Deck 46: The Child With Alterations in Respiratory Function

Question 1

A toddler-age client presents to the emergency department with a sore throat and difficulty swallowing. The nurse suspects acute epiglottitis. Which nursing action is avoided based on the current assessment data?
1) Throat culture
2) Medical history
3) Vital signs
4) Auscultation of breath sounds

Answer 1

1

Question 2

Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented?
1) "We're glad the dog can continue to sleep in our child's room."
2) "We'll keep the plants in our child's room dusted."
3) "We'll be sure to use the fireplace often to keep the house warm in the winter."
4) "We will replace the carpet in our child's bedroom with tile."

Answer 2

4

Question 3

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 (apparent life-threatening event)?
1) Place the child on an apnea monitor.
2) Place the child on nasal cannula oxygen.
3) Draw blood for arterial blood gases.
4) Place the child on contact isolation.

Answer 3

1

Question 4

Which pediatric clients would require a nursing assessment for blunt chest trauma? Select all that apply.
1) A preschool-age client who is admitted after a house fire.
2) A toddler-age client who is admitted for injuries sustained in a motor vehicle accident.
3) A school-age client who is admitted for observation after a skateboarding accident.
4) An adolescent client admitted for an asthma exacerbation.
5) An infant admitted to rule out cystic fibrosis.

Question 5

Which nursing action is appropriate when providing care to a newborn with a respiratory rate of 102 breaths per minute with lungs that are clear to auscultation?
1) Administering the bath to the neonate in the nursery
2) Transferring to the neonatal intensive care unit for further observation
3) Allowing the neonate to room-in to promote bonding
4) Providing the first feeding in the nursery

Question 6

Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis?
1) "I will administer this medication 4 times each day."
2) "I will administer this medication twice each day."
3) "I will administer this medication with meals and snacks."
4) "I will administer this medication every 6 hours around the clock."

Question 7

The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for treatment of tuberculosis because she saw that the child's urine was orange. Which response by the nurse is accurate?
1) "Encourage your child to drink cranberry juice."
2) "An orange discoloration of urine is expected while your child is on this medication."
3) "Bring your child to the clinic for a urinalysis."
4) "Bring your child to the clinic for a radiograph of the kidneys."

Question 8

Which is the priority nursing action for a premature neonate who is experiencing apnea?
1) Administering oxygen
2) Performing back blows and chest thrusts
3) Calling a code blue
4) Providing stimulation by stroking the back

Question 9

Which immunization should the nurse include in a teaching session for parents of a toddler-age client to decrease the risk for epiglottitis?
1) Hepatitis B
2) Polio
3) Measles, mumps, and rubella (MMR)
4) Haemophilus influenzae type B (HIB)

Question 10

Which should the nurse assess to determine oxygenation during the respiratory assessment for a pediatric client? Select all that apply.
1) Mucous membranes
2) Nail beds
3) Skin
4) Sclerae
5) Corneas

Question 11

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

Question 12

Which is the priority nursing action for a child who presents in the emergency department after a motor vehicle accident with a sucking wound of the chest?
1) Placing the child in a Trendelenburg position
2) Beginning rescue breathing for the child
3) Beginning cardiac resuscitation for the child
4) Covering the child's wound with an air occlusive dressing

Question 13

Which nursing actions are appropriate when providing care to a pediatric client who has sustained a smoke-inhalation injury? Select all that apply.
1) Assessing for respiratory distress
2) Auscultating the lungs for wheezing
3) Prescribing oxygen for low saturations
4) Administering prescribed prophylactic antibiotic therapy
5) Providing support to the family

Question 14

Which nursing diagnosis should the nurse include in the plan of care for an infant diagnosed with acute bronchiolitis due to respiratory syncytial virus (RSV)?
1) Activity Intolerance
2) Ineffective Peripheral Tissue Perfusion
3) Acute Pain
4) Decreased Cardiac Output

Question 15

Which assessment data would cause the nurse to suspect that a newborn requires further testing for cystic fibrosis?
1) Rectal prolapse
2) Constipation
3) Steatorrheic stools
4) Meconium ileus

Question 16

Which should the nurse include in a teaching session for the mother of a 3-year-old client who is concerned about her child choking?
1) Show the mother how to do cardiac compressions and rescue breathing.
2) Recommend the mother perform back blows and chest thrusts.
3) Teach the mother how to perform abdominal thrusts.
4) Tell the mother to do nothing until the child loses consciousness.

Question 17

Which data collected during the respiratory assessment would indicate the pediatric client is compromised? Select all that apply.
1) Lung sounds clear to auscultation
2) Stridor
3) Substernal retractions
4) Nasal flaring
5) Strong cry

Question 18

The mother of a toddler-age client states, "My daughter seems to be at an increased risk for complications associated with respiratory infections." Which response by the nurse is accurate?
1) "You are incorrect in your assessment."
2) "The younger child's airways are smaller and more easily occluded."
3) "Air passages are more likely to become blocked with mucus because younger children make more mucus than older children."
4) "Toddlers do not breathe as deeply as do older children."

Question 19

Which statements should the nurse include in the discharge medication teaching for a child diagnosed with asthma who is prescribed cromolyn sodium (a mast cell stabilizer)? Select all that apply.
1) "The medication works to prevent exacerbations."
2) "The medication should be administered at the first symptom of an asthmatic attack."
3) "The medication should be taken on a daily basis."
4) "The medication should not be administered if the child has a cold."
5) "The medication desensitizes the child against specific allergens."

Question 20

Which positions are appropriate for the nurse to include in a plan of care for the infant who is diagnosed with acute respiratory distress? Select all that apply.
1) Upright
2) Semi-Fowler position
3) Prone position
4) With the infant's head hyperextended
5) With the infant's head in a sniffing position

Question 21

Which nursing assessment data would indicate that a pediatric client sustained a large pulmonary contusion in a motor vehicle crash? Select all that apply.
1) Eupnea
2) Dyspnea
3) Hemoptysis
4) Fever
5) Crackles