Chapter 23: Caring for the Child With a Respiratory Condition

A child who weighs 32 lb (14.5 kg) is prescribed erythromycin (Sumycin) every 8 hours. Calculate the dose range for a single dose of this drug. (Round to the nearest hundredth).

ANS: 145-241.66 mg The safe dose range for this drug is 435-725 mg in 24 hours (30-50 mg/kg). When given in 3 doses a day (every 8 hours), the safe dose range for a single dose is 145-241.66 mg.

43. A nurse is planning a seminar to address asthma in the community. To have the greatest impact, which demographic group should the nurse target? A. African American children B. Children with allergies C. Inner-city youth, all ethnicities D. School-age children

ANS: A African American children have a 60% higher prevalence of asthma, a 260% higher rate of emergency department visits, a 250% higher hospitalization rate, and a 500% higher mortality rate than white children. To have the greatest impact on this chronic disease, the nurse should target African American children and their parents/guardians and caretakers. Up to 40% of children with asthma have no allergies. Low socioeconomic status is a risk factor, not living in an inner city specifically. Children of all ages are affected.

5. A 4-year-old girl is brought to the emergency department. She has a "frog-like" croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. Which nursing action is the priority for this patient? A. Maintain the airway. B. Obtain a throat culture. C. Start an intravenous line. D. Transport for a chest x-ray.

ANS: A Airway, breathing, and circulation are the primary concerns for all patients. When a patient has acute respiratory distress, the most important nursing intervention is maintaining an airway. Starting an IV is important, but it is not the primary concern. Obtaining a throat culture would be contraindicated at this time, as it could cause vomiting or occlusion of the airway. The child should not be transported for x-ray; it should be done with portable equipment.

10. A nurse is caring for an infant diagnosed with esophageal atresia (EA) and a tracheoesophageal fistula (TEF) prior to surgical correction. Which assessment finding indicates that a priority goal is being met? A. Airway patent with frequent suction B. Gavage feedings tolerated well C. Identification of support system by parents D. Temperature within normal range

ANS: A All assessments indicate that goals for important nursing diagnoses have been met; however, airway takes priority. Maintaining a patent airway is the most important goal.

41. The nurse checking a pediatric patient into the clinic says to a nursing student, "Wow—does that kid have some allergic shiners!" Which interpretation by the student nurse is correct? A. Dark periorbital swelling from allergies B. Extra grooves in the lower eyelids C. Macerated eyelids from rubbing eyes D. Shiny, taut skin from response to histamine

ANS: A An "allergic shiner" is a dark periorbital swelling noted in some children who have allergies. Extra grooves in the lower eyelid and skin problems due to rubbing itchy eyes are also possible symptoms of allergies.

31. A child with severe pertussis has been prescribed erythromycin (Erythrocin) and prednisone (Deltasone). Four days later, the parent informs the clinic nurse the child is sleeping more than usual and is not eating well. Which response by the nurse is the most appropriate? A. "Go to the emergency department for an infection workup." B. "Let her sleep; she is just exhausted from having pertussis." C. "Stop the prednisone for now and see how she does tomorrow." D. "Take her temperature; if it's normal bring her in tomorrow."

ANS: A Children with severe pertussis are occasionally prescribed steroids to reduce the severity of the symptoms. Steroids, including prednisone, can mask signs of infection (including temperature). A child who is lethargic and not feeding well should be seen immediately for a sepsis workup. The child is acutely ill and needs evaluation, not sleep or waiting until tomorrow to be seen. The child's temperature may be normal or subnormal due to the immune-suppressive effects of the steroids and is not a reliable indicator of infection.

3. The pediatric nurse examines a neonate and documents that the baby is pink in color when crying but turns bluish when quiet. Which question would be most appropriate to ask the parent? A. "Does the baby have trouble when eating?" B. "Have your other children had this problem?" C. "How many respiratory infections has she had?" D. "You don't ever prop her bottle, do you?"

ANS: A Choanal atresia is a congenital malformation of the nose in which there is blockage of the posterior side of the nose. It often is associated with bony abnormalities and may affect one side or both sides of the nose. A child with bilateral choanal atresia usually displays respiratory problems during development. A newborn who is pink in color when crying, yet turns bluish when quiet should be suspected of having bilateral choanal atresia or another defect impeding the nasal airway. Another sign of this disorder is feeding difficulties and resultant lack of weight gain. Because this is not genetic, asking about other children with the condition is irrelevant. The number of respiratory infections will not give information as to the possible diagnosis. Because of the potential for aspiration, the baby should be fed in a semi-upright to upright position; however, the wording of the question might make the parent feel defensive.

17. The parents of a child diagnosed with cystic fibrosis (CF) consult the nurse, stating they want to have more children but are worried about subsequent children also having the disease. Which information does the nurse provide the parents? A. "Each child has a 25% chance of inheriting the disease." B. "This disease is rare, so other children should not be affected." C. "Unfortunately, there is no way to predict if they will have it." D. "You should have genetic testing to see who the carrier is."

ANS: A Cystic fibrosis is an inherited autosomal recessive disorder. When both parents carry the defective gene, each child has a 25% chance of inheriting the defective gene from both parents and manifesting the disease. It is a common disorder, especially in Caucasians, affecting 1 in 3,000 live births.

11. A nurse is caring for a child who has a chest tube. After ambulating and returning the child to bed, the nurse notes that the child has dyspnea and decreasing oxygen saturation readings. Which nursing action is the priority? A. Assess the tubing for kinks. B. Call the rapid response team. C. Facilitate a portable chest x-ray. D. Provide bag-valve-mask breathing.

ANS: A In order to function properly, the chest tube system should be at least 1 ft below the level of the lungs, and the tubing must be free of kinks. After positioning the child in bed, the potential for kinking the tubing is fairly high, so the nurse should quickly assess the tubing before taking any other actions. If the system is working, other interventions need to occur, including calling the rapid response team.

36. The parent of a 7-month-old baby who has been diagnosed with influenza asks the nurse if the baby can have Tamiflu (oseltamivir). Which response by the nurse is the most appropriate? A. "Children younger than 1 year old cannot take this medication," B. "I'm not sure; let's see how much your baby weighs today." C. "No, children can't take it because it contains aspirin products." D. "Yes, and you can take it, too, if you develop flu symptoms."

ANS: A Tamiflu is contraindicated in children younger than 1 year old. The nurse should advise the parent of this fact.

35. A father calls the pediatric clinic to report that his child was diagnosed with influenza at an urgent care facility yesterday and was prescribed oseltamivir (Tamiflu). The father worries that the dose of 75 mg twice a day is too high. He reports that his child weighs 90 lb (40.9 kg). Which response by the nurse is best? A. "No, that is an appropriate dose for your child." B. "No, that is way too little medicine for your child." C. "Tamiflu should not be used in children under 100 lb." D. "Yes, that is double the normal dose for a child."

ANS: A The dose of Tamiflu for children weighing over 88 lb (40 kg) is 75 mg twice a day. The nurse should advise the father that the dose is appropriate.

1. Which statement by the nursing student indicates a correct understanding of the anatomy and physiology of the respiratory system? A. Air passes through the trachea into the bronchus. B. Oxygen exchange with the bloodstream occurs in the veins. C. Oxygen passes from the larynx to the pharynx. D. The bronchus divides into smaller branches or acini.

ANS: A The oxygen passes from the pharynx to the larynx. From the larynx, air passes through the trachea, which branches into the left and right bronchi. Each bronchus divides into smaller branches called bronchioles. The bronchioles end in a cluster of air sacs called acini. Oxygen exchange with the bloodstream occurs in the capillaries.

46. The pediatric nurse is observing a student nurse teach a child how to use a peak flow meter. Which instruction by the student requires intervention by the pediatric nurse? A. "Exhale for as long as you can to empty your lungs." B. "Keep your tongue away from the mouthpiece." C. "Stand up straight and tall when using the meter." D. "Write down the highest of the three readings."

ANS: A The proper way to use the peak flow meter is to blow hard and fast when exhaling. The nurse should intervene when the student states otherwise. The other instructions are correct.

7. The mother of a 5-year-old girl describes her daughter's symptoms to the nurse in the emergency room. She states that her daughter has had "a dry, hacking cough for the past 3 days that gets worse during the night." She further states that "now she is coughing up phlegm." Which discharge instruction does the nurse plan to provide? A. "Do not be surprised if she vomits her secretions." B. "Give your child cough drops as often as needed." C. "Return if she is not better after 3 days of antibiotics." D. "You can use a warm-mist humidifier in her room."

ANS: A This child has manifestations of bronchitis, which is frequently viral in nature. A dry, hacking cough gives way to a productive cough. Older children can be encouraged to cough up their secretions, but younger children often swallow them, leading to vomiting. Cough drops are not generally used, so as to encourage secretion mobilization. Because this disease is usually viral in nature, antibiotics are not routinely used. Cool-mist humidifiers are preferred over warm.

The parents of a school-age child with frequent sinus infections ask the nurse how to prevent the infections from occurring. Which questions by the nurse to the parents would elicit helpful information as to the cause of the problem? (Select all that apply.) A. "Do your other children have frequent infections?" B. "Has your child ever had allergy testing?" C. "Is your child around anyone who smokes?" D. "Was your child born prematurely or at term?" E. "Who watches your child before and after school?"

ANS: A, B, C, E Causes of sinusitis include allergies, exposure to other sick people (e.g., siblings or children at day care), exposure to cigarette smoke, and exposure to allergens. Eliminating these factors would help decrease the number of episodes of sinusitis, so it is appropriate to ask questions about these topics. Term versus premature birth is not a contributing factor.

The pediatric clinic nurse cares for many children with viral upper respiratory infections. Which seasonal characteristics of these infections would the clinic nurse include when educating parents? (Select all that apply.) A. Adenovirus is very prevalent in the winter. B. Coronavirus is commonly seen in the spring. C. Infections with parainfluenza are seen in autumn. D. Respiratory syncytial virus is a problem in summer. E. Rhinovirus is more common in the early fall.

ANS: A, B, C, E The seasonal nature of common viruses leading to respiratory infections includes the following correlations: adenovirus is common in winter and spring, coronavirus is common in winter and spring, parainfluenza is common in winter, respiratory syncytial virus is common in winter and spring, and rhinovirus is common in early fall and late spring.

The pediatric clinic nurse is teaching a parent home-care measures for a 12-year-old child diagnosed with viral pharyngitis. Which information is appropriate for the nurse to include in the teaching session? (Select all that apply.) A. Bedrest for a couple days will help recovery. B. Have the child gargle with warm saline. C. Make sure your child continues to eat. D. Offer fluids in small amounts, frequently. E. Warm liquids are better tolerated than cold.

ANS: A, B, D Children with pharyngitis will recover faster if they stay in bed while acutely ill. An older child can be taught to gargle with warm saline and to use throat lozenges. Cool, bland liquids are usually tolerated better than warm or hot liquids and solid food. The child should not be forced to eat while it is painful, but should stay hydrated.

The nursing student reads the diagnosis of a lower respiratory infection in a patient's chart. The student knows that the lower respiratory system is composed of which structures? (Select all that apply.) A. Alveoli B. Bronchi C. Larynx D. Lungs E. Pharynx

ANS: A, B, D The lower respiratory tract is composed of the lungs, bronchi, bronchioles, and alveoli. The larynx and pharynx are part of the upper respiratory system.

A nurse is providing anticipatory guidance to parents of a toddler. Which objects does the nurse include as a frequent cause of aspiration? (Select all that apply.) A. Balloons B. Hot dog bits C. Licorice sticks D. Peanuts E. Popcorn

ANS: A, B, D, E Small, often roundish, objects such as peanuts, popcorn, hot dog bits, vegetable pieces, gel fruit snacks, balloons, coins, pen tops, button eyes, small toy parts, and pins are often aspirated.

The pediatric nurse is providing care to a neonate diagnosed with cystic fibrosis. When discussing the clinical manifestations of this disease process, which topics will the nurse include in the teaching session? (Select all that apply.) A. Anemia B. Malnutrition C. Scant, hard stools D. Meconium ileus E. Rectal prolapse

ANS: A, B, D, E The initial presentation of cystic fibrosis in the neonate appears in the gastrointestinal system. The newborn may have a meconium ileus, with meconium so thick that it causes obstruction and requires surgical removal. The infant may initially have bulky stools that are frothy and foul-smelling. Prolapse of the rectum may also occur in infancy and childhood. Malnutrition, anemia, and growth failure persists despite normal caloric intake.

The nurse is caring for a child who experiences frequent ear infections. The child's mother wants to know why this is occurring. Which anatomical differences in the pediatric patient increase the risk for otitis media? (Select all that apply.) A. Impaired drainage B. Longer, thinner eustachian tubes C. Shorter, horizontal eustachian tubes D. Typical lying-down position of infants E. Underdeveloped cartilage lining

ANS: A, C, D, E The following factors lead to otitis media in children: the eustachian tubes are short, wide, and straight and lie in a horizontal plane; the cartilage lining is undeveloped, making the tubes more distensible; the normally abundant pharyngeal lymphoid tissue readily obstructs the eustachian tube openings in the nasopharynx; immature humoral defense mechanisms increase the risk of infections; and the lying-down position of infants favors the pooling of fluid, such as formula, in the pharyngeal cavity.

44. The nurse caring for children with asthma recognizes which immunoglobulin to be involved in causing activation of the airway mast cells and macrophages? A. IgA B. IgE C. IgG D. IgM

ANS: B The allergen antigen binds to the allergen-specific immunoglobulin E surface, causing activation of the resident airway mast cells and macrophages. This begins the cycle of an asthmatic exacerbation.

A parent brings a 2-year-old child to the clinic, reporting that the child has an ear infection. Which assessment information leads the nurse to suspect a diagnosis of bacterial otitis media? (Select all that apply.) A. Acute otalgia B. Dull, throbbing pain C. Fever of 104°F (40°C) D. High-pitched crying E. Poor feeding F. Rubbing the ear

ANS: A, C, E, F Manifestations of acute otitis media include otalgia, irritability, otorrhea, fever that may be high, poor feeding, rubbing or pulling at the ear, bulging tympanic membrane, enlarged lymph glands, and visualization of purulent material during an otoscopic exam.

13. The nurse suspects a pediatric patient is experiencing acute respiratory distress syndrome (ARDS). What laboratory finding correlates to this condition? A. HCO3 of 22 mEq/L B. PCO2 of 88 mm Hg C. pH of 7.34 D. PO2 of 60 mm Hg

ANS: B Arterial blood gas results in a child with ARDS include hypoxemia, hypercarbia, and acidosis. All values here are normal except for the PCO2, which is high (hypercarbia).

33. All members of a newly arrived immigrant family from a third-world country have received positive tuberculosis skin test results. The family consists of parents, a 2-year-old, and a 7-year-old. Which therapy regimen does the family practice nurse coordinate for this family? A. A course of intravenous pyrazinamide (PZA) given once a month in the clinic B. Directly observed therapy with isoniazid (INH) and rifampin (Rifadin) for 9 months C. Isoniazid and rifampin once a week for 6 months, given by the nurse in the clinic D. Isoniazid daily for 9 months, followed by rifampin once a week for 3 months

ANS: B Because the duration of therapy for TB is so long, noncompliance is an issue that must be addressed by the nurse. Directly observed therapy (DOT) helps with compliance, which reduces relapses, treatment failure, and drug resistance, especially in children and adolescents. Because all members of the family must take the medication, and because they are immigrants who may have limited English proficiency, limited health literacy, and perhaps values and beliefs that contradict Western medical care, directly observed therapy is vital to ensure cure and to prevent spread of the disease. Drugs used include isoniazid and rifampin for 9 months. Pyrazinamide can be added, decreasing the treatment time to 6 months.

26. A child has been seen in the clinic and diagnosed with bronchitis. The next day, the mother calls the clinic to ask about using cough medicine to decrease the child's cough. Which response by the nurse is the most appropriate? A. "Children should never use cough medicine for bronchitis." B. "If she can't sleep due to a cough, a dose would be okay at night." C. "It would be alright to use, but watch her for hyperactivity." D. "Yes, give her over-the-counter cough medicine every 4 hours."

ANS: B Cough medication is used with caution in children with bronchitis in order to facilitate secretion removal. However, if the child cannot sleep due to coughing, a dose at night would be appropriate. Many cough medications contain alcohol, which could lead to sleepiness.

16. A nurse is teaching the parents of a 10-year-old child diagnosed with cystic fibrosis. Which instruction by the nurse is most appropriate? A. "For Pseudomonas infections, we can use penicillin antibiotics." B. "Preventing respiratory infections is crucial for quality of life." C. "Unfortunately, your child is sterile and unable to have children." D. "With pancreatic enzymes, vitamin replacement is not needed."

ANS: B Cystic fibrosis (CF) is characterized by frequent, severe respiratory infections, often caused by Pseudomonas, which is treated with tobramycin (TOBI) or azithromycin (Zithromax). Preventing respiratory infections is a crucial part of caring for the child with CF. Reproduction is often affected in people with CF, but without testing, it is impossible to say that the child is sterile. Vitamin replacement is needed along with pancreatic enzyme replacement.

21. A 7-year-old child is brought to the clinic with what the parent describes as "tonsillitis." The child has a moderate fever, foul breath, and dysphagia, and occasionally spits up lumps of foul-smelling material. Which medication does the nurse prepare to instruct the parents on based on the child's symptoms? A. Amoxicillin (Amoxil) B. Clindamycin (Cleocin) C. Erythromycin (Erythrocin) D. Tetracycline (Sumycin)

ANS: B For acute tonsillitis, penicillin, amoxicillin, or erythromycin are the most commonly prescribed antibiotics. However, with the history of this child spitting up lumps of foul-smelling material, it is more likely he or she has chronic tonsillitis, which is best treated with cephalosporin or clindamycin.

29. An infant is being discharged from the hospital after treatment for respiratory syncytial virus (RSV). The infant still has some mild respiratory distress at times. Which discharge instruction is the priority for this infant? A. "Bring the child back if she runs a temperature." B. "Feed baby small amounts while she is sitting up." C. "Give her antibiotics right after feeding her." D. "If you need to use the bulb suction, bring her back."

ANS: B Guidelines for feeding a child with respiratory distress revolve around preventing aspiration. The child should be fed in an upright position and given small amounts, perhaps more often. An elevated temperature is usually seen in RSV. Antibiotics are not generally used for this disease. Parents needs to know how to use the bulb suction to help manage the accompanying rhinitis.

37. A 3-year-old child is brought to the emergency department with sudden onset of hoarseness, wheezing, and cough. The child has a history of asthma, but the parent is worried about an aspirated toy part. Which action by the nurse would quickly differentiate between the two? A. Administer an inhaled bronchodilator. B. Auscultate lungs for unilateral wheezing. C. Obtain a stat portable chest x-ray. D. Quickly obtain an oxygen saturation.

ANS: B In foreign body aspiration (FBA), wheezing would more likely be heard unilaterally. In an asthma exacerbation, wheezing would be bilateral. The other measures are appropriate care measures in either case, but the quickest way to assess for FBA is to auscultate the lungs.

45. A child is admitted after a severe asthma attack. Respiratory status is stable at this time. Which is the priority intervention for this child? A. Determining the trigger B. Ensuring hydration C. Promoting rest D. Providing support

ANS: B Priorities in any emergency are airway, breathing, and circulation. Because the respiratory status is now stable, attention is placed on ensuring that the child is hydrated. This is important for two reasons: first, hydration helps liquefy secretions; second, the mouth-breathing child will have lost a great deal of fluid through insensible loss, which needs to be replaced. All other options are important parts of care of this child; however, hydration is the priority.

39. A 10-year-old child is brought to the emergency department by the rescue squad from the scene of a house fire. The child is confused and agitated. Which action by the nurse is the priority for this child? A. Assess the child for a head injury. B. Give the child 100% oxygen. C. Obtain a complete history of the fire. D. Wait for the parents to obtain consent.

ANS: B The child's confusion and agitation indicate hypoxemia, which is common in victims of fires. The nurse should treat the child first as an emergency, and then obtain consent when the parents arrive (if they are conscious and able to give consent). A head injury can cause confusion and agitation, but with the history of being in a fire, inhalation injuries would be suspected first. A complete history of the fire can wait, but will ultimately be important to obtain.

23. A new nurse in the emergency department is examining a 4-year-old child who is sitting upright, is drooling, and is restless. Which action by the new nurse causes an experienced nurse to intervene? A. Attaches a cardiac monitor and oximeter B. Attempts to assess throat with a tongue blade C. Permits child to remain in an upright position D. Prepares to administer racemic epinephrine (MicroNefrin)

ANS: B This child has manifestations of acute epiglottitis. The nurse should not look into the child's throat, as this may precipitate laryngeal spasm and total airway obstruction. The experienced nurse should intervene if the new nurse attempts to do so. The other interventions are appropriate.

25. A child in the family practice clinic reports that "my ear itches." On otoscopic exam, the ear canal is swollen, red, and full of debris. Which instruction does the nurse anticipate giving the parent? A. Clean the ear canals occasionally with a cotton swab. B. Dry the ear canals with a hair dryer set on low heat. C. Give the full course of antibiotics even if the child is better. D. Your child should not be allowed to swim in the future.

ANS: B This child has manifestations of otitis externa. Often called swimmer's ear, it is not always associated with swimming. However, the parents need to investigate strategies for keeping the ears dry, including using a hair dryer set on low, wearing ear plugs or a swimming cap, or using solutions designed to promote drying. The parents should not insert anything into the ear canal. Antibiotics are not used with this condition. Swimming is not prohibited.

42. An 11-year-old child who has a history of asthma is brought to the family practice clinic by a parent who reports that the child has white plaque over the inside of the mouth and coating the tongue. Which question by the nurse would elicit the most useful information? A. "Are you brushing your teeth and tongue regularly?" B. "Do you rinse your mouth after using your inhaler?" C. "Have you ever had something like this before?" D. "When was the last time you went to the dentist?"

ANS: B Use of inhalers for asthma, especially corticosteroids, can cause yeast infection (candidiasis) if the patient does not rinse the mouth afterward. The other questions are not helpful in this situation.

A 2-year-old child has croup. Which nursing interventions are appropriate for this child? (Select all that apply.) A. Administering oral or intravenous antibiotics B. Administering racemic epinephrine (Micronefrin) C. Applying oxygen via an oxygen tent D. Teaching the parents how to give cough medication E. Using a warm-mist humidifier

ANS: B, C Commonly, mild cases of croup are treated with cool mist. In the hospital setting, oxygen hoods for infants and oxygen tents for toddlers are used. Nebulized racemic epinephrine (Adrenalin) and l-epinephrine are equally effective in inducing mucosal vasoconstriction, with a consequent decrease in subglottic edema, thus relieving the symptoms. Antibiotics are not used in the management of croup, as it is primarily viral in nature. Cool-mist humidifiers should be used rather than warm mist due to the potential for bacterial growth in the warm-mist system.

Parents of a 3-year-old call the clinic and ask for information on sinusitis. Which symptoms will the nurse include in the explanation to the parents? (Select all that apply.) A. "Cold" lasting more than 5 days B. Cough worse when lying down C. Periorbital swelling D. Postnasal drip E. Thin, clear nasal discharge.

ANS: B, C, D The signs and symptoms of sinusitis include a cold lasting more than 10-14 days, sometimes with low-grade fever, thick yellow-green nasal discharge, and postnasal drip leading to sore throat; cough (worse at night or when lying down); bad breath; nausea and vomiting; headaches; irritability and fatigue; and swelling around eyes.

The pediatric nurse describes the effects of cystic fibrosis on the body systems to the parents of a child recently diagnosed with the disease. Which statements does the nurse include to the parents? (Select all that apply.) A. Altered protein and vitamin metabolism causes a type of dementia in older children. B. Increased mucus obstructs the airways, and stasis of fluid causes infections. C. Pancreatic ducts are often blocked by mucus, leading to poor nutrition. D. Reproduction is affected, as ovarian ducts and the vas deferens are occluded. E. Thick mucus affects several body systems, preventing some organs from working.

ANS: B, C, D, E Cystic fibrosis is an inherited autosomal recessive disorder that causes the production of thick mucus that blocks exocrine glands and affects several body systems, including the respiratory, gastrointestinal, and reproductive systems. It does not lead to a type of dementia.

A nurse is caring for an infant born with esophageal atresia (EA) and tracheoesophageal fistula (TEF) prior to surgery. Which actions taken by a student nurse cause the registered nurse to intervene? (Select all that apply.) A. Assesses the infant's intravenous site B. Irrigates the orogastric tube as needed C. Raises the head of the bed at least 30° D. Suctions the trachea every 2 hours E. Teaches parents about barium contrast

ANS: B, D, E Preoperatively, care for an infant with EA and TEF includes assessing IV sites, frequent suctioning to prevent aspiration (as needed, not on an every-2-hours schedule), raising the head of the bed 30-40°and turning the head to the side to help prevent aspiration, and possibly administering antibiotics, as aspiration pneumonia is likely. If the infant has a nasogastric or orogastric tube inserted into the blind pouch, the nurse does not irrigate it, as this increases the risk of aspiration. Contrast radiology studies can be done with dilute water-soluble contrast, but not barium.

14. The nurse is caring for a child with bronchopulmonary dysplasia receiving furosemide (Lasix). Which finding would lead the nurse to conclude the child has a side effect of this drug? A. Acidosis B. Hypercarbia C. Hypokalemia D. Thrombocytopenia

ANS: C A side effect of Lasix is hypokalemia. The other laboratory abnormalities are not associated with this drug.

30. A 5-month-old child is brought to the pediatric clinic by the parent, who reports the child has had a cough for 4 weeks. When reviewing the child's history, the nurse assesses that the child's last DTaP vaccination was at 2 months of age. Which action by the nurse is the most appropriate? A. Inform the provider that both child and parent need antibiotics. B. Make an appointment for the next vaccination at 6 months. C. Obtain nasal washings for a culture and PCR testing. D. Weigh and measure the child; document all findings in the chart.

ANS: C All children with a chronic cough lasting longer than 3 weeks should have diagnostic testing for pertussis, including nasal washings for culture and PCR tests. This child has the risk factor for pertussis of inadequate immunizations; he should have had a second vaccination at 4 months. The best action by the nurse is to collect the specimens. If positive, both child and caretakers will need antibiotics, as pertussis is highly contagious. The child should receive a booster shot as soon as he is recovered. All children should be weighed and measured and findings documented in the chart.

18. A nurse working in a pediatric clinic is collecting data on children as part of a research study. What action by the nurse is most appropriate? A. Do not inform children or parents of the data collection. B. Obtain parental consent only for all children enrolled. C. Obtain written assent from children 12 and older. D. Only inform the parents of the research study and methods.

ANS: C Children in research studies are considered vulnerable subjects and extra care must be taken to ensure their rights. This includes obtaining written assent from older children (generally 12-13 or older).

28. A child is admitted to the pediatric unit with respiratory syncytial virus (RSV). Which action by the nurse is best for infection control? A. Adhere to policy on hand hygiene. B. Do not assign pregnant caregivers. C. Place the child in contact isolation. D. Use meticulous standard precautions.

ANS: C Children with RSV are placed in contact isolation due to the ease of spreading the disease. Of course nurses should adhere to facility policy on hand washing, but further action is required. There is no precaution against pregnant caregivers. Standard precautions are used on all patients, but a child with RSV needs contact isolation.

9. A pediatric clinic nurse teaches parents how to care for their toddler who has nasal congestion. What anatomical difference between children and adults is a concern with congestion in children? A. Children this age should not have congestion. B. Larger tonsils trap mucus, leading to gagging. C. The narrow trachea can become obstructed easily. D. Phlegm can migrate into the eustachian tubes.

ANS: C Excess mucus production can lead to airway obstruction in children due to the narrowed lumen size of their tracheas.

40. A 6-year-old child is admitted after being in a fire at school. The physician plans to perform a bronchoscopy to assess for airway damage. Which nursing action is the priority for this child? A. Document any teaching done in the child's chart. B. Let the child perform the procedure on a doll. C. Obtain written consent from the parent/guardian. D. Tell the child he or she won't remember the procedure.

ANS: C For this invasive procedure, written consent is required. Documenting teaching is important, but does not take priority. Allowing the child to simulate the bronchoscopy with a doll with help alleviate fears, but again does not take priority. Telling the child that he or she will not remember the procedure is false reassurance and may not end up being true, causing the child to lose trust in the nurse.

6. A nurse is educating the parents of a 5-year-old with bacterial otitis media. Which discharge instruction is most important? A. "Bring her back if she is not better in 1 week." B. "Do not allow your child to swim in the future." C. "Give the full course of antibiotics even if she is better." D. "Ice packs are a good way to manage her ear pain."

ANS: C Giving the full course of antibiotics is crucial to prevent the development of resistant bacteria. If the child is not showing improvement in 48 to 72 hours, she should be reassessed. Swimming is not prohibited after the infection heals. Heat is a better option for ear pain.

38. A 2-year-old child in a pediatric unit accidentally swallows a loose toy part and begins to exhibit signs of choking and wheezing. The pediatric nurse begins the Heimlich maneuver. After performing abdominal thrusts, what action does the nurse take next? A. Begin performing cardiopulmonary resuscitation (CPR). B. Activate the rapid response team then return to the child. C. Continue until the object is dislodged or the child becomes unconscious. D. Give five back blows, then alternate back blows and abdominal thrusts.

ANS: C The Heimlich maneuver for a child over 1 year of age consists of giving abdominal thrusts until the object is dislodged or the child becomes unconscious. Abdominal thrusts are done by standing behind the child, wrapping your arms around the child, and placing the fist of one hand thumb side down into the child's abdomen, slightly above the umbilicus. You then squeeze the child's abdomen using rapid, forceful thrusting motions directed upward and inward. If the child becomes unconscious, begin CPR.

49. A nurse is assessing a 10-year-old child with asthma. The child and parents report daily symptoms, but the child only wakes up coughing once or twice a week, uses an albuterol (Ventolin) inhaler daily, and is occasionally prevented from participating in physical activity by symptoms. What asthma severity classification does the nurse assign to the child? A. Intermittent B. Mild persistent C. Moderate persistent D. Severe persistent

ANS: C The child's symptoms place him or her in the moderate persistent category.

48. A 1-year-old child has the following arterial blood gas values (ABGs): pH: 7.28, PCO2: 58 mm Hg, PO2: 77 mm Hg, HCO3: 14 mEq/L, O2 saturation: 88%. Which interpretation of the results by the nurse is the most accurate? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

ANS: C The low pH indicates acidosis; the high CO2 level indicates respiratory involvement. The child is also hypoxemic.

34. The mother of a child diagnosed with influenza in the emergency department last night calls the family practice clinic to ask if she can give the child store-brand "flu medicine." Which response by the nurse is the most appropriate? A. "If your child is that sick she should take Tamiflu." B. "No, your child should not be sick enough for medicine." C. "Yes, if it's labeled for children you can give it to her." D. "You must make sure it does not contain salicylates."

ANS: D Medications containing aspirin products (salicylates) should not be given to children with viral illnesses due to the correlation with Reye syndrome. If a parent is asking about an over-the-counter medication, the nurse should advise the parent to ensure it does not contain this compound. The other responses are not appropriate.

2. The pediatric nurse explains to the parents of a 1-year-old patient with pneumonia that the differences between the adult's and child's respiratory system affect function and subsequent respiratory conditions. Which difference does the nurse include in the discussion with the patient's parents? A. Infants are obligate nose breathers until 6 months of age. B. The epiglottis in the child under 8 is shorter and more rigid. C. The larynx and the glottis are higher in the younger child's neck. D. In the child, there are more functional muscles in the neck and less soft tissue.

ANS: C Until about age 4 weeks, infants are obligate nose breathers and do not open their mouths to breathe. The epiglottis in the younger (usually age 8 years and younger) child is longer and flaccid (floppy), which makes it more susceptible to swelling. The larynx and the glottis are higher in the younger child's neck, which makes the child more prone to aspiration. There are fewer functional muscles in the neck, and the increased amount of soft tissue makes the younger child more susceptible to infection and edema.

The nurse is assessing a patient diagnosed with cystic fibrosis. Which findings support the patient's diagnosis? (Select all that apply.) A. Concave chest B. Dry, scaly skin C. Protuberant abdomen D. Wasted buttocks E. Thick extremities

ANS: C, D Protuberant abdomen, barrel chest, wasted buttocks, and thin extremities are common features in children with cystic fibrosis.

A child with pertussis is in the catarrhal stage of the disease. Which assessment findings correlate with this condition? (Select all that apply.) A. Chronic cough lasting weeks B. Intense cough causing vomiting C. Low-grade fever D. Sweating and fatigue after coughing E. Upper respiratory symptoms

ANS: C, E The catarrhal stage of pertussis is characterized by upper respiratory symptoms and low-grade fever. Sweating, fatigue, and intense coughing with vomiting are characteristic of the paroxysmal stage. A chronic cough lasting weeks is seen in the convalescent stage.

20. A 5-year-old child is brought into the clinic by a parent, who reports the child has a "sore throat." Which assessment finding would require immediate notification to the health-care provider? A. Difficulty swallowing B. Inflamed, red pharynx C. Refusing to eat the last 2 days D. Strawberry-colored tongue

ANS: D A strawberry-red tongue, petechiae on the palate, and a fine red rash on the trunk or abdomen are consistent with pharyngitis caused by Streptococcus A infection, which needs immediate treatment. The other manifestations are seen with viral pharyngitis infections.

47. A nurse is using the CUPS method of assessing a child's respiratory status and documents the following: open airway containing secretions, increased respiratory rate and effort, wheezing, mucous membranes pale pink in color, and fever. Based on this system, which is the appropriate rating for this child? A. Critical B. Potentially unstable C. Stable D. Unstable

ANS: D According to this scale, the child has four determinants of unstable status (increased breathing rate, increased breathing effort, wheezing, and pale pink mucous membranes). An open airway with secretions and presence of fever both characterize the potentially unstable category. The nurse would classify this child as unstable.

22. A child had a tonsillectomy this morning. What action by the nurse is most important for the child's safety? A. Avoid giving her red popsicles. B. Limit activity the first night. C. Offer ice cream when awake. D. Position the child on her side.

ANS: D After tonsillectomy, children are placed on their side to facilitate drainage and prevent aspiration. Maintaining a patent airway is the priority. Red-colored foods or fluids are not given, as the nurse may not be able to differentiate between the food and bloody drainage; however, this is not a priority for safety. Activity should be limited, but this does not take priority over maintaining the airway. Ice cream and other dairy products are not given because they coat the throat and usually cause coughing or throat clearing, which can lead to bleeding.

4. A school-age child has asthma and lives in a home where both parents smoke. The nurse has provided extensive education to the parents on the dangers of second-hand smoke. Which assessment by the nurse indicates that goals for a family nursing diagnosis have been met? A. Child's clothing no longer smells of cigarette smoke B. Father states he has quit smoking; mother has cut down C. Parents state they smoke only in the basement now D. Significant decrease in asthma "attacks" over a year

ANS: D An important goal for this family is understanding how to avoid exposing their child to second-hand smoke. The only objective assessment data to show that the child is not exposed to smoke is the decrease in asthma "attacks" the child has had in the last year. New clothing will not smell like smoke; if the mother continues to smoke even in lesser amounts, the child will still be exposed; and smoking anywhere in the house pollutes all the air in the house.

32. A mother brings her newly adopted non-English-speaking 8-year-old daughter to the clinic for follow-up after a complete physical and immunizations before starting school. The child's tuberculin skin test results in redness and induration of 12 mm. Which response by the nurse is best? A. Ask the mother what country the child was adopted from. B. Give the child a mask to wear while in the clinic. C. Instruct the mother on directly observed TB therapy. D. Tell the mother the result does not show tuberculosis.

ANS: D An induration of 10 mm or more is a positive result in children under 4 years of age, so this result is not diagnostic for TB in an 8-year-old child. Knowing what country the child was from originally might provide useful information because if the child received bacille Calmette-Guerin vaccine for TB (common in some foreign countries) the skin test results will be inaccurate. However, the nurse would need to know which countries use the vaccine in order for this information to be useful. Because the result is not positive for TB, the child does not need to wear a mask, nor does the mother need instruction on directly observed therapy.

19. The mother of a 5-year-old child calls the clinic to ask if her child has a mild respiratory infection or needs to be seen. Which question by the nurse would elicit the most helpful information? A. "Can your child swallow without pain?" B. "Does the child have a sore throat?" C. "Is your child coughing occasionally?" D. "Was the onset gradual or sudden?"

ANS: D Common "colds" or nasopharyngitis usually have a gradual onset. A rapid onset would indicate a more serious condition. The other manifestations are commonly seen in this disorder.

15. A father brings his 1-year-old son to the clinic and states that when he kisses the child's cheek, it tastes salty. Which diagnostic test does the nurse educate the father on based on the father's statement? A. Large bowel barium series B. Pancreatic enzyme analysis C. Pulmonary function studies D. Quantitative sweat chloride test

ANS: D Salty-tasting sweat and tears are a characteristic finding in cystic fibrosis. The diagnostic test for this disorder is the quantitative sweat chloride test. Pancreatic enzyme studies are invasive and not usually performed on children. Pulmonary function studies are done in older children who can cooperate. Large bowel barium studies are not needed.

24. An emergency department nurse is supervising a nursing student who is preparing a racemic epinephrine (MicroNefrin) nebulizer treatment for a child with stridor from suspected epiglottitis. The student prepares 0.75 mg in 2 mL of normal saline. Which action by the registered nurse is most appropriate? A. Allow the student to administer the nebulizer treatment. B. Have the student explain the action and side effects of the drug. C. Remind the student to assess lung sounds after the treatment. D. Tell the student to look up the drug dosage information again.

ANS: D The correct dose of racemic epinephrine is 0.25-0.5 mg in 3 mL of normal saline. The nurse should have the student look up the dosing information again. The other actions would be appropriate if the student had the correct dose.

8. The nursing student studying respiratory anatomy and physiology learns that which tissue or organ grows faster than any other tissue or organ in a child? A. Diaphragm B. Epiglottis C. Lungs D. Tonsils

ANS: D The lymphoid tissue of the tonsils is absent at birth, but grows more rapidly in a child than any other tissue.

12. A diabetic mother delivers an infant at 36 weeks' gestation who has Apgar scores of 5 and 6, has central cyanosis, and has a respiratory rate of 66 breaths/minute. What medication does the nurse anticipate the child will receive? A. Albuterol (Ventolin) B. Caffeine (Cafergot) C. Epinephrine (Adrenalin) D. Surfactant (Surfaxin)

ANS: D This child most likely has respiratory distress syndrome (RDS), which is treated with surfactant.

27. Four children are in the pediatric clinic waiting to be seen. Which patient should the nurse see first? A. Afebrile, parent reports harsh barky cough B. Pulling on ear, temperature 103°F (39.5°C) C. Salty-tasting sweat, poor weight gain D. Wheezing, retracting, no wet diapers today

ANS: D This child not only has a respiratory problem, he or she is also dehydrated and is the sickest of the four. The nurse should see this patient first. The child with the barky cough is afebrile and has no signs of respiratory distress. Pulling on the ear indicates an ear infection, and these children often run high fevers. The child with salty-tasting sweat and poor weight gain is demonstrating a chronic condition, most likely cystic fibrosis.