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

Accepted Answer

Throat culture involves inserting a swab into the back of the throat to collect a sample for bacterial testing. This procedure may cause further irritation to the already inflamed and swollen epiglottis, which could lead to complete airway obstruction. Therefore, it is contraindicated in suspected cases of acute epiglottitis. Instead, the diagnosis is based on clinical findings and immediate interventions are required to maintain the airway. Medical history, vital signs, and auscultation of breath sounds are important components of the assessment and should be performed.

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

Accepted Answer

Replacing carpet with tile can reduce the amount of dust and allergens that can trigger asthma symptoms. Option A is incorrect because having a dog in the room can worsen asthma symptoms. Option B is not enough, dusting alone is not sufficient when it comes to asthma triggers. Option C is also incorrect because using a fireplace can release smoke and other irritants into the air, worsening asthma symptoms.

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)?
A) Place the child on an apnea monitor.
B) Place the child on nasal cannula oxygen.
C) Draw blood for arterial blood gases.
D) Place the child on contact isolation.

Accepted Answer

The appropriate independent nursing action in this scenario would be to place the child on an apnea monitor. This is because the infant has been admitted with a diagnosis of ALTE, which means they may experience sudden apnea or a pause in breathing. Placing them on an apnea monitor will help to monitor their breathing patterns and alert the healthcare team in case of any abnormalities. Placing the child on nasal cannula oxygen or drawing blood for arterial blood gases would be dependent nursing actions that require a physician's order. Placing the child on contact isolation is unnecessary as ALTE is not infectious.

Question 4

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

Accepted Answer

Blunt chest trauma is a common injury in children, and it can be caused by a variety of accidents, such as motor vehicle accidents, falls, and sports injuries. Preschool-age children are at a higher risk for blunt chest trauma because they are more likely to be involved in accidents and because their bones are still developing. Toddler-age children are also at a higher risk for blunt chest trauma because they are more likely to be involved in accidents and because their lungs are still developing. School-age children are less likely to be involved in accidents, but they are more likely to be involved in sports injuries that can lead to blunt chest trauma. Adolescent clients are less likely to be involved in accidents, but they are more likely to be involved in sports injuries that can lead to blunt chest trauma. Infants are less likely to be involved in accidents, but they are more likely to have underlying medical conditions that can make them more susceptible to blunt chest trauma.

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?
A) Administering the bath to the neonate in the nursery
B) Transferring to the neonatal intensive care unit for further observation
C) Allowing the neonate to room-in to promote bonding
D) Providing the first feeding in the nursery

Accepted Answer

A respiratory rate of 102 breaths per minute is significantly higher than the normal range for a newborn, which is typically 40-60 breaths per minute. Even though the lungs are clear upon auscultation, the elevated respiratory rate indicates potential respiratory distress or an underlying condition that requires closer monitoring and possibly intervention, which is best done in a neonatal intensive care unit (NICU).

Question 6

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

Accepted Answer

Pancreatic enzymes need to be administered with every meal and snacks to ensure proper digestion and absorption of nutrients. Option A is not specific enough regarding how often the medication should be administered. Option B is not sufficient for adequate digestion and absorption. Option D provides a time frame but does not specify how many times the medication should be administered.

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?
A) "Encourage your child to drink cranberry juice."
B) "An orange discoloration of urine is expected while your child is on this medication."
C) "Bring your child to the clinic for a urinalysis."
D) "Bring your child to the clinic for a radiograph of the kidneys."

Accepted Answer

An orange discoloration of urine is an expected side effect of rifampin (Rimactane) and does not indicate a need for further evaluation or intervention. Encouraging the child to drink cranberry juice or ordering a urinalysis or radiograph of the kidneys is not necessary.

Question 8

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

Accepted Answer

Providing stimulation by stroking the back is often the first action taken to stimulate breathing in a premature neonate experiencing apnea, as it can help restart regular breathing patterns.

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?
A) Hepatitis B
B) Polio
C) Measles, mumps, and rubella (MMR)
D) Haemophilus influenzae type B (HIB)

Accepted Answer

Haemophilus influenzae type B (HIB) is responsible for most cases of epiglottitis in young children. Therefore, the nurse should include teaching on the HIB vaccine to decrease the risk for epiglottitis.

Question 10

Which should the nurse assess to determine oxygenation during the respiratory assessment for a pediatric client? Select all that apply.
A) Mucous membranes
B) Nail beds
C) Skin
D) Sclerae
E) Corneas

Accepted Answer

Mucous membranes, nail beds, and skin are commonly assessed to determine oxygenation as they can show signs of cyanosis or pallor, indicating poor oxygenation. Sclerae and corneas are not typically used for assessing oxygenation.

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

Accepted Answer

Allowing parents to hold, touch, and rock the infant is appropriate as it can help them cope with their loss and begin the grieving process.

Answer: C
 Advising parents that an autopsy is not necessary is not appropriate as an autopsy may provide important information about the cause of the infant's death, which can help the parents gain closure and prevent future deaths.

Answer: D
 Interviewing parents to determine the cause of the incident is not appropriate as this may lead to blaming the parents and cause further emotional distress. The focus should be on providing support and empathy to the parents.

Answer: A
 Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints, is not appropriate as these items can provide comfort and tangible memories of their child.

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?
A) Placing the child in a Trendelenburg position
B) Beginning rescue breathing for the child
C) Beginning cardiac resuscitation for the child
D) Covering the child's wound with an air occlusive dressing

Accepted Answer

The priority nursing action for a child with a sucking wound of the chest is to cover the wound with an air occlusive dressing to prevent air from being sucked into the chest cavity, which can cause a tension pneumothorax. Placing the child in a Trendelenburg position would not benefit the child in this situation. Beginning rescue breathing or cardiac resuscitation may be necessary if the child becomes unresponsive, but covering the wound should be the initial priority.

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.
A) Assessing for respiratory distress
B) Auscultating the lungs for wheezing
C) Prescribing oxygen for low saturations
D) Administering prescribed prophylactic antibiotic therapy
E) Providing support to the family

Accepted Answer

Assessing for respiratory distress and auscultating the lungs for wheezing are critical to monitor the child's respiratory status. Providing support to the family is also important in pediatric care. Prescribing medications is not within a nurse's scope of practice.

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

Accepted Answer

Infants with acute bronchiolitis due to RSV may experience dyspnea, tachypnea, and fatigue, leading to activity intolerance. Therefore, it is important for the nurse to include Activity Intolerance in the plan of care to promote adequate rest and conserve the infant's energy. Ineffective Peripheral Tissue Perfusion, Acute Pain, and Decreased Cardiac Output are not commonly associated with acute bronchiolitis due to RSV.

Question 15

Which assessment data would cause the nurse to suspect that a newborn requires further testing for cystic fibrosis?
A) Rectal prolapse
B) Constipation
C) Steatorrheic stools
D) Meconium ileus

Accepted Answer

Meconium ileus, which is a condition where the meconium (first stool of the newborn) is abnormally thick and sticky, is a common symptom of cystic fibrosis in newborns. Therefore, it would cause the nurse to suspect that further testing is needed. Rectal prolapse, constipation, and steatorrheic stools may also be present in cystic fibrosis, but they are not specific enough to diagnose the condition.

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?
A) Show the mother how to do cardiac compressions and rescue breathing.
B) Recommend the mother perform back blows and chest thrusts.
C) Teach the mother how to perform abdominal thrusts.
D) Tell the mother to do nothing until the child loses consciousness.

Accepted Answer

Abdominal thrusts, also known as the Heimlich maneuver, is the recommended first aid measure for choking in children older than 1 year. The nurse should teach the mother how to properly perform abdominal thrusts to alleviate her concerns about choking. The other options are either incorrect (cardiac compressions and rescue breathing are for cardiac arrest, not choking) or potentially harmful (back blows and chest thrusts can be dangerous if done incorrectly and can cause injury). Waiting for the child to lose consciousness is not the appropriate response to choking.

Question 17

Which data collected during the respiratory assessment would indicate the pediatric client is compromised? Select all that apply.
A) Lung sounds clear to auscultation
B) Stridor
C) Substernal retractions
D) Nasal flaring
E) Strong cry

Accepted Answer

Stridor, substernal retractions, and nasal flaring are all signs of respiratory distress or compromise in a pediatric client. The lung sounds being clear and a strong cry may not necessarily indicate any respiratory compromise.

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?
A) "You are incorrect in your assessment."
B) "The younger child's airways are smaller and more easily occluded."
C) "Air passages are more likely to become blocked with mucus because younger children make more mucus than older children."
D) "Toddlers do not breathe as deeply as do older children."

Accepted Answer

The statement that younger children have smaller airways and are more prone to airway obstruction is accurate. This puts them at an increased risk for respiratory complications associated with infections. Choices A, C, and D are incorrect.

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.
A) "The medication works to prevent exacerbations."
B) "The medication should be administered at the first symptom of an asthmatic attack."
C) "The medication should be taken on a daily basis."
D) "The medication should not be administered if the child has a cold."
E) "The medication desensitizes the child against specific allergens."

Accepted Answer

A mast cell stabilizer like cromolyn sodium works to prevent asthma exacerbations, so it should be taken on a daily basis to be effective. Administering the medication at the first symptom of an asthmatic attack (B) is not an appropriate action with this medication. There is no information to support option D. Option E describes the mechanism of action for immunotherapy, not cromolyn sodium.

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.
A) Upright
B) Semi-Fowler position
C) Prone position
D) With the infant's head hyperextended
E) With the infant's head in a sniffing position

Accepted Answer

The answer of Which positions are appropriate for the nurse...

Quiz 46: The Child With Alterations in Respiratory Function

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?

Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented?

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) ?

Which pediatric clients would require a nursing assessment for blunt chest trauma? Select all that apply.

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?

Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis?

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?

Which is the priority nursing action for a premature neonate who is experiencing apnea?

Which immunization should the nurse include in a teaching session for parents of a toddler-age client to decrease the risk for epiglottitis?

Which should the nurse assess to determine oxygenation during the respiratory assessment for a pediatric client? Select all that apply.

Which nursing action is appropriate for the parents of a 4-month-old infant who died due to sudden infant death syndrome (SIDS) ?

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?

Which nursing actions are appropriate when providing care to a pediatric client who has sustained a smoke-inhalation injury? Select all that apply.

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) ?

Which assessment data would cause the nurse to suspect that a newborn requires further testing for cystic fibrosis?

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?

Which data collected during the respiratory assessment would indicate the pediatric client is compromised? Select all that apply.

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?

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.

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.