exam 3 - 3444
The nurse educator is teaching a group of nursing students how to perform a respiratory assessment for a newborn in the newborn intensive care unit (NICU) diagnosed with respiratory distress syndrome (RDS). Which normal characteristics of the newborns respiratory system increase the risk for obstruction? Standard Text: Select all that apply. 1. Shorter and narrower airway 2. Higher trachea 3. Bronchial branching at different angles 4. Inadequate smooth muscle bundles 5. Diaphragmatic breather
1, 2, 3 Normal characteristics of the pediatric respiratory system that increase the risk for obstruction include a shorter and narrower airway, a higher trachea, and a different angle for bronchial branching. Inadequate smooth muscle bundles and being diaphragmatic breathers are characteristics that do not increase the risk of obstruction.
The nurse is providing care to an infant who is diagnosed with bronchiolitis. Which breath sounds indicate the infant is experiencing respiratory distress? Select all that apply. 1. Tachypnea 2. Wheezing 3. Grunting 4. Retractions 5. Eupnea
1, 2, 3 Wheezing and grunting are adventitious respiratory sounds that indicates respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachynpea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound. Eupnea is the medical term for normal breathing.
The nurse is preparing an educational session for sexually active adolescents. Which statements are appropriate for the nurse to include when educating about sexually transmitted infections (STIs)? Select all that apply. 1. Frequently diagnosed STIs include chlamydia, genital herpes, gonorrhea, human papillomavirus, trichomoniasis, and syphilis. 2. Your risk for contracting an STI can be decreased by using a condom when having sex. 3. Birth control pills are useful in decreasing your risk of contracting an STI. 4. Risk factors for pelvic inflammatory disease (PID) include multiple sexual partners, lack of barrier protection during intercourse, and history of an STI. 5. Pelvic inflammatory disease (PID) is an infection of the lower genital tract.
1, 2, 4 It is appropriate for the nurse to include the frequently diagnosed STIs, the fact that the risk is decreased by using a condom, and the risk factors for pelvic inflammatory disease. Birth control pills are useful in decreasing the risk of pregnancy but are not useful for decreasing the risk of contracting an STI. PID is an infection of the upper genital tract, not the lower genital tract.
The nurse is caring for a school-age client who had an appendectomy after a ruptured appendix. Which orders does the nurse anticipate for this client? Select all that apply. 1. Antibiotics 2. A clear liquid diet 3. NG tube 4. Vital signs every 4 hours 5. Frequent monitoring of bowel sounds
1, 3, 4, 5 Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.
A nurse is caring for a visually impaired 20-month-old who has not begun to walk. Which nursing diagnosis is the most appropriate for this client? 1. Delayed growth and development 2. Impaired physical mobility 3. Self-care deficit 4. Impaired home maintenance
1: A 20-month-old child who is not walking is delayed in growth and development. The child's mobility is not due to a physiological problem, so impaired mobility is not appropriate. Self-care deficit does not apply to this age of child. There is not enough data to determine if home maintenance is impaired.
A school-age client diagnosed with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention is a priority for this client? 1. Reposition the child every two hours. 2. Monitor BP every 30 minutes. 3. Encourage fluids. 4. Limit visitors.
1: A child with severe edema, on bed rest, is at risk for altered skin integrity. To prevent skin breakdown, the child should be repositioned every two hours. Vital signs are taken every four hours, fluids need to be monitored and should not be encouraged, and the child needs social interaction, so visitors should not be limited.
Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)? 1. Activity Intolerance 2. Decreased Cardiac Output 3. Pain, Acute 4. Tissue Perfusion, Ineffective (peripheral)
1: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.
The nurse is providing care to a male infant who is diagnosed with hypospadias. Which clinical manifestation does the nurse anticipate when assessing this infant? 1. A urethral meatus that is located on the ventral surface of the penis 2. The presence of foreskin 3. A small opening or a fissure that extends the entire length of the penis 4. An opening on the dorsal surface of the penis
1: For an infant diagnosed with hypospadias, the nurse would anticipate a urethral meatus that is located on the ventral surface of the penis. Infants diagnosed with hypospadias may also have a partial absence of the foreskin. A small opening or a fissure that extends the entire length of the penis or an opening on the dorsal side of the penis would be expected for an infant diagnosed with epispadias.
A preschool-age client diagnosed with with nephrotic syndrome is placed on prednisone for several weeks. Which teaching point is appropriate for the nurse to include in the teaching plan for this client? 1. Never stop the medication suddenly. 2. This drug is taken once a week on Sunday. 3. The child should always take the medication at night before bed. 4. This drug should be taken with meals.
1: Prednisone, a corticosteroid with anti-inflammatory action, is frequently used to treat nephrotic syndrome. It should never be stopped suddenly. The drug is taken more than once a week and can be taken any time during the day, but should remain on a constant schedule. Taking with food is always appropriate for most medications, but it does not have to be with a meal.
The nurse suspects that an infant has a visual disorder caused by abnormal musculature. Which test will the nurse perform to detect this disorder? 1. A cover/uncover test 2. An ophthalmologic exam 3. A vision-acuity exam 4. A pupil-reaction-to-light test
1: The cover/uncover test can detect abnormal musculature of the eye that can lead to asymmetric eye movement. An ophthalmologic eye exam allows the practitioner to view the internal structures of the eye, not abnormal musculature. A vision acuity test is used to test for myopia. A pupil-reaction-to-light test evaluates neurological status.
A child is showing signs of acute respiratory distress. Which position will the nurse place this child? 1. Upright 2. Side-lying 3. Flat 4. In semi-Fowlers
1: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowlers (head up slightly) do not allow for as optimal chest expansion as the upright position.
An infant is born with an esophageal atresia and tracheoesophageal fistula. Which preoperative nursing diagnosis is the priority for this infant? 1. Risk for Aspiration Related to Regurgitation 2. Acute Pain Related to Esophageal Defect 3. Ineffective Infant Feeding Pattern Related to Uncoordinated Suck and Swallow 4. Ineffective Tissue Perfusion: Gastrointestinal, Related to Decreased Circulation
1: With the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea. Pain is not usually experienced preoperatively with this condition. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. Tissue perfusion is not a problem with this condition.
A nurse is assessing infants for visually related developmental milestones. Which infant is showing a delay in meeting an expected milestone? 1. 4-month-old who has a social smile 2. 8-month-old who has just begun to inspect her own hand 3. 12-month-old who stacks blocks 4. 7-month-old who picks up a raisin by raking
2: An 8-month-old who has just begun to inspect her own hand is delayed. The infant usually inspects her own hand beginning at 3 months. A 4-month-old with a social smile, a 12-month-old who stacks blocks, and a 7-month-old who picks up a raisin by raking are all showing appropriate visually related milestones.
An infant is diagnosed with acute otitis media. Which intervention is most appropriate for the nurse to teach the infants parents? 1. Keep the baby in a flat lying position during sleep. 2. Administer acetaminophen (Tylenol) to relieve discomfort. 3. Administer a decongestant. 4. Place baby to sleep with a pacifier.
2: An infant with a bulging tympanic membrane because of acute otitis media will have pain. Parents are taught to administer acetaminophen (Tylenol) to relieve the discomfort associated with acute otitis media. A flat lying position may exacerbate the discomfort. Elevating the head slightly is recommended. Decongestants are not recommended for treatment of acute otitis media. Placing infants to sleep with a pacifier may increase the incidence of otitis media.
A child diagnosed with acute glomerulonephritis is in the playroom and experiences blurred vision and headache. Which action by the nurse is the most appropriate? 1. Check the urine to see if hematuria has increased. 2. Obtain a blood pressure on the child; notify the healthcare provider. 3. Reassure the child, and encourage bed rest until the headache improves. 4. Obtain serum electrolytes, and send a urinalysis to the lab.
2: Blurred vision and headache may be signs of encephalopathy, a complication of acute glomerulonephritis. A blood pressure (BP) should be obtained and the healthcare provider notified. The healthcare provider may decide to order an antihypertensive to bring down the BP. This is a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, the other options (checking urine for hematuria, encouraging bed rest, and obtaining serum electrolytes) do not directly address the potential problem of encephalopathy.
A newborn is diagnosed with Hirschsprung disease. Which clinical manifestations found on assessment support this newborns diagnosis? 1. Acute diarrhea; dehydration 2. Failure to pass meconium; abdominal distention 3. Currant jelly; gelatinous stools; pain 4. Projectile vomiting; altered electrolytes
2: Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distention. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.
A child is admitted to the hospital with pneumonia. The childs oximetry reading is 88 percent upon admission to the pediatric floor. Which is the priority nursing intervention for this child? 1. Obtain a blood sample to send to the lab for electrolyte analysis. 2. Begin oxygen per nasal cannula. 3. Medicate for pain. 4. Begin administration of intravenous fluids.
2: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child's oxygenation status has been addressed.
A nurse is preparing to admit a child with possible obstructive uropathy. Which laboratory test should the nurse expect to draw on this child? 1. Platelet count 2. Blood urea nitrogen (BUN) and creatinine 3. Partial thromboplastin time (PTT) 4. Blood culture
2: The blood urea nitrogen (BUN) and creatinine are serum lab tests for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the BUN and creatinine will be elevated. Platelet count and partial thromboplastin time (PTT) are drawn when a bleeding disorder is suspected. A blood culture is done when an infectious process is suspected.
A preschool-age client is diagnosed with acute glomerulonephritis and is admitted to the hospital. Which nursing diagnosis is most appropriate for this client? 1. Risk for Injury Related to Loss of Blood in Urine 2. Fluid-Volume Excess Related to Decreased Plasma Filtration 3. Risk for Infection Related to Hypertension 4. Altered Growth and Development Related to a Chronic Disease
2: The fluid is excessive, and fluid and electrolyte balance should be monitored. There is no risk for injury because the blood loss in the urine is not such that it causes anemia. While a risk for infection may be present, it is not related to the hypertension. Growth and development is not normally affected because this is an acute process, not a chronic one.
The nurse is providing care to an infant in the emergency department. Upon assessment, the infant is noted to have to be experiencing tachypnea, wheezing, retractions, and nasal flaring. The infant is irritable and the parents state the infant has had poor fluid intake for two days. Pulse ox reading is currently at 85% on room air. The infants blood gas is pending. Which diagnosis does the nurse anticipate for this infant? 1. Bronchitis 2. Bronchiolitis 3. Pneumonia 4. Active pulmonary tuberculosis
2: The nurse anticipates the infant will be diagnosed with bronchiolitis. Symptoms of bronchiolitis include mild respiratory symptoms that progress to tachypnea, wheezing, retractions, nasal flaring, irritability, poor fluid intake, hypoxia, cyanosis, and decreased mental status. Symptoms of bronchitis include a dry hacking cough, increases in severity at night, painful chest and ribs. Symptoms of pneumonia include initial rhinitis and cough, followed by fever, crackles, wheezes, dyspnea, tachypnea, restlessness, diminished breath sounds. Symptoms of active pulmonary tuberculosis include persistent cough, decreased appetite, weight loss or failure to gain weight, low-grade fever, night sweats, chills, enlarged lymph nodes.
A nurse is caring for a visually impaired school-age child. Which nursing intervention is the highest priority for this child during the admission process? 1. Explaining playroom policies 2. Orienting the child to where furniture is placed in the room 3. Letting the child touch equipment that will be used during the hospitalization 4. Taking the child on a tour of the unit
2: The priority intervention is to orient the child to furniture placement in the room. This is priority because it addresses basic safety for a visually impaired client. Policies, handling equipment, and tours can be done at a later time.
A child is prescribed rifampicin for treatment of tuberculosis. For which length of time will the nurse tell the parents that this child must remain on the medication? 1. 2 months 2. 4 months 3. 6 months 4. 8 months
3: Active and latent TB are treated with isoniazid, rifampicin, pyrazinamide, and ethambutol. Therapy for active TB usually involves a 6-month regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months and isoniazid and rifampicin for the remaining 4 months. Therefore, the child will remain on rifampicin for a total of 6 months.
A child with severe gastroenteritis is admitted to a semiprivate room on the pediatric unit. The charge nurse should place this client with which roommate? 1. An infant with meningitis 2. A child with fever and neutropenia 3. Another child with gastroenteritis 4. A child recovering from an appendectomy
3: Gastroenteritis may be viral or bacterial and can be infectious. It is best to cohort children with this infectious process. Good handwashing is essential to prevent the spread. An infant with meningitis, a child with fever and neutropenia, and a child recovering from an appendectomy should not be placed with another child with an infectious process.
Parents of a child admitted with respiratory distress are concerned because the child wont lie down and wants to sit in a chair leaning forward. Which response by the nurse is the most appropriate? 1. This helps the child feel in control of his situation. 2. The child needs to be encouraged to lie flat in bed. 3. This position helps keep the airway open. 4. This confirms the child has asthma.
3: Leaning forward helps keep the airway open. The child is not in control just because he is leaning forward
A child is admitted to the hospital unit with a diagnosis of minimal-change nephrotic syndrome (MCNS). Which clinical manifestations does the nurse anticipate when conducting the admission assessment? 1. Hematuria, bacteriuria, weight gain 2. Gross hematuria, albuminuria, fever 3. Massive proteinuria, hypoalbuminemia, edema 4. Hypertension, weight loss, proteinuria
3: Nephrotic syndrome is an alteration in kidney function secondary to increased glomerular basement membrane permeability to plasma protein. It is characterized by massive proteinuria, hypoalbuminemia, and edema. While hematuria and hypertension may be present, they are not pronounced. Gross hematuria and hypertension are associated with glomerulonephritis. Bacteriuria and fever are associated with a urinary tract infection. Because of the edema, a weight gain, not a weight loss, would be seen.
A nurse is planning to teach school-age children about the common cold. Which information should the nurse include in the teaching session? 1. Vaccinations can prevent contraction of a nasopharyngitis virus. 2. Antibiotics will eliminate the nasopharyngitis virus. 3. Proper handwashing can prevent the spread of the infection. 4. Aspirin should be taken for alleviation of fever if the common cold is contracted.
3: Proper handwashing should be taught to school-age children to reduce the spread of the common cold virus. No vaccine can prevent the common cold. Antibiotics are not used to treat viral infections. Aspirin should not be taken for fever because of its association with Reye syndrome.
The nurse is providing instruction to the parents of an infant with a colostomy. Which statement by the parents indicates appropriate understanding of the teaching session? 1. We will change the colostomy bag with each wet diaper. 2. We will use adhesive enhancers when we change the bag. 3. We will watch for skin irritation around the stoma. 4. We will expect a moderate amount of bleeding after cleansing the area around the stoma.
3: Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.
The nurse is evaluating an infants tolerance of feedings after a pyloromyotomy. Which finding indicates that the infant is not tolerating the feeding? 1. Need for frequent burping 2. Irritability during feeding 3. The passing of gas 4. Emesis after two feedings
4: An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.
Which symptoms are characteristic of a preschool-age client who is diagnosed with a urinary tract infection? 1. Foul-smelling urine, elevated blood pressure, and hematuria 2. Severe flank pain, nausea, headache 3. Headache, hematuria, vertigo 4. Urgency, dysuria, fever
4: Clinical manifestations of a urinary tract infection (UTI) in a preschool-age client include fever, urgency, and dysuria. While hematuria may be present, there is no elevated blood pressure, headache, or vertigo.
A nurse is assessing a neonate. Which assessment finding indicates that the neonates respiratory status is worsening? 1. Acrocyanosis 2. Arterial CO2 of 40 3. Periorbital edema 4. Grunting respirations with nasal flaring
4: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.
A child with inflammatory bowel disease is prescribed prednisone daily. At which time is it most appropriate for the family to administer the prednisone? 1. Between meals 2. One hour before meals 3. At bedtime 4. With meals
4: Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.
A school-age client is recovering after abdominal surgery. The nurse is planning care for the return of bowel function. Which intervention should be included in the clients plan of care? 1. Fowlers position three times per day for 30 minutes each time 2. Assist the child in choosing a low-fat diet. 3. Commode at bedside 4. Ambulate 3-4 times a day.
4: The best data that indicate return of bowel sounds are flatus and passage of stool. Ambulation is the primary intervention to assist with both. A Fowlers position, bedside commode, and a low-fat diet will not assist with bowel function.
A nurse is caring for a child who has Hirschsprung's disease. Which of the following actions should the nurse take? a. Encourage a high-fiber, low-protein, low-calorie diet b. Prepare family for surgery c. Place NG tube for decompression d. Initiate bed rest
B) Hirschsprung's disease requires surgery to remove the affected segment of the intestine.
The nurse is preparing to ambulate a school-age client who had an appendectomy. In addition to pharmacological pain management, the nurse can use which nonpharmacological pain-management strategy for this client? 1. A heating pad 2. A warm, moist pack 3. A pillow on the abdomen 4. An ice pack
3: A pillow placed on the abdomen can be a nonpharmacological strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incisional area as they can impair the healing process of the wound.
A nurse is teaching a parent of an infant about gastrointestinal reflux disease. Which of the following should the nurse include in the teaching? Select all that apply. a. Offer frequent feedings b. Thicken formula with rice cereal c. Use bottle with one-way valve d. Position baby upright after feedings e. Use wide-based nipple for feedings
A, B, D
A nurse is assessing an infant who has hypertrophic pyloric stenosis. Which of the following findings should the nurse expect? Select all that apply. a. Projectile vomiting b. Dry mucous membranes c. Currant jelly stools d. Sausage-shaped abdominal mass e. Constant hunger
A, B, E Currant jelly stools and a sausage-shaped abdominal mass are associated with intussusception.
A child with asthma will be receiving an oral dose of prednisone. The order reads prednisone 2 mg/kg per day. The child weighs 50 lbs. The child will receive ____ milligrams daily. Round the answer to the nearest whole number.
Correct Answer: 45.5 = 46
