Chapter 40: Respiratory Disorders

Question 1

1. The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The
   nurse anticipates which test as most helpful in determining the extent of the child's
   hypoxia?
   A. Pulmonary function test
   B. Pulse oximetry
   C. Peak expiratory flow
   D. Chest radiograph

Answer 1

Answer: B
Rationale: Pulse oximetry is a useful tool for determining the extent of hypoxia. It can be used by the nurse for continuous or intermittent monitoring. Pulmonary function testing
measures respiratory flow and lung volumes and is indicated for asthma, cystic fibrosis, and chronic lung disease. Peak expiratory flow testing is used to monitor the adequacy
of asthma control. Chest radiographs can show hyperinflation, atelectasis, pneumonia, foreign bodies, pleural effusion, and abnormal heart or lung size.

Question 2

2. The nurse is discussing discharge instructions with the parents of a 6-year-old who had a tonsillectomy. What is the most important thing to stress?
   A. Administer analgesics.
   B. Encourage the child to drink liquids.
   C. Inspect the throat for bleeding.
   D. Apply an ice collar.

Answer 2

Answer: C
Rationale: Inspecting the throat for bleeding is the most important discharge information to give the parents. Hemorrhage is unusual postoperatively but may occur any time from the immediate postoperative period to as late as 10 days after surgery. The nurse should inspect the throat for bleeding. Mucus tinged with blood may be expected, but
fresh blood in the secretions indicates bleeding. Administering analgesics, encouraging fluids and applying an ice color are important but not as important as assessing for
bleeding.

Question 3

3. A nurse is administering 100% oxygen to a child with a pneumothorax based on the understanding that this treatment is used primarily for which reason?
   A. Improve gas exchange
   B. Bypass the obstruction
   C. Hasten air reabsorption
   D. Prevent hypoxemia

Answer 3

Answer: C
Rationale: Administration of 100% oxygen is used to treat pneumothorax primarily because it hastens the reabsorption of air. Generally this is used only for a few hours. Although the oxygen also improves gas exchange and prevents hypoxemia, these are not the reasons for its use in this situation. There is no obstruction with a pneumothorax.

Question 4

4. Bacterial pneumonia is suspected in a 4-year-old boy with fever, headache, and chest pain. Which assessment finding would most likely indicate the need for this child to be
   hospitalized?
   A. Fever
   B. Oxygen saturation level of 96%
   C. Tachypnea with retractions
   D. Pale skin color

Answer 4

Answer: C
Rationale: Pneumonia is usually a self-limiting disease. Children with bacterial pneumonia can be successfully managed at home if the work of breathing is not severe
and oxygen saturation is within normal limits. Hospitalization would most likely be required for the child with tachypnea, significant retractions, poor oral intake, or lethargy for the administration of supplemental oxygen, intravenous hydration, and antibiotics. Fever, although common in children with pneumonia, would not necessitate
hospitalization. An oxygen saturation level of 96% would be within normal limits. Pallor (pale skin color) occurs as a result of peripheral vasoconstriction in an effort to conserve
oxygen for vital functions; this finding also would not necessitate hospitalization.

Question 5

5. The nurse is assessing a 5-year-old girl who is anxious, has a high fever, speaks in a
   whisper, and sits up with her neck thrust forward. Based on these findings, what would
   be least appropriate for the nurse to perform?
   A. Providing 100% oxygen
   B. Visualizing the throat
   C. Having the child sit forward
   D. Auscultating for lung sounds

Answer 5

Answer: B
Rationale: The child is exhibiting signs and symptoms of epiglottitis, which can be life-threatening. Under no circumstances should the nurse attempt to visualize the throat. Reflex laryngospasm may occur, precipitating immediate airway occlusion. Providing 100% oxygen in the least invasive manner that is most acceptable to the child is a sound intervention, as is allowing the child to assume a position of sitting forward with the neck extended. Auscultation would reveal breath sounds consistent with an
obstructed airway.

Question 6

6. The nurse is educating the parents of a 7-year-old boy with asthma about the
   medications that have been prescribed. Which drug would the nurse identify as an
   adjunct to a β2-adrenergic agonist for treatment of bronchospasm?
   A. Ipratropium
   B. Montelukast
   C. Cromolyn
   D. Theophylline

Answer 6

Answer: A
Rationale: Ipratropium is an anticholinergic administered via inhalation to produce bronchodilation without systemic effects. It is generally used as an adjunct to a β2-
adrenergic agonist. Montelukast decreases the inflammatory response by antagonizing the effects of leukotrienes. Cromolyn prevents release of histamine from sensitized mast cells. Theophylline provides for continuous airway relaxation.

Question 7

7. The nurse is caring for a 3-year-old girl with a respiratory disorder. The nurse
   anticipates the need for providing supplemental oxygen to the child when performing
   which action?
   A. Suctioning a tracheostomy tube
   B. Administering drugs with a nebulizer
   C. Providing tracheostomy care
   D. Suctioning with a bulb syringe

Answer 7

Answer: A
Rationale: Supplemental oxygenation may be necessary before, and is always performed after, suctioning a child with a tracheostomy tube. Providing tracheostomy
care, administering drugs with a nebulizer, and suctioning with a bulb syringe do not require supplemental oxygen.

Question 8

8. The nurse is examining a 5-year-old. Which sign or symptom is a reliable first
   indication of respiratory illness in children?
   A. Slow, irregular breathing
   B. A bluish tinge to the lips
   C. Increasing lethargy
   D. Rapid, shallow breathing

Answer 8

Answer: D
Rationale: Tachypnea, or increased respiratory rate, is often the first sign of respiratory illness in infants and children. Slow, irregular breathing and increasing listlessness are
signs that the child's condition is worsening. Cyanosis (a bluish tinge to the lips) or the degree of cyanosis present is not always an accurate indication of the severity of
respiratory involvement.

Question 9

9. A child requires supplemental oxygen therapy at 8 liters per minute. Which delivery
   device would the nurse most likely expect to be used?
   A. Simple mask
   B. Venturi mask
   C. Nasal cannula
   D. Oxygen hood

Answer 9

Answer: A
Rationale: A simple mask would be used to deliver a flow rate of 8 liters per minute. A Venturi mask would be used to deliver a specific percentage of oxygen, from 24% to
50%. A nasal cannula would be used to deliver no more than 4 liters per minute. An oxygen hood requires a liter flow of 10 to 15 liters per minute.

Question 10

10. A group of nursing students are reviewing information about the variations in
    respiratory anatomy and physiology in children in comparison to adults. The students
    demonstrate understanding of the information when they identify which finding?
    A. Children’s demand for oxygen is lower than that of adults.
    B. Children develop hypoxemia more rapidly than adults do.
    C. An increase in oxygen saturation leads to a much larger decrease in pO2.
    D. Children’s bronchi are wider in diameter than those of an adult.

Answer 10

Answer: B
Rationale: Children develop hypoxemia more rapidly than adults do because they have a significantly higher metabolic rate and faster resting respiratory rates than adults do,
which leads to a higher demand for oxygen. A smaller decrease in oxygen saturation reflects a disproportionately much larger decrease in pO2. The bronchi in children are
narrower than in adults, placing them at higher risk for lower airway obstruction.

Question 11

11. The nurse is providing care to several children who have been brought to the clinic
    by the parents reporting cold-like symptoms. The nurse would most likely suspect
    sinusitis in which child?
    A. A 2-year-old with thin watery nasal discharge
    B. A 3-year-old with sneezing and coughing
    C. A 5-year-old with nasal congestion and sore throat
    D. A 7-year-old with halitosis and thick, yellow nasal discharge

Answer 11

Answer: D
Rationale: The frontal sinuses, those most commonly associated with sinus infection, develop by age 6 to 8 years. Therefore, the 7-year-old would most likely experience
sinusitis. In addition, this child also exhibits halitosis and a thick, yellow nasal discharge, other findings associated with sinusitis. Thin watery discharge in a 2-year-old is more
likely to indicate allergic rhinitis. A 3-year-old with coughing and sneezing or a 5-year- old with nasal congestion and sore throat suggests the common cold.

Question 12

12. A parent asks the nurse about immunizing her 7-month-old daughter against the flu.
    Which response by the nurse would be most appropriate?
    A. “She really doesn’t need the vaccine until she reaches 1 year of age.”
    B. “She will probably receive it the next time she is to get her routine shots.”
    C. “Since your daughter is older than 6 months, she should get the vaccine every year.”
    D. “The vaccine has many side effects, so she wouldn’t get it until she’s ready to go to school.”

Answer 12

Answer: C
Rationale: The current recommendations are for all children older than 6 months of age to be immunized yearly against influenza.

Question 13

13. A child with a pneumothorax has a chest tube attached to a water drainage seal system. When assessing the child, the nurse notices that the chest tube has become
    disconnected from the drainage system. What would the nurse do first?
    A. Notify the physician.
    B. Apply an occlusive dressing.
    C. Clamp the chest tube.
    D. Perform a respiratory assessment.

Answer 13

Answer: C
Rationale: If a chest tube becomes disconnected from the water seal drainage system, the nurse would first clamp the chest tube to prevent air from entering the child’s chest cavity. Then the nurse would perform a respiratory assessment and notify the physician. An occlusive dressing would be applied first if the chest tube became dislodged from the child’s chest.

Question 14

14. A nurse is preparing a teaching plan for the family of a child with allergic rhinitis.
    When describing the immune reaction that occurs, the nurse would identify the role of
    which immunoglobulin?
    a. IgA
    b. IgE
    c. IgG
    d. IgM

Answer 14

Answer: B
Rationale: The immunoglobulin involved in the immune response associated with allergic rhinitis is IgE. IgA, IgG, and IgM are not involved in this response.

Question 15

15. A group of nursing students are reviewing the medications used to treat asthma.
    The students demonstrate understanding of the information when they identify which
    agent as appropriate for an acute episode of bronchospasm?
    A. Salmeterol
    B. Albuterol
    C. Ipratropium
    D. Cromolyn

Answer 15

Answer: B
Rationale: Albuterol is a short-acting β2-adrenergic agonist that is used for treatment of acute bronchospasm. Salmeterol is a long-acting β2-adrenergic agonist used for long-term control or exercise-induced asthma. Ipratropium is an anticholinergic agent used as an adjunct to β2- adrenergic agonists for treatment of bronchospasm. Cromolyn is a mast cell stabilizer used prophylactically but not to relieve bronchospasm during an
acute wheezing episode.

Question 16

16. The nurse is preparing to perform a physical examination of a child with asthma.
    Which technique would the nurse be least likely to perform?
    a. Inspection
    b. Palpation
    c. Percussion
    d. Auscultation

Answer 16

Answer: B
Rationale: When examining the child with asthma, the nurse would inspect, auscultate, and percuss. Palpation would not be used.

Question 17

17. A nursing instructor is preparing a class on chronic lung disease. What information
    would the instructor include when describing this disorder?
    A. It is a result of cystic fibrosis.
    B. It is seen most commonly in premature infants.
    C. It typically affects females more often than males.
    D. It is characterized by bradypnea.

Answer 17

Answer: B
Rationale: Chronic lung disease, formerly known as bronchopulmonary dysplasia, is often diagnosed in infants who have experienced respiratory distress syndrome, most
commonly seen in premature infants. Male gender is a risk factor for development. Tachypnea and increased work of breathing are characteristic of chronic lung disease.

Question 18

18. A nurse is teaching the parents of a child diagnosed with cystic fibrosis about
    medication therapy. Which would the nurse instruct the parents to administer orally?
    A. Recombinant human DNase
    B. Bronchodilators
    C. Anti-inflammatory agents
    D. Pancreatic enzymes

Answer 18

Answer: D
Rationale: Pancreatic enzymes are administered orally to promote adequate digestion and absorption of nutrients. Recombinant human DNase, bronchodilators, and anti-
inflammatory agents are typically administered by inhalation.

Question 19

19. When performing the physical examination of a child with cystic fibrosis, what would
    the nurse expect to assess?
    A. Dullness over the lung fields
    B. Increased diaphragmatic excursion
    C. Decreased tactile fremitus
    D. Hyperresonance over the liver

Answer 19

Answer: C
Rationale: Examination of a child with cystic fibrosis typically reveals decreased tactile fremitus over areas of atelectasis, hyperresonance over the lung fields from air trapping,
decreased diaphragmatic excursion, and dullness over the liver when enlarged.

Question 20

20. The nurse is preparing to provide tracheostomy care to an infant. After gathering the
    necessary equipment, what would the nurse do next?
    A. Position the infant supine with a towel roll under the neck.
    B. Cut the new tracheostomy ties to the appropriate length.
    C. Cut the tracheostomy ties from around the tracheostomy tube.
    D. Cleanse around the site of the tracheostomy with the prescribed solution.

Answer 20

Answer: A
Rationale: After gathering the necessary equipment, the nurse would position the infant supine with a blanket or towel roll to extend the neck. Then the nurse would open all the packaging and cut the new tracheostomy ties to the appropriate length. This would be followed by cleaning the site with the appropriate solution and then rinsing it. After
placing the precut sterile gauze under the tracheostomy tube, the nurse would cut the ties and remove them from the tube while an assistant holds the tube in place.

Question 21

21. A child is brought to the emergency department by his parents because he suddenly
    developed a barking cough. Further assessment leads the nurse to suspect that the
    child is experiencing croup. What would the nurse have most likely assessed?
    A. High fever
    B. Dysphagia
    C. Toxic appearance
    D. Inspiratory stridor

Answer 21

Answer: D
Rationale: A child with croup typically develops a bark-like cough, often at night. This may be accompanied by inspiratory stridor and suprasternal retractions. Temperature may be normal or slightly elevated. A high fever, dysphagia, and toxic appearance are associated with epiglottitis.

Question 22

22. A child has been prescribed a nasal cannula for oxygen delivery. What should the
    nurse do before applying the cannula?
    A. Assess patency of the nares
    B. Test the oxygen saturation
    C. Add humidification to the delivery device
    D. Assess the lung sounds

Answer 22

Answer: A
Rationale: A nasal cannula is a good delivery device for children, because it allows them to eat and talk unobstructed. Because the device is designed for flow through the nares, the patency of the nares should be assessed prior to using the cannula. If the nares are blocked from secretions, suctioning may be required. If there is a defect in the upper airway causing blockage, the nasal cannula may not be an appropriate oxygen delivery device. The oxygen saturation should have been measured and used as a guide for the prescription of oxygen therapy. Adding humidification is a way to keep the upper airways from becoming too dry, but oxygen can be started before humidity is added. Anytime a child is sick enough to require oxygen all respiratory assessments, including lung sounds, should be done. It does not matter, however, what the lung
sounds are if the child is in enough distress to require oxygen. The lung sounds can be assessed after oxygen is started.

Question 23

23. The nurse is obtaining a health history of a child suspected of tuberculosis. What
    question would the nurse ask first about the child's cough?
    A. “How long has your child had a cough?”
    B. “Does your child cough only at night?”
    C. “Does your child cough up anything when coughing?”
    D. “Has your child been around anyone who is coughing?”

Answer 23

Answer: A
Rationale: Tuberculosis is a highly contagious disease. Most children contract it from an infected immediate household member. When taking the health history, the nurse
should ask about symptoms such as malaise, weight loss, anorexia, chest tightness, and cough. The child’s cough from tuberculosis is described as progressing slowly over
several weeks and months rather than having an acute onset. Asking about the production from the cough is a way to determine if hemoptysis has occurred. Asking about being around anyone coughing is a way to determine if the child has been exposed to anyone with tuberculosis. Coughing only at night could be related to other respiratory disorders such as asthma.

Question 24

24. The nurse is teaching the parent of a child with cystic fibrosis about nutrition
    requirements for the child. What should be included in this teaching?
    A. “Give your child high-calorie foods and snacks.”
    B. “Feed your child foods that are high in protein.”
    C. “Administer water soluble vitamins.”
    D. “Give pancreatic enzymes with meals.”
    E. “Give your child foods high in fat.”

Answer 24

Answer: A, B, D
Rationale: Children with cystic fibrosis (CF) have trouble digesting and absorbing nutrients. They tend to be underweight. For optimal health, their diets should be high in calories and high in protein, with the supplementation of fat soluble vitamins and pancreatic enzymes. This diet helps with growth and the optimal nutrients. The fat soluble vitamins (vitamins A, D, E and K) are needed, because children with CF have trouble absorbing fat and need the vitamin supplementation to aid in fat absorption. Water soluble vitamins (the B vitamins and vitamin C) do not aid in fat absorption. The child should not have a high-fat diet, because the extra fat is difficult to digest and be absorbed. Pancreatic enzymes are necessary because they are missing due to the disease process. They are necessary to aid in digestion. They should be ingested with meals.

Question 25

25. The nurse is preparing a room for a child being transferred out of the intensive care
    unit. The child has a tracheostomy. What item(s) are essential for the nurse to have
    available at the bedside in case of emergency? Select all that apply.
    A. A new tracheostomy tube of the same size
    B. A new tracheostomy tube of a smaller size
    C. A bag valve mask
    D. A sterile tracheostomy kit
    E. Cleaning supplies for the tracheostomy

Answer 25

Answer: A, B, C
Rationale: A child with a tracheostomy can have an emergent situation for any number of reasons. It is important to always have emergency equipment at the bedside to provide immediate care when these situations arrive. Two spare tracheostomy tubes should always be at the bedside, one the same size as in place and once a size smaller. These would be needed if the tube became dislodged. A bag valve mask needs to remain at the bedside at all times. Ideally it should be connected to oxygen, but that is an individual protocol for the health care organization. The bag can be used to hyperoxygenate the child prior to or following suctioning or it can be used in an
emergent situation such as a respiratory arrest. Sterile tracheostomy kits and cleaning supplies can be available at the bedside, but they are used for routine cleaning and not
for emergencies.

Question 26

26. A parent with a child who has cystic fibrosis asks the nurse how to determine if the
    child is receiving an adequate amount of pancreatic enzymes. How should the nurse
    respond? Select all that apply.
    A. “The dose is adequate when your child is only having 1 to 2 stools per day.”
    B. “The dose is adequate when your child’s weight is improving.”
    C. “The dose prescribed is based on your child’s pancreatic laboratory values so it should be correct.”
    D. “When your child starts to eat more quantity of food you will need to adjust the amount of enzyme pills.”
    E. “You will need to give your child less enzyme pills when high-fat foods are eaten.”

Answer 26

Answer: A, B, D
Rationale: Pancreatic enzymes are required for the child with cystic fibrosis (CF) to help absorb nutrients from the diet and to aid in digestion. They are given with each meal
and snack the child eats. The number of capsules required at each dose depends upon the diagnosis of how the pancreas is functioning and the amount of food needing to be digested. The pancreatic laboratory values may determine a baseline for the number of pills to start with but the dosage is adjusted regularly. The dosage of pancreatic
enzymes is adjusted until an adequate growth pattern is established and the child is having no more than 1 to 2 stools per day. The child should be given an increased
number of enzyme pills when a meal with high-fat content is consumed, not fewer.

Question 27

27. A child is in the emergency department with an asthma exacerbatation. Upon
    auscultation the nurse is unable to hear air movement in the lungs. What action should
    the nurse take first?
    A. Administer a beta-2 adrenergic agonist
    B. Administer oxygen
    C. Start a peripheral IV
    D. Administer corticosteroids

Answer 27

Answer: A
Rationale: When lungs sounds are unable to be heard in a child with asthma, the child is very ill. This means there is severe airway obstruction. The air movement is so severe
wheezes cannot be heard. The priority treatment is to administer an inhaled short term bronchodilator (beta-2 adrenergic agonist). The child may require numerous inhalations until bronchodilation occurs and air can pass through the bronchi. Oxygen can be started but until the bronchi are dilated no oxygen can get through to the lung fields. An IV would need to be started and IV steroids administered to reduce the inflammation, but the priority is bronchodilation.

Question 28

28. A hospitalized child suddenly begins reporting "my chest hurts," is tachypneic, and
    has tachycardia. The nurse auscultates the lung sounds and finds absent breath sounds
    on one side. After notifying the health care provide what action would the nurse take
    first?
    A. Prepare for chest tube insertion
    B. Administer oxygen
    C. Obtain oxygen saturation measurement
    D. Prepare for mechanical ventilation

Answer 28

Answer: A
Rationale: A pneumothorax is a collection of air in the pleural space. Trapped air consumes space in the pleural cavity causing a partial or complete collapse. The priority
symptom a nurse would assess is the decreased or absent lung sounds on the affected side. A pneumothorax can occur spontaneously in a healthy child or it can occur in a
child with chronic lung disease, has been on a ventilator or has had thoracic surgery. Additional symptoms the child would experience would be chest pain, tachypnea,
retractions, grunting, cyanosis and tachycardia. Many of these symptoms could be present with any child with an acute or chronic lung disease or respiratory distress, but the defining symptom is the absent breath sounds. The treatment for a pneumothorax is with a chest tube so the priority action would be to gather supplies and prepare for the health care provider to insert a chest tube. Obtaining an oxygen saturation level measurement will only provide data, it will not help the child in distress. Oxygen may need to be administered, but with a pneumothorax it will be very ineffective. Mechanical ventilation would be a last resort and could actually make the situation worse if the lung was not reinflated.

Question 29

29. A child is hospitalized with pneumonia. The nurse assesses an increase in the work
    of breathing and in the respiratory rate. What intervention should the nurse do first to
    help this child?
    A. Elevate the head of the bed
    B. Administer oxygen
    C. Notify the health care provider
    D. Obtain oxygen saturation levels

Answer 29

Answer: A
Rationale: The child who is experiencing increased work of breathing should be placed in a position to better open the airway and provide more room for lung expansion.
Generally this is accomplished by elevating the head of the bed. If this does not improve the work of breathing, then administering oxygen should be done. The oxygen
saturation should be measured because it will provide information as to the severity of the respiratory problem, but measurement will not directly help the child. The health
care provider should be notified if the child continues to deteriorate.

Question 30

30. An infant with a high respiratory rate is NPO and is receiving IV fluids. What
    assessment(s) will the nurse make to assure this infant is hydrated? Select all that
    apply.
    A. Measure skin turgor
    B. Palpate anterior fontanel
    C. Determine urine output
    D. Review electrolyte laboratory results
    E. Assess the lung sounds

Answer 30

Answer: A, B, C
Rationale: IV fluids are necessary many times for infants and children who are experiencing high respiratory rates. The high respiratory rates make the child very tired from the increased work of breathing. In an infant there are very little reserves so the infant tires very quickly, especially when the work of sucking is added to the compromised respiratory state. To determine if the infant is hydrated the nurse should assess the skin turgor, palpate for a flat anterior fontanel, observe for moist mucus membranes and measure the urine output. The output should be 1 to 2ml/kg/hr. The
electrolyte laboratory results will tell the nurse if the infant has an electrolyte imbalance, not a fluid imbalance. Assessing the lung sounds will not tell if the child is hydrated, only if the lungs are “wet” and fluid overloaded. The infant would also exhibit additional signs of respiratory distress if the lungs are fluid overloaded.