Midterm ch 20 Flashcards
Which of the following is the primary cause of the thickened secretions seen in cystic fibrosis (CF)?
a) Increased sodium absorption and impaired chloride-ion transport
b) Overproduction of mucous in the lungs
c) Impaired protein synthesis in epithelial cells
d) Abnormal activation of digestive enzymes in the pancreas
a) Increased sodium absorption and impaired chloride-ion transport
Rationale: The defective CFTR gene impairs chloride-ion transport across epithelial cells, and increased sodium absorption leads to thickened secretions in various organs, including the lungs and pancreas.
A 4-year-old child with cystic fibrosis (CF) presents with a persistent cough, wheezing, and difficulty breathing. The nurse knows that chronic bacterial and fungal colonization in the airways can result in which of the following long-term complications?
a) Pneumothorax
b) Hyperglycemia
c) Hypotension
d) Nephrotic syndrome
a) Pneumothorax
Rationale: Chronic bacterial and fungal colonization, along with bronchiectasis (abnormal dilation of the bronchi), can lead to respiratory complications such as pneumothorax and hemothorax in children with CF.
A child with cystic fibrosis is experiencing failure to thrive. Which of the following is the most likely cause of this nutritional deficit?
a) Excessive caloric intake due to malabsorption
b) Impaired digestive enzyme flow from the pancreas
c) Hypermetabolism due to chronic respiratory infections
d) Insulin resistance leading to poor glucose absorption
b) Impaired digestive enzyme flow from the pancreas
Rationale: Obstructions in the pancreatic ducts impair enzyme flow, affecting digestion of fats, fat-soluble vitamins, and proteins, leading to malabsorption and failure to thrive.
A newborn is diagnosed with cystic fibrosis after presenting with meconium ileus. The nurse understands that meconium ileus is a result of which of the following?
a) Inadequate secretion of chloride and fluid into the intestines
b) Dehydration due to excessive sodium loss
c) Thickened secretions in the airway causing airway obstruction
d) Accumulation of undigested food in the gastrointestinal tract
a) Inadequate secretion of chloride and fluid into the intestines
Rationale: Meconium ileus occurs due to the failure to secrete adequate chloride and fluid into the intestines, resulting in a small bowel obstruction, commonly seen in 15% of newborns with CF.
A 10-year-old child with cystic fibrosis is at risk for hyponatremic dehydration due to excessive electrolyte loss through perspiration. The nurse should monitor for which of the following symptoms of hyponatremic dehydration?
a) Increased thirst and dark, concentrated urine
b) Weight gain and edema
c) Hyperactivity and irritability
d) Rapid pulse and dry mouth
d) Rapid pulse and dry mouth
Rationale: Excessive electrolyte loss in CF leads to hyponatremic dehydration, which can manifest as a rapid pulse, dry mouth, and signs of dehydration such as decreased urine output.
A 5-year-old child with cystic fibrosis (CF) is experiencing chronic sinusitis, purulent nasal discharge, and postnasal drip. Which of the following is most likely contributing to these symptoms?
a) Excessive production of ciliary action in the nasal passages
b) Increased airway hyperinflation in the lungs
c) Thickened mucus in the sinuses leading to obstruction
d) Increased insulin production causing fluid retention
c) Thickened mucus in the sinuses leading to obstruction
Rationale: In CF, the thickened mucus due to impaired chloride transport leads to blocked sinuses, resulting in chronic sinusitis and related symptoms such as purulent nasal discharge and postnasal drip.
A child with cystic fibrosis is demonstrating chronic, productive cough, wheezing, and coarse crackles on auscultation. What is the primary cause of these respiratory symptoms?
a) Impaired ciliary clearance and bacterial colonization in the airways
b) Overproduction of surfactant in the alveoli
c) Accumulation of undigested food particles in the lungs
d) Increased mucus secretion in the upper respiratory tract
a) Impaired ciliary clearance and bacterial colonization in the airways
Rationale: The impaired ciliary function and thickened mucus lead to airway obstruction, bacterial colonization, and chronic respiratory symptoms, including a productive cough, wheezing, and coarse crackles.
Which of the following is a common clinical manifestation of cystic fibrosis related to pancreatic dysfunction?
a) Insulin resistance leading to hyperglycemia
b) Inadequate secretion of digestive enzymes resulting in malabsorption
c) Overproduction of digestive enzymes resulting in pancreatitis
d) Decreased bile flow leading to constipation
b) Inadequate secretion of digestive enzymes resulting in malabsorption
Rationale: The obstruction of pancreatic ducts in CF prevents the secretion of digestive enzymes, leading to malabsorption, which can result in poorly digested food and nutritional deficiencies.
A nurse is assessing a child with cystic fibrosis who is presenting with greasy, foul-smelling stools that float. Which of the following is the most likely cause of this clinical manifestation?
a) Decreased bile secretion from the liver
b) Increased production of digestive enzymes by the pancreas
c) Impaired pancreatic enzyme secretion leading to steatorrhea
d) Malabsorption of water in the gastrointestinal tract
c) Impaired pancreatic enzyme secretion leading to steatorrhea
Rationale: The impaired pancreatic enzyme secretion in CF leads to malabsorption of fats, resulting in steatorrhea (greasy, foul-smelling stools that float).
Which of the following would be the most appropriate nursing intervention for a child with cystic fibrosis who is experiencing constipation and abdominal distention?
a) Administering a low-sodium diet to prevent dehydration
b) Reducing fat intake to prevent further abdominal discomfort
c) Withholding oral nutrition until symptoms resolve
d) Encouraging increased fluid intake and regular physical activity
d) Encouraging increased fluid intake and regular physical activity
Rationale: Increasing fluid intake and promoting physical activity can help alleviate constipation and improve gastrointestinal motility, addressing symptoms of abdominal distention and constipation.
A 12-year-old child with cystic fibrosis is being evaluated for growth and development. The nurse observes delayed onset of puberty and poor weight gain. Which of the following is most likely contributing to these issues?
a) Chronic respiratory infections leading to decreased appetite
b) Vitamin A, D, E, and K deficiencies from poor fat absorption
c) Inadequate insulin production causing hyperglycemia
d) Increased caloric intake due to accelerated metabolism
b) Vitamin A, D, E, and K deficiencies from poor fat absorption
Rationale: The impaired pancreatic function in CF leads to malabsorption of fat and fat-soluble vitamins (A, D, E, and K), contributing to growth delays, poor weight gain, and delayed puberty.
A newborn with cystic fibrosis is diagnosed with meconium ileus. What is the pathophysiological cause of this condition?
a) Failure to secrete sufficient chloride and fluid into the intestines
b) Excessive production of bile obstructing the intestines
c) Malabsorption of nutrients causing intestinal inflammation
d) Decreased motility of the small intestine due to nerve damage
a) Failure to secrete sufficient chloride and fluid into the intestines
Rationale: Meconium ileus occurs when insufficient chloride and fluid are secreted into the intestines, leading to thickened meconium that causes small bowel obstruction.
A nurse is assessing a male adolescent with cystic fibrosis who is concerned about fertility. What is the most common cause of male infertility in cystic fibrosis?
a) Abnormal sperm morphology
b) Reduced production of sperm due to hormonal imbalances
c) Absence of the vas deferens
d) Decreased semen volume due to inadequate prostate fluid production
c) Absence of the vas deferens
Rationale: In males with cystic fibrosis, the absence of the vas deferens is the most common cause of infertility, resulting in obstructive azoospermia.
A child with cystic fibrosis is noted to have a barrel chest and clubbing of the fingers and toes. These clinical manifestations are primarily indicative of which of the following?
a) Chronic respiratory infections leading to airway damage and oxygenation issues
b) Cardiac failure due to insufficient blood flow to the lungs
c) Nutritional deficiencies causing delayed bone development
d) Electrolyte imbalances leading to abnormal skeletal development
a) Chronic respiratory infections leading to airway damage and oxygenation issues
Rationale: The barrel chest and clubbing of the fingers and toes are long-term signs of chronic respiratory issues, such as chronic infections and airway damage, leading to impaired oxygenation and pulmonary function in cystic fibrosis.
A 7-year-old child with cystic fibrosis is being taught about airway clearance techniques. Which of the following interventions should the nurse include in the teaching plan to help the child expel secretions?
a) Encourage the child to practice deep breathing exercises while lying flat
b) Use chest physiotherapy twice a day, including percussion or vibration
c) Instruct the child to avoid coughing as it could cause airway injury
d) Recommend using an oscillating chest vest only once a week
b) Use chest physiotherapy twice a day, including percussion or vibration
Rationale: Chest physiotherapy is crucial for promoting the drainage of secretions from the lungs. It should be performed twice daily, using techniques like percussion or vibration to help expel mucus from the lungs and prevent airway obstruction.
A 4-year-old child with cystic fibrosis is receiving immunizations. What is the primary reason for administering vaccinations to children with cystic fibrosis?
a) To prevent gastrointestinal infections and improve digestion
b) To decrease the risk of diabetes-related complications
c) To reduce the risk of viral and bacterial infections that may worsen lung function
d) To ensure adequate caloric intake and nutritional status
c) To reduce the risk of viral and bacterial infections that may worsen lung function
Rationale: Children with cystic fibrosis are at higher risk for respiratory infections, which can lead to further lung damage. Immunizations help prevent viral and bacterial infections that could exacerbate respiratory symptoms and decline in lung function.
A nurse is preparing to administer chest tube drainage for a child with cystic fibrosis who has developed a pneumothorax. What is the primary goal of this therapy?
a) To improve oxygenation and reduce respiratory distress
b) To remove excess mucus from the lungs
c) To correct electrolyte imbalances caused by the disease
d) To prevent bacterial infection in the lungs
a) To improve oxygenation and reduce respiratory distress
Rationale: Chest tube drainage is used to relieve pneumothorax by removing air from the pleural space, improving lung expansion, and reducing respiratory distress.
A child with cystic fibrosis is undergoing a thoracoscopy to repair ruptured alveoli. What is the primary benefit of this procedure for this patient?
a) It improves gastrointestinal function by relieving abdominal distention
b) It repairs areas of recurrent pneumothorax and prevents future episodes in the same location
c) It improves the absorption of pancreatic enzyme supplements
d) It helps in the management of cystic fibrosis-related diabetes
b) It repairs areas of recurrent pneumothorax and prevents future episodes in the same location
Rationale: Thoracoscopy is performed to repair ruptured alveoli, a common cause of recurrent pneumothorax in cystic fibrosis patients. The procedure helps prevent future episodes by sealing the damaged area of the lung.
A nurse is educating the parents of a child with cystic fibrosis about the importance of a high-calorie, high-fat diet. What is the rationale for this dietary recommendation?
a) It helps reduce mucus production in the lungs
b) It decreases the risk of pancreatitis and gastrointestinal complications
c) It improves insulin production and controls blood sugar levels
d) It promotes weight maintenance and growth while supporting lung function
d) It promotes weight maintenance and growth while supporting lung function
Rationale: A high-calorie, high-fat diet is essential for children with cystic fibrosis to support growth, weight maintenance, and increased lung capacity. It helps provide adequate energy to combat the high metabolic demands of the body and maintain nutritional status.
A 3-year-old with cystic fibrosis is diagnosed with meconium ileus. Which of the following treatments is most appropriate to relieve this condition?
a) Hyperosmolar enemas or isotonic fluid lavage
b) Pancreatic enzyme replacement therapy
c) High-calorie, high-fat diet
d) Vitamin A, D, E, and K supplementation
a) Hyperosmolar enemas or isotonic fluid lavage
Rationale: Meconium ileus is a bowel obstruction caused by thick meconium in newborns with cystic fibrosis. Hyperosmolar enemas or isotonic fluid lavage can help relieve the obstruction by flushing out the thickened meconium and improving intestinal motility.
A nurse is preparing to administer pancreatic enzyme supplements to a child with cystic fibrosis. What is the primary purpose of these supplements?
a) To improve lung function and prevent infections
b) To reduce gastric acid production and protect the pancreas
c) To increase insulin production and prevent diabetes
d) To promote digestion of fats and proteins and prevent malnutrition
d) To promote digestion of fats and proteins and prevent malnutrition
Rationale: Pancreatic enzyme supplements are essential for aiding the digestion of fats and proteins in children with cystic fibrosis, as their impaired pancreas cannot produce sufficient digestive enzymes. This prevents malnutrition and promotes adequate growth.
A nurse is teaching a child with cystic fibrosis about the role of exercise and physical fitness in managing the disease. What is the most important benefit of regular exercise for this child?
a) It reduces the frequency of gastrointestinal disturbances
b) It improves immune function and prevents respiratory infections
c) It helps maintain lung function and prevent further damage
d) It prevents electrolyte imbalances related to sweat gland dysfunction
c) It helps maintain lung function and prevent further damage
Rationale: Regular exercise is essential for maintaining lung function in children with cystic fibrosis. It helps improve airway clearance, reduces the risk of lung infections, and may slow the progression of respiratory decline.
A 6-year-old child with cystic fibrosis has been receiving acid suppression therapy. Which of the following is the most appropriate reason for administering this therapy to the child?
a) To reduce the risk of lung infections by improving immune function
b) To prevent the damage caused by gastroesophageal reflux, which worsens lung function
c) To reduce pancreatic enzyme secretion that could worsen abdominal distention
d) To improve digestion by enhancing the absorption of nutrients from the intestines
b) To prevent the damage caused by gastroesophageal reflux, which worsens lung function
Rationale: Acid suppression therapy is used to manage gastroesophageal reflux in cystic fibrosis patients. Reflux can worsen lung function by promoting aspiration of gastric contents into the lungs, contributing to respiratory infections and further damage.
A nurse is planning care for a 10-year-old child with cystic fibrosis and their family. Which of the following nursing diagnoses is most appropriate for this child?
a) Ineffective Airway Clearance related to thick mucus in lungs
b) Anxiety related to long-term effects of cystic fibrosis
c) Risk for Impaired Skin Integrity related to frequent respiratory treatments
d) Risk for Ineffective Coping related to uncertainty of long-term prognosis
a) Ineffective Airway Clearance related to thick mucus in lungs
Rationale: Ineffective airway clearance is a key nursing diagnosis for children with cystic fibrosis due to the thick mucus production in the lungs, which can lead to respiratory complications. This diagnosis will guide interventions aimed at improving airway clearance.
During a follow-up visit, a nurse notes that a child with cystic fibrosis is not maintaining an appropriate growth pattern. What should the nurse do first?
a) Increase the child’s caloric intake
b) Assess the child’s appetite and dietary intake
c) Initiate a referral to a dietitian for nutritional counseling
d) Ask the parents to begin supplemental feeding immediately
b) Assess the child’s appetite and dietary intake
Rationale: Before making any changes to the diet, it is important to assess the child’s current eating habits and identify any potential barriers to adequate nutrition, such as appetite changes or difficulties with food digestion.
A nurse is caring for a child with cystic fibrosis who is at risk for infection. Which of the following interventions is most important for preventing infections in the hospital setting?
a) Routinely administering prophylactic antibiotics
b) Rooming children with cystic fibrosis together for support
c) Practicing strict hand hygiene and isolation precautions
d) Limiting visitors to only the child’s immediate family members
c) Practicing strict hand hygiene and isolation precautions
Rationale: Strict hand hygiene and isolation precautions are essential to prevent cross-contamination and reduce the risk of hospital-acquired infections, particularly with highly transmissible pathogens like Pseudomonas aeruginosa.
The nurse is teaching the parents of a child with cystic fibrosis about airway clearance techniques. Which of the following is an appropriate instruction?
a) “Airway clearance techniques should only be performed during hospitalizations.”
b) “Coughing exercises should be performed before any medication is administered.”
c) “Airway clearance techniques should be avoided during episodes of fever.”
d) “Chest physiotherapy should be done twice a day to ensure optimal lung function.”
d) “Chest physiotherapy should be done twice a day to ensure optimal lung function.”
Rationale: Chest physiotherapy is an important component of the daily care routine for children with cystic fibrosis. It helps clear mucus from the airways and should be done regularly, typically twice a day, to maintain optimal lung function.
A nurse is conducting a psychosocial assessment of a child with cystic fibrosis and their family. Which statement by the parent indicates the need for further counseling?
a) “We have learned to manage the day-to-day care routine for our child’s condition.”
b) “I feel guilty for passing on the gene for cystic fibrosis to my child.”
c) “I try to shield my other children from learning too much about the disease.”
d) “The care routine is exhausting, but it has brought our family closer together.”
c) “I try to shield my other children from learning too much about the disease.”
Rationale: It’s important to address how the disease is communicated to siblings. Shielding them from the reality of cystic fibrosis may hinder their emotional adjustment and coping. Siblings need age-appropriate information about the disease.
When caring for a child with cystic fibrosis, which of the following is a priority nursing intervention during an exacerbation requiring hospitalization?
a) Initiating isolation precautions to prevent cross-infection with other cystic fibrosis patients
b) Administering a high-calorie, high-fat diet
c) Educating the child on performing airway clearance techniques independently
d) Monitoring the child’s emotional status and providing emotional support to the parents
a) Initiating isolation precautions to prevent cross-infection with other cystic fibrosis patients
Rationale: To prevent cross-infection with pathogens like Pseudomonas aeruginosa and Burkholderia cepacia, children with cystic fibrosis are placed in private rooms with standard precautions.
A child with cystic fibrosis is prescribed fat-soluble vitamin supplements (A, D, E, and K). What should the nurse teach the parents regarding these supplements?
a) “Ensure that the vitamins are given twice a day to promote absorption.”
b) “Administer the vitamins with a low-fat meal to ensure maximum absorption.”
c) “Fat-soluble vitamins are typically given in a liquid form only for children.”
d) “Give the vitamins only when the child is experiencing respiratory symptoms.”
a) “Ensure that the vitamins are given twice a day to promote absorption.”
Rationale: Fat-soluble vitamins should be given twice daily to ensure adequate absorption, as they may not be well absorbed in children with cystic fibrosis due to pancreatic insufficiency and poor fat digestion.
A nurse is administering an aerosolized bronchodilator to a child with cystic fibrosis before an airway clearance procedure. What is the most important nursing action?
a) Encourage the child to breathe rapidly to open the airways
b) Ensure the child holds their breath for 10 seconds after inhalation
c) Instruct the child to cough forcefully after the inhalation
d) Administer the medication after performing chest physiotherapy
b) Ensure the child holds their breath for 10 seconds after inhalation
Rationale: The child should hold their breath for 10 seconds after inhalation to allow the bronchodilator to work effectively, opening the airways before airway clearance techniques are performed.
A nurse is teaching the family of a child with cystic fibrosis about pancreatic enzyme supplements. Which of the following is the most important instruction regarding the administration of these supplements?
a) “Administer the enzymes with a high-fat meal only.”
b) “Ensure enzymes are given with meals and snacks to aid digestion.”
c) “Give the enzymes on an empty stomach for better absorption.”
d) “The enzymes should be taken after meals to prevent stomach upset.”
b) “Ensure enzymes are given with meals and snacks to aid digestion.”
Rationale: Pancreatic enzyme supplements should be taken with meals and snacks to aid in the digestion of fats, proteins, and carbohydrates, which are often poorly digested in cystic fibrosis patients due to pancreatic insufficiency.
A child with cystic fibrosis is prescribed ibuprofen to slow the progression of lung function decline. What should the nurse emphasize to the parents regarding this medication?
a) “Make sure your child avoids taking any vitamin supplements with this medication.”
b) “Monitor for signs of gastrointestinal bleeding, such as black, tarry stools.”
c) “This medication should be taken on an empty stomach for optimal absorption.”
d) “It is safe to take aspirin along with ibuprofen for enhanced lung protection.”
b) “Monitor for signs of gastrointestinal bleeding, such as black, tarry stools.”
Rationale: Ibuprofen can cause gastrointestinal irritation and bleeding. Parents should monitor for signs of bleeding and should not give their child aspirin or other NSAIDs unless approved by the healthcare provider.
A nurse is teaching the parents of a child with cystic fibrosis about the use of aerosolized hypertonic saline (7%). What is the primary action of this medication?
a) To hydrate the airway mucus and stimulate coughing
b) To prevent gastrointestinal reflux
c) To increase mucus production and promote airway clearance
d) To reduce airway hyperresponsiveness and prevent bronchospasm
a) To hydrate the airway mucus and stimulate coughing
Rationale: Hypertonic saline (7%) is used to hydrate the mucus in the airways, stimulating coughing and improving lung function by promoting mucus clearance.
A nurse is administering aerosolized dornase alpha (Pulmozyme) to a child with cystic fibrosis. What is the primary purpose of this medication?
a) To promote bronchial dilation and prevent bronchospasm
b) To hydrate airway mucus and improve coughing
c) To loosen, liquefy, and thin pulmonary secretions
d) To treat bacterial infections in the lungs
c) To loosen, liquefy, and thin pulmonary secretions
Rationale: Dornase alpha (Pulmozyme) is used to thin and break down pulmonary secretions in cystic fibrosis patients, making it easier to clear mucus from the airways and reduce exacerbations.
A nurse is caring for an infant diagnosed with RSV bronchiolitis. Which of the following symptoms is most concerning and indicates the need for immediate intervention?
a) Rhinitis and mild cough
b) Tachypnea greater than 70 breaths per minute
c) Nasal flaring and poor feeding
d) Low-grade fever and irritability
b) Tachypnea greater than 70 breaths per minute
Rationale: Tachypnea greater than 70 breaths per minute is a sign of severe respiratory distress and indicates that the infant may be at risk for respiratory failure, requiring immediate intervention.
Which of the following infants is at highest risk for developing severe RSV infection?
a) An infant born at 35 weeks’ gestation
b) An infant with a history of asthma
c) A 10-month-old infant with a mild upper respiratory infection
d) An infant born at 28 weeks’ gestation who required supplemental oxygen for the first few weeks of life
d) An infant born at 28 weeks’ gestation who required supplemental oxygen for the first few weeks of life
Rationale: Infants born prematurely (less than 32 weeks’ gestation) and those requiring supplemental oxygen are at higher risk for severe RSV infection due to their immature lungs and respiratory system.
A nurse is caring for a child with RSV. The child has increasing irritability, nasal flaring, and wheezing. The nurse notes diminishing breath sounds. What is the nurse’s priority action?
a) Administer nebulized hypertonic saline
b) Reassess the child’s respiratory status frequently
c) Initiate chest physiotherapy to clear the airways
d) Provide a dose of corticosteroids
b) Reassess the child’s respiratory status frequently
Rationale: Diminishing breath sounds indicate that airflow is decreasing, which may signal worsening respiratory status. Frequent reassessment is essential to determine if further interventions, such as oxygen or mechanical ventilation, are needed.
Which of the following is the most appropriate initial treatment for an infant with severe RSV bronchiolitis and hypoxemia?
a) Nebulized albuterol
b) Humidified oxygen therapy
c) Intravenous antibiotics
d) Oral corticosteroids
b) Humidified oxygen therapy
Rationale: Humidified oxygen therapy is the standard treatment for infants with severe RSV bronchiolitis and hypoxemia to maintain adequate oxygen saturation and relieve respiratory distress.
A nurse is preparing to administer palivizumab (Synagis) to a high-risk infant. Which of the following is the correct administration schedule for this medication?
a) Every month for 5 months, starting in October
b) Once during the RSV season, before the first symptoms appear
c) Every 2 months for 3 months, starting in January
d) Monthly for 12 months, starting in January
a) Every month for 5 months, starting in October
Rationale: Palivizumab is administered once a month for 5 months, starting in October or November, at the onset of the RSV season, to help prevent severe RSV infection in high-risk infants.
Which of the following interventions should be avoided in the management of an infant with RSV bronchiolitis?
a) Nasal suctioning before feeding
b) Continuous positive airway pressure (CPAP)
c) Chest physiotherapy
d) Intravenous hydration
c) Chest physiotherapy
Rationale: Chest physiotherapy is not recommended for infants with RSV bronchiolitis as it can be ineffective and potentially harmful in clearing the mucus, and may cause further respiratory distress.
A nurse is teaching parents about the supportive care for their child with mild RSV bronchiolitis at home. Which of the following should the nurse include in the teaching?
a) “Antibiotics are necessary if your child develops a fever.”
b) “Use humidified air to ease your child’s breathing and help with mucus clearance.”
c) “Bronchodilators should be used as often as needed to relieve wheezing.”
d) “The child should be kept in isolation from other children for the next 2 months.”
b) “Use humidified air to ease your child’s breathing and help with mucus clearance.”
Rationale: Humidified air can help relieve breathing difficulties and facilitate the clearance of mucus in children with RSV bronchiolitis. Antibiotics are not necessary unless a bacterial infection is present.
An infant with RSV is presenting with signs of increasing respiratory distress, including grunting and retractions. The nurse should anticipate which of the following diagnostic tests?
a) Chest radiograph
b) Blood culture
c) Arterial blood gas (ABG)
d) Pulmonary function test
d) Pulmonary function test
Rationale: A chest radiograph will help identify signs of hyperinflation, atelectasis, and other findings associated with RSV infection and bronchiolitis.
Which of the following is a primary risk factor for severe RSV infection in infants?
a) Maternal smoking during pregnancy
b) A history of allergic rhinitis
c) Presence of a sibling with RSV
d) A birth weight above 3,500 grams
a) Maternal smoking during pregnancy
Rationale: Maternal smoking during pregnancy increases the risk of respiratory infections in infants, including severe RSV infection, due to impaired lung development.
A child with RSV bronchiolitis has tachypnea, cyanosis, and lethargy. The nurse should expect which of the following to be the most concerning laboratory finding?
a) Decreased hemoglobin level
b) Increased white blood cell count
c) Elevated blood urea nitrogen (BUN)
d) Decreased oxygen saturation
d) Decreased oxygen saturation
Rationale: Decreased oxygen saturation is the most concerning finding in a child with severe RSV infection, indicating hypoxia and potential respiratory failure.
Which of the following is the most appropriate nursing diagnosis for an infant with severe RSV bronchiolitis and hypoxemia?
a) Impaired Gas Exchange related to alveolar hypoventilation and airway obstruction
b) Fluid Volume Excess related to pulmonary edema
c) Risk for Infection related to impaired immune system
d) Anxiety related to hospitalization
a) Impaired Gas Exchange related to alveolar hypoventilation and airway obstruction
Rationale: RSV bronchiolitis leads to alveolar hypoventilation and airway obstruction, which causes impaired gas exchange and hypoxemia, a critical nursing diagnosis for this condition.
The nurse is educating the parents of a preterm infant who is receiving palivizumab. Which statement by the parent indicates the need for further education?
a) “Palivizumab will help protect my baby from severe RSV infection.”
b) “My baby should still receive all regular vaccinations even while on palivizumab.”
c) “We will continue to monitor for RSV symptoms even though my baby is receiving palivizumab.”
d) “Palivizumab should
be given once a year during the RSV season.”
d) “Palivizumab should be given once a year during the RSV season.”
Rationale: Palivizumab is given monthly for 5 months during the RSV season, not just once a year, to help protect high-risk infants from severe RSV infection.
A nurse is caring for a child with RSV bronchiolitis and dehydration. Which of the following interventions is most appropriate?
a) Encourage the child to drink small amounts of clear fluids frequently
b) Administer IV fluids and restrict oral intake
c) Offer a high-sugar beverage to help with fluid retention
d) Restrict fluids to prevent fluid overload
a) Encourage the child to drink small amounts of clear fluids frequently
Rationale: Encouraging the child to drink small amounts of fluids frequently is the most appropriate intervention for managing dehydration in a child with RSV, ensuring proper hydration while not overloading the system.
Which of the following is an important component of home care education for parents of an infant with mild RSV?
a) “You should start antibiotics immediately if your baby develops a fever.”
b) “Administer nebulized albuterol as needed for wheezing.”
c) “Suction the nasal passages before feeding to make it easier for your baby to eat.”
d) “Keep your baby isolated from all other children for the next few months.”
c) “Suction the nasal passages before feeding to make it easier for your baby to eat.”
Rationale: Nasal suctioning before feeding helps clear mucus and makes it easier for the infant to eat and breathe, a key component of supportive care at home for RSV.
A nurse is caring for a child with RSV who is receiving humidified oxygen. The nurse notes that the child’s oxygen saturation is 90%. What is the nurse’s next best action?
a) Increase the flow rate of the oxygen
b) Reposition the child and reassess oxygen saturation
c) Notify the healthcare provider immediately
d) Document the findings and continue to monitor
b) Reposition the child and reassess oxygen saturation
Rationale: Repositioning the child may help improve oxygenation by facilitating better lung expansion. If the oxygen saturation remains low after repositioning, further interventions may be necessary.
A nurse is caring for a 6-month-old infant hospitalized with RSV bronchiolitis. The nurse notices that the infant’s oxygen saturation is 88%, and the infant is showing signs of respiratory distress such as grunting, tachypnea, and nasal flaring. Which action should the nurse take first?
A. Administer a bronchodilator
B. Place the infant in a prone position
C. Notify the physician of the changes in respiratory status
D. Increase the oxygen flow and apply a nasal cannula
C. Notify the physician of the changes in respiratory status
Rationale: Respiratory distress, decreased oxygen saturation, and other signs of worsening respiratory status in an infant with RSV require immediate notification of the physician to intervene and prevent respiratory failure.
A nurse is performing a psychosocial assessment on the parents of a 3-month-old infant with bronchiolitis due to RSV. Which of the following is the best approach to address the parents’ potential anxiety?
A. Provide reassurance that the infant will recover quickly
B. Educate the parents about RSV and its management plan
C. Encourage the parents to leave the hospital to reduce their stress
D. Avoid discussing the severity of the illness to prevent increasing anxiety
B. Educate the parents about RSV and its management plan
Rationale: Educating parents helps to reduce anxiety by providing them with a clear understanding of the illness and the treatment plan.
Which of the following nursing diagnoses is most appropriate for a child with RSV bronchiolitis who is having difficulty breathing due to increased airway secretions?
A. Impaired Gas Exchange related to airway obstruction
B. Activity Intolerance related to fever and dehydration
C. Ineffective Airway Clearance related to increased airway secretions
D. Risk for Injury related to decreased mental status
C. Ineffective Airway Clearance related to increased airway secretions
Rationale: RSV bronchiolitis leads to airway obstruction from excessive secretions, making Ineffective Airway Clearance an appropriate nursing diagnosis.
A nurse is caring for an infant with severe RSV bronchiolitis who is requiring supplemental oxygen. Which of the following interventions will best promote oxygen intake in the infant?
A. Administer IV fluids to hydrate the child
B. Elevate the head of the bed to reduce the risk of aspiration
C. Suction the infant’s mouth to remove secretions
D. Use a bulb syringe and saline nose drops to clear the nasal passages
D. Use a bulb syringe and saline nose drops to clear the nasal passages
Rationale: Clearing the nasal passages is important to ensure the infant can breathe freely and receive oxygen effectively.
A nurse is monitoring a hospitalized child with RSV bronchiolitis. The child’s oxygen saturation is 89% despite receiving humidified oxygen. The child is also exhibiting signs of central cyanosis and decreased mental status. Which of the following is the most appropriate intervention?
A. Increase the oxygen flow and prepare for intubation
B. Administer a bronchodilator and reassess after 30 minutes
C. Offer fluids and monitor urine output
D. Notify the physician immediately for further assessment and intervention
D. Notify the physician immediately for further assessment and intervention
Rationale: The signs of worsening respiratory status, including hypoxia, cyanosis, and decreased mental status, require immediate physician intervention.
The nurse is providing education to the parents of a 9-month-old infant who has been diagnosed with RSV. Which of the following statements should the nurse include in the teaching?
A. “Most children with RSV require antibiotics to treat the infection.”
B. “RSV bronchiolitis typically resolves within 5 to 7 days.”
C. “It is important to give the child large volumes of fluids to prevent dehydration.”
D. “There is a vaccine available to prevent RSV bronchiolitis in all infants.”
B. “RSV bronchiolitis typically resolves within 5 to 7 days.”
Rationale: RSV bronchiolitis typically resolves within 5 to 7 days with supportive care, and antibiotics are not recommended unless a bacterial infection is present.
A nurse is assessing a child with community-acquired pneumonia (CAP) for hydration status. Which of the following findings would be most concerning in this child?
A. Dry mucous membranes and decreased urine output
B. Increased appetite and weight gain
C. Clear, pale urine and moist mucous membranes
D. Mild edema in the lower extremities
A. Dry mucous membranes and decreased urine output
Rationale: Dry mucous membranes and decreased urine output are signs of dehydration, which is a concern for children with pneumonia, as it can lead to further complications and poor recovery.
A child with community-acquired pneumonia (CAP) is hospitalized and the nurse is monitoring for signs of worsening condition. Which of the following findings should prompt immediate intervention?
A. Decreased fever after 24 hours of antibiotic therapy
B. Mild abdominal pain and general irritability
C. Increased energy and interest in playing
D. Refusal to take fluids and increased breathing difficulty
D. Refusal to take fluids and increased breathing difficulty
Rationale: Refusal to take fluids and increased difficulty breathing are signs of worsening pneumonia and indicate the need for immediate intervention to prevent further complications.
A nurse is educating a parent on how to prevent the spread of pneumonia in the household. Which of the following statements by the parent indicates an accurate understanding of the preventive measures for pneumonia?
A. “I should wait until my child recovers fully before seeking vaccination for Haemophilus influenzae type B (Hib).”
B. “The 23-valent pneumococcal vaccine is recommended for my child because of their asthma.”
C. “I should make sure my child receives the pneumococcal conjugate (PCV13) vaccine.”
D. “There is no need to follow up with the pediatrician about vaccines once they are given.”
C. “I should make sure my child receives the pneumococcal conjugate (PCV13) vaccine.”
Rationale: The PCV13 vaccine is recommended to prevent some causes of pneumonia in children. The Hib and 23-valent pneumococcal vaccines are also important for specific groups but are typically recommended for older children or those with certain health conditions.
A child with community-acquired pneumonia (CAP) is hospitalized, and the physician prescribes acetaminophen for pain management and temperature control. What is the most important consideration when administering acetaminophen to this child?
A. Ensure the child receives the medication every 4 hours regardless of temperature
B. Administer the medication with food to prevent gastric irritation
C. Monitor the child for signs of hepatotoxicity, especially in those with preexisting liver conditions
D. Avoid giving the medication if the child is experiencing dehydration
C. Monitor the child for signs of hepatotoxicity, especially in those with preexisting liver conditions
Rationale: Acetaminophen can cause liver damage, especially with overuse or in children with existing liver conditions. Monitoring for signs of hepatotoxicity is crucial to ensure safe administration.
A nurse is educating the parents of a child with community-acquired pneumonia (CAP) on home management. Which of the following statements by the parent indicates the need for further education regarding the administration of antibiotics?
A. “I will continue giving the antibiotics until they are gone, even if my child starts feeling better.”
B. “I should stop the antibiotics if my child develops a rash.”
C. “I will call the doctor if my child refuses fluids or is having more trouble breathing.”
D. “I will monitor my child’s temperature and give fever-reducing medicine as prescribed.”
B. “I should stop the antibiotics if my child develops a rash.”
Rationale: A rash can be a sign of an allergic reaction to antibiotics, and parents should notify the healthcare provider rather than stopping the antibiotics themselves. It is important to complete the full course of antibiotics as prescribed.
A child with community-acquired pneumonia (CAP) is hospitalized. The nurse is assessing the child’s respiratory status. Which of the following assessments is most important for detecting worsening respiratory distress in this child?
A. Temperature and heart rate
B. Respiratory rate and pulse oximetry readings
C. Pain level with coughing and color of mucous membranes
D. Urine output and gastrointestinal symptoms
B. Respiratory rate and pulse oximetry readings
Rationale: Respiratory rate and oxygen saturation are critical indicators of the child’s respiratory status and can help detect worsening respiratory distress or inadequate oxygenation.
A child is admitted with pneumonia following a recent episode of RSV infection. The physician prescribes antiviral therapy. Which of the following is most likely the goal of antiviral therapy in this case?
A. To cure the pneumonia caused by the RSV infection
B. To improve the child’s appetite and feeding tolerance
C. To increase immune function and prevent further viral replication
D. To reduce the duration of symptoms and prevent secondary bacterial infection
D. To reduce the duration of symptoms and prevent secondary bacterial infection
Rationale: Antiviral therapy for RSV pneumonia aims to reduce symptom duration and lower the risk of secondary bacterial infections, rather than completely cure the infection.
A 5-year-old child with suspected bacterial pneumonia presents with increased work of breathing, fever, and poor appetite. The child is also showing signs of restlessness. Based on the nurse’s assessment, which of the following actions should be prioritized?
A. Administer an antipyretic to control fever
B. Provide oral fluids and encourage hydration
C. Perform a complete blood count to assess for infection
D. Initiate oxygen therapy to improve oxygenation
D. Initiate oxygen therapy to improve oxygenation
Rationale: The child’s increased work of breathing and restlessness are indicative of respiratory distress, requiring immediate intervention with oxygen therapy to maintain adequate oxygen saturation.
A nurse is caring for a child with pneumonia who has been prescribed high-dose amoxicillin for 5 days. The nurse educates the parents on the treatment plan. Which of the following statements by the parents indicates the need for further teaching?
A. “We should finish the entire course of antibiotics even if our child starts feeling better.”
B. “I should bring my child back for a follow-up visit after 2 days.”
C. “We will watch for any signs of a rash or allergic reaction.”
D. “I should call the doctor if my child’s fever doesn’t improve after 48 hours.”
B. “I should bring my child back for a follow-up visit after 2 days.”
Rationale: Routine follow-up after 2 days is not typically required for uncomplicated bacterial pneumonia. Parents should call the doctor if the child’s condition worsens or if fever persists.
A 6-year-old child presents with fever, crackles, and a productive cough. The child has a history of upper respiratory infection and now exhibits tachypnea and chest pain. Based on these symptoms, which of the following is most likely the cause of the pneumonia?
A. RSV (Respiratory Syncytial Virus)
B. Staphylococcus aureus
C. Mycoplasma pneumoniae
D. Parainfluenza virus
C. Mycoplasma pneumoniae
Rationale: Mycoplasmal pneumonia is more common in children aged 5 years and older, and it is often preceded by an upper respiratory infection. It is also associated with a dry cough and chest pain.
A 4-year-old child is hospitalized for severe community-acquired pneumonia (CAP) with a suspected bacterial etiology. The physician orders a chest radiograph and blood cultures. Which of the following findings is most likely associated with bacterial pneumonia?
A. Scattered patchy infiltrates in both lungs
B. Enlarged lymph nodes and air trapping
C. Hyperinflation of the lungs and wheezing
D. A localized consolidation in one lung lobe
D. A localized consolidation in one lung lobe
Rationale: Bacterial pneumonia often leads to a unilateral lobar pneumonia pattern, which is typically characterized by a localized consolidation in one lung lobe.
A 3-year-old child presents with a barking cough, hoarseness, and inspiratory stridor. Which of the following croup syndromes is most likely responsible for these symptoms?
A. Acute spasmodic laryngitis
B. Epiglottitis
C. Bacterial tracheitis
D. Laryngotracheobronchitis (LTB)
D. Laryngotracheobronchitis (LTB)
Rationale: Laryngotracheobronchitis (LTB) is the most common croup syndrome and presents with the characteristic barking cough, hoarseness, and inspiratory stridor. It is often viral in nature and affects young children.
A nurse is caring for a child with acute spasmodic laryngitis (spasmodic croup). Which of the following nursing interventions would be most appropriate to manage the child’s airway?
A. Administer antibiotics as prescribed
B. Provide humidified oxygen and encourage fluid intake
C. Perform chest physiotherapy to clear secretions
D. Intubate the child immediately for airway protection
B. Provide humidified oxygen and encourage fluid intake
Rationale: Acute spasmodic laryngitis is typically managed with supportive care such as humidified oxygen to ease breathing and encouraging fluids to prevent dehydration. Antibiotics are not indicated for viral infections, and intubation is not typically required unless respiratory distress is severe.
A 2-year-old child presents with a fever, inspiratory stridor, and a high-pitched, musical cough. The child’s symptoms worsen at night. Which of the following conditions is most likely causing these symptoms?
A. Epiglottitis
B. Acute spasmodic laryngitis
C. Bacterial tracheitis
D. Laryngotracheobronchitis (LTB)
B. Acute spasmodic laryngitis
Rationale: Acute spasmodic laryngitis is characterized by sudden onset of symptoms, often at night, and is typically marked by inspiratory stridor, a barking cough, and hoarseness. This condition is commonly viral and resolves with supportive care.
A nurse is educating the parents of a child who was recently vaccinated with the Haemophilus influenzae type B (Hib) vaccine. Which of the following conditions would the nurse inform the parents the vaccine helps prevent?
A. Epiglottitis
B. Acute spasmodic laryngitis
C. Laryngotracheobronchitis (LTB)
D. Bacterial tracheitis
A. Epiglottitis
Rationale: The Hib vaccine is effective in preventing epiglottitis, a serious bacterial infection of the epiglottis that used to be common before the widespread use of the vaccine. Epiglottitis is now rare in the United States due to the vaccine.
A nurse is caring for a child with bacterial tracheitis. Which of the following signs or symptoms would most likely indicate a worsening of the child’s condition?
A. A gradual decrease in fever and improvement in stridor
B. The appearance of a persistent barking cough and hoarseness
C. Increased difficulty in breathing and a rise in fever despite antibiotics
D. Increased irritability but no significant change in respiratory status
C. Increased difficulty in breathing and a rise in fever despite antibiotics
Rationale: Bacterial tracheitis is a serious condition that often worsens despite initial antibiotic treatment. Increased difficulty breathing and a persistent high fever are signs that the infection is not responding to treatment and may require more aggressive interventions.
A 5-year-old child presents with a sudden onset of a barking cough, mild respiratory distress, and a low-grade fever. The child’s symptoms improve within 48 hours. Which condition is most likely responsible for these symptoms?
A. Laryngotracheobronchitis (LTB)
B. Acute spasmodic laryngitis (spasmodic croup)
C. Bacterial tracheitis
D. Epiglottitis
C. Bacterial tracheitis
Rationale: Acute spasmodic laryngitis typically presents with a sudden onset of symptoms, such as a barking cough and mild respiratory distress, that resolves within 24 to 48 hours. This condition is usually recurrent and often related to viral infections or allergies.
A 2-year-old child with a fever of 39.5°C (103.1°F) develops a brassy cough, inspiratory stridor, and increasing respiratory distress. Which condition is the child most likely suffering from?
A. Laryngotracheobronchitis (LTB)
B. Acute spasmodic laryngitis (spasmodic croup)
C. Bacterial tracheitis
D. Epiglottitis
A. Laryngotracheobronchitis (LTB)
Rationale: LTB often presents with a gradual onset of symptoms such as a viral croupy cough, high fever, and inspiratory stridor. It can progress to respiratory distress and requires close observation.
Which of the following treatments is most appropriate for a child with bacterial tracheitis?
A. Oral dexamethasone and nebulized epinephrine
B. Immediate endotracheal intubation and intravenous antibiotics
C. Oral antibiotics and supportive care at home
D. Intravenous fluids and oxygen therapy
B. Immediate endotracheal intubation and intravenous antibiotics
Rationale: Bacterial tracheitis is a serious condition that may require endotracheal intubation to protect the airway and intravenous antibiotics to treat the infection. The condition is progressive and can be life-threatening.
A 4-year-old child with a fever of 40.2°C (104.4°F), drooling, and difficulty swallowing is diagnosed with epiglottitis. Which of the following nursing interventions should be prioritized?
A. Administer oral dexamethasone and nebulized epinephrine
B. Encourage oral fluid intake to prevent dehydration
C. Prepare for the child to undergo chest physiotherapy
D. Ensure the child remains in an upright position to facilitate breathing
D. Ensure the child remains in an upright position to facilitate breathing
Rationale: In epiglottitis, the child should be kept in an upright position with the neck extended to help maintain the airway. Intubation may be necessary to prevent airway obstruction. The condition requires immediate intervention and close monitoring.
A 3-year-old child is diagnosed with laryngotracheobronchitis (LTB) and is being treated with nebulized epinephrine. Which of the following symptoms would indicate a need for further intervention?
A. Decrease in fever and improvement in stridor
B. Persistent tachypnea and retractions
C. Improvement in the cough and overall comfort
D. Absence of drooling and difficulty swallowing
B. Persistent tachypnea and retractions
Rationale: Persistent tachypnea and retractions may indicate worsening respiratory distress or the development of airway obstruction, necessitating further medical intervention.
Which of the following is the most common causative organism for epiglottitis?
A. Staphylococcus aureus
B. Group A beta-hemolytic streptococcus
C. Haemophilus influenzae type B
D. Mycoplasma pneumoniae
C. Haemophilus influenzae type B
Rationale: Haemophilus influenzae type B is the primary causative organism for epiglottitis, but vaccination has made this condition less common in the United States.
A nurse is caring for a child with acute spasmodic laryngitis. Which of the following interventions is most likely to alleviate the child’s symptoms?
A. Administering oral dexamethasone and nebulized epinephrine
B. Encouraging the child to lie flat to ease breathing
C. Offering cool mist humidification and hydration
D. Administering high-dose antibiotics
C. Offering cool mist humidification and hydration
Rationale: Acute spasmodic laryngitis is typically managed with supportive care such as cool mist humidification and ensuring adequate hydration. This helps reduce inflammation and improve breathing.
A nurse is caring for a child with bacterial tracheitis. The child’s condition is not improving despite treatment for LTB. Which of the following is the next step in management?
A. Begin oral antibiotics
B. Continue nebulized epinephrine therapy
C. Discharge the child with oral steroids
D. Initiate blood cultures and endotracheal intubation
D. Initiate blood cultures and endotracheal intubation
Rationale: Bacterial tracheitis may present after an initial viral LTB infection, requiring more aggressive treatment, including blood cultures and endotracheal intubation to protect the airway. This condition can worsen rapidly and requires close monitoring.
Which of the following clinical manifestations would most likely be seen in a child with epiglottitis?
A. Barking cough and low-grade fever
B. Inspiratory stridor and mild respiratory distress
C. Drooling, dysphagia, and high fever
D. Cough, rhinorrhea, and sore throat
C. Drooling, dysphagia, and high fever
Rationale: Epiglottitis typically presents with a high fever, drooling, difficulty swallowing (dysphagia), and a preference for an upright position. These symptoms indicate significant airway obstruction, making this a medical emergency.
A nurse is educating parents about managing acute spasmodic laryngitis at home. Which of the following instructions is most appropriate?
A. “If the child’s breathing becomes labored, bring the child to the emergency department immediately.”
B. “You can give ibuprofen for the fever, but avoid using a humidifier in the child’s room.”
C. “Monitor the child for stridor and increased respiratory distress; if symptoms worsen, administer antibiotics.”
D. “It is safe to allow the child to sleep in a lying position to reduce discomfort.”
A. “If the child’s breathing becomes labored, bring the child to the emergency department immediately.”
Rationale: Parents should monitor the child for worsening symptoms such as labored breathing and seek emergency care if these occur. Humidifiers may help, and antibiotics are not indicated for this viral condition.
A nurse is preparing to administer nebulized epinephrine to a child with laryngotracheobronchitis (LTB). Which of the following should the nurse monitor most closely during this treatment?
A. Blood pressure
B. Oxygen saturation levels
C. Temperature
D. Heart rate
D. Heart rate
Rationale: Nebulized epinephrine can cause tachycardia as a side effect, so the nurse should closely monitor the child’s heart rate during treatment.
Which of the following is a key characteristic that differentiates bacterial tracheitis from viral laryngotracheobronchitis (LTB)?
A. Presence of a “barking” cough
B. Gradual onset of symptoms
C. High fever with purulent secretions
D. Improvement with nebulized epinephrine
C. High fever with purulent secretions
Rationale: Bacterial tracheitis often presents with a high fever, purulent secretions, and a more severe clinical course compared to LTB, which typically presents with a viral croupy cough and responds to nebulized epinephrine.
A 3-year-old child with croup syndrome is admitted to the hospital. The nurse is monitoring the child’s respiratory status. Which of the following findings would indicate the need for immediate intervention?
A. Increase in retractions and use of accessory muscles
B. Persistent barking cough with low-grade fever
C. Child’s preference to sit upright with neck extended
D. Audible stridor with slight improvement in respiratory effort
A. Increase in retractions and use of accessory muscles
Rationale: An increase in retractions and the use of accessory muscles suggests worsening respiratory distress and the need for immediate intervention. The nurse should monitor the child closely for further signs of airway obstruction.
A nurse is assessing a child with croup syndrome. Which of the following findings would be the most concerning?
A. Decreased intensity of stridor and retractions
B. Noisy breathing with coarse breath sounds
C. Increased respiratory rate and heart rate
D. Diminished breath sounds with decreasing responsiveness
D. Diminished breath sounds with decreasing responsiveness
Rationale: Diminished breath sounds and decreased responsiveness indicate a worsening respiratory condition, potentially due to hypoxemia, and require immediate medical attention to prevent airway obstruction.
A 4-year-old child with bacterial tracheitis is being managed in the PICU. Which intervention should the nurse prioritize?
A. Administer oral rehydration fluids
B. Perform frequent suctioning to clear thick tracheal secretions
C. Encourage the child to drink fruit-flavored drinks
D. Administer nebulized epinephrine
B. Perform frequent suctioning to clear thick tracheal secretions
Rationale: Bacterial tracheitis involves thick tracheal secretions that can obstruct the airway, so frequent suctioning is essential to maintain airway patency and prevent respiratory distress.
A nurse is caring for a child with croup syndrome who is experiencing respiratory distress. Which action should the nurse take first?
A. Ensure that resuscitation equipment and an intubation tray are available
B. Administer oxygen therapy
C. Encourage the child to drink fluids
D. Provide a cool mist humidifier
A. Ensure that resuscitation equipment and an intubation tray are available
Rationale: Ensuring that resuscitation equipment and an intubation tray are available is the first priority to prepare for potential respiratory deterioration, especially in children with severe croup syndrome.
A nurse is educating parents of a child with croup syndrome about fluid and nutritional management. Which of the following statements is most appropriate?
A. “Offer carbonated, acidic drinks to help with hydration.”
B. “Encourage the child to eat large meals to ensure adequate nutrition.”
C. “Offer cool, noncarbonated, nonacidic drinks such as oral rehydration fluids.”
D. “Allow the child to eat only popsicles for the next 24 hours.”
C. “Offer cool, noncarbonated, nonacidic drinks such as oral rehydration fluids.”
Rationale: Cool, noncarbonated, nonacidic drinks, such as oral rehydration fluids, help maintain hydration and provide essential calories without irritating the throat or exacerbating respiratory distress.
A 2-year-old child with croup syndrome is becoming increasingly distressed. The nurse should prioritize which of the following actions?
A. Perform venipuncture to assess fluid status
B. Provide humidified oxygen to relieve respiratory distress
C. Administer oral fluids to encourage hydration
D. Encourage the child to lie flat to rest
B. Provide humidified oxygen to relieve respiratory distress
Rationale: Humidified oxygen helps ease respiratory distress by moisturizing the airway, which is important in the management of croup syndrome.
A nurse is caring for a child with croup syndrome who is showing signs of respiratory fatigue. What is the most important assessment to perform next?
A. Assess the child’s level of consciousness
B. Measure the child’s blood pressure
C. Monitor the child’s intake and output
D. Auscultate for bowel sounds
A. Assess the child’s level of consciousness
Rationale: Respiratory fatigue can lead to hypoxemia, which may cause a decrease in the child’s level of consciousness. It is crucial to assess this to prevent further deterioration.
A nurse is caring for a child with croup syndrome who is crying during an IV insertion. Which of the following actions should the nurse take?
A. Perform the venipuncture immediately to avoid delaying treatment
B. Provide sedation to calm the child before the procedure
C. Encourage the child to drink fluids during the procedure
D. Postpone the procedure until the child’s airway is secure
D. Postpone the procedure until the child’s airway is secure
Rationale: Crying can exacerbate respiratory distress and potentially cause airway obstruction, particularly in children with croup syndrome. Procedures like venipuncture should be postponed until the child’s airway is secure.
Which of the following is most important for a nurse to assess when a child with asthma presents to the emergency department with increased difficulty breathing?
A. Oxygen saturation levels
B. Last dose of a short-acting beta-agonist
C. Parent’s understanding of asthma management
D. Child’s current weight and growth pattern
A. Oxygen saturation levels
Rationale: Oxygen saturation levels are critical to assess in a child with asthma exacerbations to determine the severity of respiratory distress and guide further treatment.
A nurse is caring for a child with asthma who requires long-term medication management. Which of the following is the most common class of medication used for asthma maintenance?
A. Leukotriene receptor antagonists
B. Inhaled corticosteroids
C. Systemic corticosteroids
D. Anticholinergic agents
B. Inhaled corticosteroids
Rationale: Inhaled corticosteroids are the most commonly prescribed long-term medications for asthma, as they reduce inflammation in the airways and help prevent asthma attacks.
A nurse is teaching a parent about avoiding asthma triggers. Which of the following is an appropriate recommendation for a child with asthma who has seasonal allergies?
A. Keep windows open during peak pollen season
B. Encourage the child to play outside during high pollen count times
C. Avoid using any medications during allergy season
D. Use air conditioning to filter air indoors
D. Use air conditioning to filter air indoors
Rationale: Using air conditioning during peak pollen season can help filter allergens and provide relief from seasonal asthma triggers.
Which of the following treatments is considered effective for children aged 12 years and older with moderate to severe asthma?
A. Regular use of oral corticosteroids
B. Subcutaneous omalizumab (Xolair)
C. Daily use of short-acting beta-agonists
D. Continuous nebulized albuterol
B. Subcutaneous omalizumab (Xolair)
Rationale: Omalizumab is effective for treating moderate to severe asthma in children aged 12 and older by targeting the immune system’s IgE response.
A child with asthma is experiencing increased symptoms during the spring. The nurse suspects seasonal allergic asthma. Which of the following interventions would be most appropriate?
A. Administering oral corticosteroids
B. Instructing the family to use a humidifier indoors
C. Prescribing antihistamines and inhaled bronchodilators
D. Encouraging the child to engage in vigorous outdoor activities
C. Prescribing antihistamines and inhaled bronchodilators
Rationale: Seasonal allergic asthma can be treated with antihistamines to control allergic symptoms and bronchodilators to relieve airway constriction.
Which of the following is a primary goal of asthma action plans for children with asthma?
A. To prevent the need for hospitalization due to asthma attacks
B. To provide treatment for acute respiratory infections
C. To encourage the use of inhaled corticosteroids only during asthma exacerbations
D. To minimize the child’s exposure to physical activity
A. To prevent the need for hospitalization due to asthma attacks
Rationale: The primary goal of an asthma action plan is to prevent severe asthma attacks that may lead to hospitalization, ensuring that symptoms are managed appropriately through medication and lifestyle adjustments.
A nurse is teaching a parent about managing their child’s asthma symptoms. Which of the following statements indicates the need for further education?
A.“I should encourage my child to take their asthma medications every day, even when they feel fine.”
B. “If my child is having trouble breathing, I should use the rescue inhaler first, then the controller medications.”
C. “We should avoid known allergens and irritants to help prevent asthma attacks.”
D. “If my child’s asthma symptoms are controlled, I can stop using the maintenance inhaler.”
D. “If my child’s asthma symptoms are controlled, I can stop using the maintenance inhaler.”
Rationale: Maintenance inhalers should be used consistently even when asthma symptoms are controlled to prevent exacerbations. Stopping the medication without a doctor’s guidance can worsen symptoms.
Which of the following is most commonly a trigger for intermittent asthma?
A. Allergens such as mold and pollen
B. Viral respiratory infections
C. Environmental pollutants such as smoke
D. Exercise and physical activity
B. Viral respiratory infections
Rationale: Intermittent asthma is typically triggered by viral respiratory infections, and the asthma symptoms resolve after the infection subsides.
A child with asthma is prescribed omalizumab. Which of the following is the most important nursing consideration when administering this medication?
A. Monitor for signs of anaphylaxis after subcutaneous administration
B. Assess for systemic fungal infections
C. Encourage the child to drink fluids to reduce the risk of dehydration
D. Monitor for hypoglycemia
A. Monitor for signs of anaphylaxis after subcutaneous administration
Rationale: Omalizumab is administered subcutaneously, and a rare but serious side effect is anaphylaxis, so the nurse should monitor the child closely after administration.
A nurse is developing an asthma action plan for a child with persistent asthma. Which of the following is most important to include in the plan?
A. Encouraging the child to participate in sports
B. A regimen of daily maintenance medications
C. Use of rescue medications only during allergy season
D. Avoiding all physical activities to prevent exacerbations
B. A regimen of daily maintenance medications
Rationale: Persistent asthma requires ongoing treatment, and daily maintenance medications, such as inhaled corticosteroids or long-acting bronchodilators, are essential to manage symptoms and prevent exacerbations.
Which of the following is the primary characteristic of asthma?
A. Bronchial constriction, hyperresponsive airways, and airway inflammation
B. Decreased lung capacity and increased tidal volume
C. Pulmonary edema and increased alveolar ventilation
D. Chronic respiratory infections and reduced air exchange
A. Bronchial constriction, hyperresponsive airways, and airway inflammation
Rationale: Asthma is characterized by bronchial constriction, hyperresponsiveness of the airways, and airway inflammation, which lead to difficulty breathing and wheezing.
