the nasal passages.
B) Limit fluids.
C) Suction the airway to relieve the obstruction.
D) Lay the child on his back.

Question 53

The nurse is planning care for the client diagnosed with chronic obstructive pulmonary disease (COPD)who has a breathing rate of 32 per minutes,elevated blood pressure,and fatigue.Which nursing diagnosis is the priority for this client?

A) Ineffective Coping
B) Ineffective Airway Clearance
C) Anxiety
D) Ineffective Breathing Pattern

Question 54

The mother of a 5-month-old baby,who attends daycare,is concerned because the child has developed a runny nose,cough,and low-grade fever over the last few days.Based on this data,which diagnosis does the nurse anticipate?

A) Meningitis
B) Respiratory syncytial virus (RSV) bronchiolitis
C) Bronchitis
D) The common cold

Question 55

The nurse is caring for a Spanish-speaking client admitted for exacerbation of chronic obstructive pulmonary disease (COPD).The client speaks very little English and is a smoker.Which action would be the most beneficial for this client?

A) Have the adult child of the client translate during the assessment process
B) Encourage aerobic activity
C) Encourage the client to write down questions prior to seeing the healthcare provider
D) Obtain educational materials about smoking cessation written in Spanish.

Question 56

The nurse caring for a client diagnosed with chronic obstructive pulmonary disease (COPD)is educating the client on effective coughing techniques.Which statement made by the client indicates a need for further teaching?

A) "I should inhale by sniffing."
B) "I should avoid aerosol sprays."
C) "I should limit my fluid intake to 1-1.5 quarts daily."
D) "I should get a flu vaccine every year."

Question 57

The nurse is providing care to a client with respiratory syncytial virus (RSV).The client's condition is not severe and there is no history of immune compromise.Which pharmacologic therapies does the nurse anticipate based on this data? Select all that apply.

A) Nebulized epinephrine
B) Ribavirin
C) Systemic corticosteroids
D) Antibiotics
E) Antipyretics

Question 58

The mother of an 8-month-old baby who has developed respiratory syncytial virus (RSV)/bronchiolitis wants to know which factors contribute to the risk of contracting RSV.Which response by the nurse is appropriate?

A) "There is a higher risk in children who are being breastfed."
B) "There is no way to avoid the illness."
C) "There is a higher risk in children who are exposed to secondary cigarette smoke."
D) "It is seen more frequently in children who do not attend daycare."

Question 59

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD)? Which factors in the client's history support the current diagnosis? Select all that apply.

A) Working in an industrial environment
B) Working in an office setting with air conditioning
C) History of asthma
D) Current cigarette smoking
E) Playing golf several times a week

Question 60

The nurse is providing care to a client diagnosed with respiratory syncytial virus (RSV)bronchiolitis.Which assessment finding indicate that treatment has been effective?

A) Client ingesting small amounts of clear fluids when encouraged
B) Client resting in bed with limited interest in play or activities
C) Client respiratory rate within normal limits for age
D) Client coughing copious amounts of green sputum and requires occasional suctioning.

Question 61

The nurse is developing a plan of care for a toddler-age client diagnosed with respiratory syncytial virus (RSV).Which intervention is inappropriate for this client?

A) Offer small, frequent meals.
B) Encourage to ambulate frequently.
C) Encourage oral intake.
D) Monitor intake and output.

Question 62

A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS).Which interventions are appropriate to decrease an infant's risk for SIDS? Select all that apply.

A) Using firm bedding
B) Ensuring the room temperature is at least 80 degrees F at all times
C) Avoiding smoking around infants
D) Recommending bed sharing
E) Placing the infant in a prone-position for sleeping

Question 63

The nurse is evaluating care provided to a new mother whose infant is at risk for sudden death syndrome (SIDS).Which statement by the mother indicates teaching has been effective?

A) "I need to purchase loose-fitting sheets and blankets for the bed."
B) "I plan to quit smoking."
C) "I will place my baby in a side-lying position for sleep."
D) "I will bottle-feed my baby since breastfeeding is a risk factor for SIDS."

Question 64

The nurse is instructing new parents on ways to decrease the risk of sudden infant death syndrome (SIDS)with their newborn son.What should be included in these instructions? Select all that apply.

A) There is nothing that can be done, so requirements for toys and bedding are of no consequence.
B) Instruct that it is more common in babies from ages 6 months to 18 months.
C) Avoid placing the baby in the prone or side-lying position for sleep.
D) Remind the parents that the syndrome is more common in females than males, and that they have a male child.
E) Do not smoke near the child and reduce all exposure to secondhand smoke.

Question 65

A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS).Which should the nurse include when presenting significant stressors that contribute to SIDS? Select all that apply.

A) Prone sleeping
B) Side sleeping
C) Face-down sleeping
D) Bed sharing
E) Supine sleeping

Question 66

The student nurse attends a workshop on culture and diversity with regard to sudden infant death syndrome (SIDS)and is now aware that the rate of occurrence is highest among which group of infants?

A) American Indians
B) African-Americans
C) Asians
D) Hispanics

Question 67

The nurse is providing supportive care for the parents of an infant who died from sudden infant death syndrome (SIDS).Which action by the nurse are appropriate?

A) Advising the parents that an autopsy is not necessary.
B) Sheltering the parents from their grief by not giving them any personal items of the infant, such as footprints.
C) Interviewing the parents to determine the cause of the SIDS incident.
D) Allowing the parents to hold, touch, and rock the infant.

Question 68

The student nurse attends a workshop on culture and diversity with regards to respiratory syncytial virus (RSV).Which statement made by the student at the end of the workshop indicates understanding of the information presented?

A) "RSV is the major cause of hospitalization for Alaskan Native infants."
B) "RSV is the major cause of hospitalization for African-American infants."
C) "RSV is the major cause of hospitalization for Native American infants."
D) "RSV is the major cause of hospitalization for Asian-American infants."

Question 69

The nurse working in the emergency department provides care to an infant who arrived in cardiac and respiratory arrest.Resuscitative efforts failed and the infant's cause of death is sudden infant death syndrome (SIDS).The parents are grieving and will need collaborative interventions.Which interventions does the nurse plan for when providing care to these parents? Select all that apply.

A) A psychosocial assessment
B) A grief counselor referral
C) A psychotherapist referral
D) A visit from the chaplain
E) A social services consult

Question 70

The pediatric nurse is providing education to a new mother regarding ways to decrease the risk of sudden infant death syndrome (SIDS).Which statement by the nurse is appropriate?

A) "You should the baby with you at all times to assess for apnea."
B) "There is no one cause for the syndrome; the best thing is to keep the baby healthy."
C) "It is recommended that you place your baby in a face-down position for sleep."
D) "SIDS has been linked to immunizations. I recommend that you avoid immunizing your baby."

Question 71

The nurse is planning care for a new mother of African-American descent who smoked during the pregnancy and whose sister lost a child to sudden infant death syndrome (SIDS).Which interventions are appropriate for the nurse to include in the plan of care for the new mother and baby? Select all that apply.

A) Information on bottle-feeding the infant
B) Reasons why the child should sleep with others
C) Ages at which the child should receive immunizations
D) Using bedding that is firm
E) Smoking cessation information

Question 72

The nurse working in the emergency department (ED)is assessing an infant client.Whch findings support the diagnosis of respiratory syncytial virus (RSV)? Select all that apply.

A) Rhinorrhea
B) Irritability
C) Grunting
D) Bradypnea
E) Tachypnea

Question 73

The nurse is providing care for an African-American male infant who is two months of age.The infant is brought to the appointment by the mother.When reinforcing instructions regarding reducing the infant's risk for sudden infant death syndrome (SIDS),which teaching point is the most appropriate for the nurse to include when teaching the infant's mother?

A) Instruct on side-lying and face-down positions when in the crib.
B) Instruct on face-up position when in the crib.
C) Ensure adequate nutritional intake for the mother and newborn.
D) Encourage good hand washing.

Question 74

The nurse is planning care for a baby of African-American descent born to a mother who smoked during the pregnancy.Which nursing diagnosis would be appropriate for this baby?

A) Risk for Sudden Infant Death Syndrome (SIDS)
B) Readiness for Enhanced Parenting
C) Anxiety
D) Deficient Knowledge

Question 75

The nurse is placing a newborn baby in the nursery crib with the baby's back down.The mother tells the nurse that she doubts the baby will be able to sleep that way,as all the family members sleep on their stomachs.Which action by the nurse is appropriate?

A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS).
B) Place the baby on the stomach.
C) Suggest the mother place the baby on the stomach when at home.
D) Instruct the mother that babies do not really care in which position they are in but placing on the back is easier to provide care.

Question 76

When assessing the risk of a newborn for sudden infant death syndrome (SIDS),which are risk factors that the nurse should consider? Select all that apply.

A) Race
B) Gender
C) Father's age
D) Age
E) Eye color