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?
- “You are incorrect in your assessment.”
- “The younger child’s airways are smaller and more easily occluded.”
- “Air passages are more likely to become blocked with mucus because younger children make more mucus than older children.”
- “Toddlers do not breathe as deeply as do older children.”
2
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)?
- Activity Intolerance
- Ineffective Peripheral Tissue Perfusion
- Acute Pain
- Decreased Cardiac Output
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?
- Throat culture
- Medical history
- Vital signs
- Auscultation of breath sounds
1
Which nursing action is appropriate for the parents of a 4-month-old infant who died due to sudden infant death syndrome (SIDS)?
- Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints
- Allowing parents to hold, touch, and rock the infant
- Advising parents that an autopsy is not necessary
- Interviewing parents to determine the cause of the incident
2
Which immunization should the nurse include in a teaching session for parents of a toddler-age client to decrease the risk for epiglottitis?
- Hepatitis B
- Polio
- Measles, mumps, and rubella (MMR)
- Haemophilus influenzae type B (HIB)
4
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?
- “Encourage your child to drink cranberry juice.”
- “An orange discoloration of urine is expected while your child is on this medication.”
- “Bring your child to the clinic for a urinalysis.”
- “Bring your child to the clinic for a radiograph of the kidneys.”
2
Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented?
- “We’re glad the dog can continue to sleep in our child’s room.”
- “We’ll keep the plants in our child’s room dusted.”
- “We’ll be sure to use the fireplace often to keep the house warm in the winter.”
- “We will replace the carpet in our child’s bedroom with tile.”
4
Which assessment data would cause the nurse to suspect that a newborn requires further testing for cystic fibrosis?
- Rectal prolapse
- Constipation
- Steatorrheic stools
- Meconium ileus
4
Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis?
- “I will administer this medication 4 times each day.”
- “I will administer this medication twice each day.”
- “I will administer this medication with meals and snacks.”
- “I will administer this medication every 6 hours around the clock.”
3
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?
- Show the mother how to do cardiac compressions and rescue breathing.
- Recommend the mother perform back blows and chest thrusts.
- Teach the mother how to perform abdominal thrusts.
- Tell the mother to do nothing until the child loses consciousness.
3
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.
- Upright
- Semi-Fowler position
- Prone position
- With the infant’s head hyperextended
- With the infant’s head in a sniffing position
2,5
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?
- Administering the bath to the neonate in the nursery
- Transferring to the neonatal intensive care unit for further observation
- Allowing the neonate to room-in to promote bonding
- Providing the first feeding in the nursery
2
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)?
- Place the child on an apnea monitor.
- Place the child on nasal cannula oxygen.
- Draw blood for arterial blood gases.
- Place the child on contact isolation.
1
Which is the priority nursing action for a premature neonate who is experiencing apnea?
- Administering oxygen
- Performing back blows and chest thrusts
- Calling a code blue
- Providing stimulation by stroking the back
4
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.
- “The medication works to prevent exacerbations.”
- “The medication should be administered at the first symptom of an asthmatic attack.”
- “The medication should be taken on a daily basis.”
- “The medication should not be administered if the child has a cold.”
- “The medication desensitizes the child against specific allergens.”
1,3
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?
- Placing the child in a Trendelenburg position
- Beginning rescue breathing for the child
- Beginning cardiac resuscitation for the child
- Covering the child’s wound with an air occlusive dressing
4
Which data collected during the respiratory assessment would indicate the pediatric client is compromised? Select all that apply.
- Lung sounds clear to auscultation
- Stridor
- Substernal retractions
- Nasal flaring
- Strong cry
2,3,4
Which should the nurse assess to determine oxygenation during the respiratory assessment for a pediatric client? Select all that apply.
- Mucous membranes
- Nail beds
- Skin
- Sclerae
- Corneas
1,2,3
Which nursing actions are appropriate when providing care to a pediatric client who has sustained a smoke-inhalation injury? Select all that apply.
- Assessing for respiratory distress
- Auscultating the lungs for wheezing
- Prescribing oxygen for low saturations
- Administering prescribed prophylactic antibiotic therapy
- Providing support to the family
1,2,5
Which pediatric clients would require a nursing assessment for blunt chest trauma? Select all that apply.
- A preschool-age client who is admitted after a house fire.
- A toddler-age client who is admitted for injuries sustained in a motor vehicle accident.
- A school-age client who is admitted for observation after a skateboarding accident.
- An adolescent client admitted for an asthma exacerbation.
- An infant admitted to rule out cystic fibrosis.
2,3
Which nursing assessment data would indicate that a pediatric client sustained a large pulmonary contusion in a motor vehicle crash? Select all that apply.
- Eupnea
- Dyspnea
- Hemoptysis
- Fever
- Crackles
2,3,4,5
