Midterm ch 25

Question 1

A nurse is assessing a 2-year-old child who is admitted with dehydration following a gastrointestinal infection. Which of the following findings is most concerning?

A. Dry mouth and lips
B. Reduced urine output
C. Skin turgor returning to normal within 2 seconds
D. Restlessness and irritability

Answer 1

B. Reduced urine output

Rationale: Reduced urine output is a critical sign of dehydration, especially in children, and may indicate more severe dehydration and the need for immediate intervention.

Question 2

A 4-year-old child with moderate dehydration is being treated in the emergency department. Which of the following interventions is most appropriate for rehydrating the child?

A. Administering intravenous fluids rapidly without reassessing hydration status

B. Restricting oral fluids to prevent vomiting

C. Providing only plain water to rehydrate the child

D. Offering the child small sips of water or oral rehydration solution (ORS) frequently

Answer 2

D. Offering the child small sips of water or oral rehydration solution (ORS) frequently

Rationale: ORS is specifically designed to replace both water and electrolytes lost during dehydration, and frequent small sips are effective in rehydrating without overwhelming the child’s stomach.

Question 3

A nurse is caring for a 6-month-old infant diagnosed with dehydration from acute gastroenteritis. Which clinical sign would indicate that the infant is experiencing severe dehydration?

A. Decreased urinary output
B. Sunken fontanel
C. Mild irritability
D. Moist mucous membranes

Answer 3

B. Sunken fontanel

Rationale: A sunken fontanel is a classic sign of severe dehydration in infants and indicates a significant loss of fluid volume.

Question 4

A child with dehydration is being managed with oral rehydration therapy (ORT). Which of the following statements by the parent indicates the need for further teaching?

A. “I should give my child small amounts of oral rehydration solution every 10-15 minutes.”

B. “I can give my child an oral rehydration solution that contains electrolytes, such as Pedialyte.”

C. “If my child vomits, I should immediately give them more fluids.”

D. “I will monitor my child’s hydration status by checking their urine output.”

Answer 4

C. “If my child vomits, I should immediately give them more fluids.”

Rationale: If a child vomits after oral rehydration therapy, fluids should be withheld for 5-10 minutes, then given in small sips. Immediate re-administration could exacerbate vomiting and further dehydrate the child.

Question 5

A nurse is caring for a child with moderate dehydration. Which of the following clinical signs should the nurse monitor most closely to assess for worsening dehydration?

A. Respiratory rate and pattern
B. Blood pressure
C. Presence of a rash
D. Capillary refill time

Answer 5

D. Capillary refill time

Rationale: Capillary refill time is a reliable indicator of circulatory status and can provide early evidence of worsening dehydration. Prolonged capillary refill time suggests poor perfusion.

Question 6

A nurse is preparing to administer an intravenous (IV) fluid bolus to a child with severe dehydration. Which of the following is the priority nursing action before administering the IV fluids?

A. Ensure that the child has a patent IV line and appropriate fluid type
B. Obtain a urine sample to assess kidney function
C. Monitor the child’s weight
D. Document the child’s vital signs and hydration status

Answer 6

A. Ensure that the child has a patent IV line and appropriate fluid type

Rationale: Ensuring that the child has a patent IV line and receiving the correct type of fluid is the priority to ensure safe and effective rehydration before administering IV fluids.

Question 7

A 3-year-old child is admitted with dehydration and vomiting. The nurse suspects that the child is at risk for hypokalemia due to the loss of potassium from vomiting. Which of the following interventions should the nurse anticipate?

A. Administering potassium-rich foods, such as bananas
B. Administering intravenous fluids with potassium supplementation
C. Encouraging the child to drink fruit juice
D. Monitoring the child’s blood glucose levels

Answer 7

B. Administering intravenous fluids with potassium supplementation

Rationale: Hypokalemia is a common electrolyte imbalance associated with dehydration and vomiting. Potassium supplementation is needed to prevent complications, and it is often given with IV fluids in cases of severe dehydration.

Question 8

A nurse is assessing a 10-month-old infant for signs of dehydration. Which of the following findings would be most concerning for the nurse?

A. Slightly dry skin and a slightly decreased appetite
B. Slightly increased heart rate and fever
C. A 10% decrease in body weight and a weak cry
D. Normal skin turgor and moist mucous membranes

Answer 8

C. A 10% decrease in body weight and a weak cry

Rationale: A 10% decrease in body weight is a critical sign of dehydration in infants, and a weak cry indicates poor hydration status, which requires urgent intervention.

Question 9

A nurse is caring for a child with dehydration and is providing parental education. Which of the following instructions is most appropriate?

A. “You can give your child water and juice to rehydrate them.”
B. “Offer your child small amounts of an oral rehydration solution (ORS) frequently.”
C. “Only offer your child clear fluids such as soda or clear broth.”
D. “Avoid offering your child any fluids until they are no longer vomiting.”

Answer 9

B. “Offer your child small amounts of an oral rehydration solution (ORS) frequently.”

Rationale: ORS is designed to replace lost fluids and electrolytes and is the preferred method of rehydration. Small amounts should be given frequently to avoid overwhelming the stomach.

Question 10

A nurse is caring for a 5-year-old child with dehydration secondary to diarrhea. Which of the following is the priority nursing intervention?

A. Administering antibiotics to prevent infection
B. Starting an IV line for rapid fluid resuscitation
C. Encouraging the child to eat solid foods as soon as possible
D. Monitoring for signs of electrolyte imbalances

Answer 10

D. Monitoring for signs of electrolyte imbalances

Rationale: Dehydration secondary to diarrhea can lead to significant electrolyte imbalances, such as hypokalemia and hyponatremia. Monitoring for these imbalances is a priority before other interventions.

Question 11

A nurse is caring for a 2-year-old child diagnosed with gastroenteritis. The child has been experiencing frequent watery stools and mild irritability. Which of the following interventions should the nurse implement first?

A. Administer intravenous fluids to correct fluid imbalance
B. Start oral rehydration therapy (ORT)
C. Provide an antiemetic medication
D. Administer an antidiarrheal medication

Answer 11

B. Start oral rehydration therapy (ORT)

Rationale: For mild to moderate dehydration, oral rehydration therapy is the first line of treatment to replace lost fluids and electrolytes. IV fluids are reserved for severe dehydration.

Question 12

A nurse is educating the parents of a child with gastroenteritis about the importance of rehydration. Which statement by the parent indicates the need for further teaching?

A. “I will offer my child small sips of oral rehydration solution every 10-15 minutes.”

B. “I should avoid giving my child carbonated beverages and fruit juices.”

C. “I can give my child regular milk to drink while they recover.”

D. “I will monitor my child’s urine output to ensure they are staying hydrated.”

Answer 12

C. “I can give my child regular milk to drink while they recover.”

Rationale: Regular milk should not be given during gastroenteritis as it can worsen diarrhea. Oral rehydration solutions are preferred, and the child should be given clear liquids initially.

Question 13

A 6-month-old infant is hospitalized for severe dehydration due to gastroenteritis. Which finding is most concerning and indicates the need for urgent intervention?

A. Dry mouth and sunken fontanel
B. Mild irritability and increased thirst
C. Normal urine output and alertness
D. Slightly increased heart rate and low-grade fever

Answer 13

A. Dry mouth and sunken fontanel

Rationale: A sunken fontanel and dry mouth are signs of severe dehydration in infants. Immediate intervention is needed to restore hydration.

Question 14

A child with gastroenteritis is receiving intravenous fluids for severe dehydration. The nurse notes that the child’s urine output has decreased significantly over the past few hours. What is the priority nursing action?

A. Increase the rate of IV fluids
B. Assess vital signs and reassess hydration status
C. Notify the healthcare provider to order an antibiotic
D. Administer a dose of diuretics to promote urine output

Answer 14

B. Assess vital signs and reassess hydration status

Rationale: Decreased urine output can indicate worsening dehydration or renal compromise. It is crucial to reassess the child’s hydration and monitor vital signs closely.

Question 15

A child with gastroenteritis is being treated with oral rehydration therapy (ORT). Which of the following should the nurse include in the plan of care?

A. Provide large amounts of water to the child to quickly rehydrate

B. Limit oral rehydration solution to 1-2 sips every hour

C. Encourage the child to drink small amounts of oral rehydration solution every 10-15 minutes

D. Withhold oral fluids until the child is no longer vomiting

Answer 15

C. Encourage the child to drink small amounts of oral rehydration solution every 10-15 minutes

Rationale: Small, frequent sips of oral rehydration solution help replace lost fluids and electrolytes without overwhelming the child’s stomach.

Question 16

A nurse is caring for a child with viral gastroenteritis. The child has had 5 episodes of vomiting and 6 watery stools within the past 24 hours. Which of the following clinical findings would suggest the child is at risk for hypovolemic shock?

A. Decreased heart rate and normal blood pressure
B. Decreased blood pressure and rapid, weak pulse
C. Increased urine output and irritability
D. Elevated temperature and warm, dry skin

Answer 16

B. Decreased blood pressure and rapid, weak pulse

Rationale: Decreased blood pressure and a rapid, weak pulse are signs of hypovolemic shock, which can occur if fluid and electrolyte losses from gastroenteritis are not addressed promptly.

Question 17

A nurse is caring for a child with gastroenteritis who is receiving oral rehydration therapy. Which of the following should the nurse avoid administering to the child?

A. Oral rehydration solution (ORS)
B. Clear liquids such as broth
C. Fruit juices such as apple juice
D. Small amounts of water

Answer 17

C. Fruit juices such as apple juice

Rationale: Fruit juices should be avoided in gastroenteritis because they can increase the osmotic load in the intestines, worsening diarrhea and abdominal discomfort.

Question 18

A nurse is explaining to the parents of a child with gastroenteritis that antimicrobial therapy may be prescribed if the diarrhea is caused by a bacterial infection. Which of the following would be an appropriate indication for antimicrobial therapy?

A. Watery diarrhea caused by rotavirus
B. Diarrhea accompanied by a fever over 100.4°F (38°C)
C. Diarrhea associated with lactose intolerance
D. Diarrhea caused by Escherichia coli infection

Answer 18

D. Diarrhea caused by Escherichia coli infection

Rationale: Antimicrobial therapy is indicated for bacterial infections such as those caused by Escherichia coli, but not for viral causes like rotavirus or lactose intolerance.

Question 19

A 4-year-old child is admitted with gastroenteritis. The child is experiencing mild dehydration and the nurse is planning to initiate oral rehydration therapy (ORT). Which of the following actions is appropriate for the nurse to take?

A. Administer large amounts of water immediately to rehydrate the child
B. Start the child on clear liquids and then advance to regular foods
C. Provide oral rehydration solution in small, frequent sips
D. Withhold all fluids until the child stops vomiting

Answer 19

C. Provide oral rehydration solution in small, frequent sips

Rationale: Oral rehydration solution should be given in small, frequent sips to replace fluids and electrolytes effectively without overwhelming the child’s stomach.

Question 20

A nurse is caring for an infant diagnosed with gastroenteritis. Which of the following findings is most suggestive of severe dehydration and requires immediate intervention?

A. The infant’s fontanel is sunken, and their skin is cool and clammy

B. The infant has a normal heart rate and normal skin turgor

C. The infant’s urine output is slightly decreased and they are slightly irritable

D. The infant is feeding normally and has moist mucous membranes

Answer 20

A. The infant’s fontanel is sunken, and their skin is cool and clammy

Rationale: A sunken fontanel and cool, clammy skin are signs of severe dehydration in infants and require immediate intervention to prevent further complications.

Question 21

A nurse is caring for a child with gastroenteritis and is monitoring the child’s stool. The nurse notes that the stool is watery and foul-smelling, and the child has a fever. What should the nurse do next?

A. Administer an antidiarrheal medication to reduce stool frequency
B. Isolate the child to prevent the spread of infection
C. Encourage the child to drink fruit juices to restore hydration
D. Administer intravenous fluids immediately

Answer 21

B. Isolate the child to prevent the spread of infection

Rationale: Isolation is important to prevent transmission of infectious agents, especially when the child has diarrhea and a fever. The stool’s appearance and the fever suggest an infectious etiology.

Question 22

Which of the following actions should the nurse take when assessing the child’s hydration status? (Select all that apply.)

A. Assess the child’s skin turgor

B. Weigh the child daily and compare to preadmission weight

C. Document the frequency and consistency of stools

D. Encourage the child to drink large amounts of water

E. Monitor the child’s mucous membranes for signs of dryness

Answer 22

A. Assess the child’s skin turgor

B. Weigh the child daily and compare to preadmission weight

C. Document the frequency and consistency of stools

E. Monitor the child’s mucous membranes for signs of dryness

Rationale: Assessing skin turgor, weighing the child daily, documenting stool characteristics, and monitoring mucous membranes are essential for evaluating hydration status. Encouraging large amounts of water is not appropriate for children with gastroenteritis, as it can exacerbate vomiting.

Question 23

A 4-year-old child with gastroenteritis has been vomiting and having diarrhea for 24 hours. The nurse observes that the child has dry mucous membranes, sunken eyes, and a rapid heart rate. What is the most likely cause of these symptoms?

A. An allergic reaction to food
B. Gastrointestinal bleeding
C. Acute appendicitis
D. Severe dehydration

Answer 23

D. Severe dehydration

Rationale: The dry mucous membranes, sunken eyes, and rapid heart rate are signs of severe dehydration, which can result from fluid losses due to vomiting and diarrhea.

Question 24

A nurse is caring for an infant with gastroenteritis and is planning to prevent skin breakdown. Which of the following actions should the nurse include in the care plan? (Select all that apply.)

A. Change the infant’s diaper every 2 hours
B. Apply A&D ointment with each diaper change
C. Use a mild soap to clean the diaper area after soiling
D. Leave the infant’s buttocks open to air several times a day
E. Allow the infant to wear underwear if tolerated

Answer 24

A. Change the infant’s diaper every 2 hours
B. Apply A&D ointment with each diaper change
C. Use a mild soap to clean the diaper area after soiling
D. Leave the infant’s buttocks open to air several times a day

Rationale: Frequent diaper changes, application of barrier ointment, and allowing the buttocks to air out are important in preventing and managing skin breakdown. Mild soap is appropriate for cleaning the area, and underwear should be avoided to reduce friction and moisture.

Question 25

A nurse is caring for a 2-year-old child who is being treated for gastroenteritis. The child has been vomiting and having diarrhea for the past 12 hours, and the nurse is concerned about dehydration. What should the nurse monitor to assess the child’s fluid status? A. Temperature and pulse rate B. Urine output and weight C. Respiratory rate and blood pressure D. Heart rate and oxygen saturation

Answer 25

B. Urine output and weight Rationale: Monitoring urine output and weight helps assess the child’s hydration status and fluid balance. A decrease in urine output and significant weight loss are key indicators of dehydration.

Question 26

A nurse is preparing to administer oral rehydration therapy (ORT) to a child with gastroenteritis. Which of the following is the most appropriate action for the nurse to take? A. Give the child large amounts of water all at once B. Encourage the child to drink fruit juice to restore electrolytes C. Offer the child small sips of oral rehydration solution every 10-15 minutes D. Withhold fluids until vomiting stops completely

Answer 26

C. Offer the child small sips of oral rehydration solution every 10-15 minutes Rationale: Offering small, frequent sips of oral rehydration solution helps to replace fluids and electrolytes without overwhelming the child’s stomach, especially when vomiting is present.

Question 27

A 5-year-old child presents to the emergency department with vomiting for the past 24 hours. The nurse observes that the child has dry mucous membranes, a rapid heart rate, and sunken eyes. What is the most appropriate initial intervention? A. Administer an antiemetic medication B. Start intravenous (IV) fluid resuscitation C. Provide oral rehydration solution D. Perform an abdominal ultrasound

Answer 27

B. Start intravenous (IV) fluid resuscitation Rationale: The child’s symptoms are indicative of dehydration, and IV fluid resuscitation is the most appropriate initial intervention to restore hydration and correct electrolyte imbalances. Oral rehydration may not be effective due to the vomiting.

Question 28

A nurse is caring for a child with vomiting secondary to gastroenteritis. Which of the following interventions is most appropriate for preventing further fluid and electrolyte imbalance? A. Offer small sips of clear fluids every 5 to 10 minutes B. Withhold all fluids for 12 hours to allow the gastrointestinal system to rest C. Encourage the child to drink large amounts of water quickly D. Administer antiemetic medications before offering fluids

Answer 28

A. Offer small sips of clear fluids every 5 to 10 minutes Rationale: Small, frequent sips of clear fluids help prevent dehydration while minimizing the risk of vomiting. Large amounts of fluid can overwhelm the stomach and lead to more vomiting.

Question 29

A nurse is caring for a child with vomiting and dehydration. The child is irritable and has decreased urine output. The nurse suspects the child is in the early stages of dehydration. What should the nurse assess next? A. Capillary refill and skin turgor B. Blood pressure and heart rate C. Weight and temperature D. Bowel sounds and abdominal girth

Answer 29

A. Capillary refill and skin turgor Rationale: Capillary refill and skin turgor are key indicators of hydration status. In early dehydration, these signs may be abnormal and help the nurse assess the severity of fluid loss.

Question 30

A 3-year-old child with vomiting and diarrhea has been unable to retain oral fluids for several hours. The healthcare provider prescribes intravenous fluids for rehydration. Which of the following fluids is most appropriate for initial rehydration? A. Dextrose 5% in water (D5W) B. Normal saline (0.9% NaCl) C. Hypertonic saline (3% NaCl) D. Lactated Ringer’s solution

Answer 30

D. Lactated Ringer’s solution Rationale: Lactated Ringer’s solution is the preferred IV fluid for rehydration in children with vomiting and diarrhea, as it contains electrolytes and helps to restore fluid and electrolyte balance. Normal saline could also be used in some cases, but Lactated Ringer’s is often preferred for rehydration.

Question 31

A nurse is educating the parents of a child who is experiencing vomiting due to gastroenteritis. Which of the following statements by the parents indicates a need for further education? A. “I should start giving my child small amounts of oral rehydration solution every 10 minutes.” B. “I should avoid giving my child sugary drinks like soda during this time.” C. “I will wait until my child is no longer vomiting before offering any fluids.” D. “I will notify the doctor if my child has a fever or the vomiting worsens.”

Answer 31

C. “I will wait until my child is no longer vomiting before offering any fluids.” Rationale: It is important to begin offering fluids as soon as vomiting decreases, even if the child has not fully stopped vomiting. Withholding fluids may worsen dehydration and slow recovery.

Question 32

A 2-year-old child with vomiting and dehydration is receiving intravenous fluids as prescribed. The nurse monitors the child for signs of overhydration. Which of the following findings would indicate fluid overload? A. Decreased urine output B. Increased heart rate C. Dry mucous membranes D. Edema and respiratory distress

Answer 32

D. Edema and respiratory distress Rationale: Edema and respiratory distress are signs of fluid overload. These symptoms may indicate that the child has received too much fluid too quickly, overwhelming the circulatory system.

Question 33

A 9-year-old child presents to the emergency department with right lower quadrant pain, fever, and nausea. The nurse suspects appendicitis. Which of the following signs is most indicative of a ruptured appendix? A. Decreased abdominal pain after the child moves B. Relief of pain with flexion of the legs C. Sudden, severe pain followed by a decrease in pain intensity D. Pain localized to the epigastric region

Answer 33

C. Sudden, severe pain followed by a decrease in pain intensity Rationale: A sudden relief of pain after intense abdominal pain is a classic sign of a ruptured appendix, as the rupture can temporarily reduce the pressure and pain. However, this can quickly be followed by the onset of peritonitis.

Question 34

A 10-year-old child is diagnosed with appendicitis. The nurse is preparing the child for surgery. Which of the following interventions is most important in the preoperative phase? A. Administering prescribed antibiotics B. Encouraging oral fluids to maintain hydration C. Performing an abdominal assessment for rebound tenderness D. Providing emotional support and reassurance

Answer 34

A. Administering prescribed antibiotics Rationale: Antibiotics are typically administered preoperatively to prevent infection, especially if there is a risk of perforation or peritonitis. Fluid intake and emotional support are also important but secondary to infection prevention.

Question 35

A child with appendicitis is admitted to the hospital for observation. Which of the following is the most critical nursing intervention during the acute phase of appendicitis? A. Monitoring for signs of peritonitis B. Administering pain medication as prescribed C. Encouraging the child to ambulate early D. Restricting oral intake until surgery

Answer 35

A. Monitoring for signs of peritonitis Rationale: Peritonitis is a life-threatening complication of appendicitis, particularly if the appendix ruptures. Monitoring for symptoms such as fever, tachycardia, and rigid abdomen is critical in the acute phase.

Question 36

The nurse is caring for a 6-year-old child who had an appendectomy 24 hours ago. The child is complaining of severe abdominal pain and has a distended abdomen. Which of the following actions should the nurse take first? A. Administer the prescribed pain medication B. Check the child’s vital signs C. Assess the child’s incision site for signs of infection D. Notify the healthcare provider

Answer 36

B. Check the child’s vital signs Rationale: Abdominal distention and severe pain may indicate complications such as infection, bowel obstruction, or peritonitis. Checking vital signs, including temperature and blood pressure, is critical to assess for signs of infection or sepsis.

Question 37

A nurse is educating the parents of a child recovering from appendectomy about signs of infection. Which of the following should the nurse include in the teaching? A. “Expect some swelling around the incision site, which should resolve in a few days.” B. “The child may experience some mild nausea for up to two weeks after surgery.” C. “Contact the doctor immediately if you notice a fever over 100.4°F (38°C).” D. “Pain should improve after 24 hours, but if it worsens, it is likely normal."

Answer 37

C. “Contact the doctor immediately if you notice a fever over 100.4°F (38°C).” Rationale: A fever over 100.4°F may indicate infection, such as wound infection or peritonitis, and requires immediate medical attention. Mild nausea and temporary swelling are not uncommon after surgery.

Question 38

A 12-year-old child is admitted with suspected appendicitis. The nurse performs an assessment and notes tenderness at McBurney’s point. Which of the following is the nurse’s most appropriate action? A. Administer pain medication and notify the healthcare provider B. Assess for rebound tenderness and monitor for fever C. Encourage the child to ambulate to help relieve discomfort D. Immediately prepare the child for surgery

Answer 38

B. Assess for rebound tenderness and monitor for fever Rationale: McBurney’s point tenderness is a classic sign of appendicitis. Assessing for rebound tenderness and monitoring for fever helps evaluate the severity and progression of the condition before surgical intervention.

Question 39

A child with appendicitis undergoes a laparoscopic appendectomy. Which of the following is the most important post-operative nursing assessment? A. Assessing the child’s pain level and administering analgesics as prescribed B. Monitoring the child’s nutritional intake and bowel sounds C. Encouraging early ambulation to prevent deep vein thrombosis D. Checking for signs of surgical site infection and peritonitis

Answer 39

D. Checking for signs of surgical site infection and peritonitis Rationale: After surgery, it is crucial to monitor for complications such as infection or peritonitis. Monitoring for fever, abdominal rigidity, and tenderness helps identify these life-threatening conditions early.

Question 40

A child with appendicitis is being discharged after an appendectomy. Which of the following is the most important instruction for the nurse to give the parents at discharge? A. “Your child can return to school in 3 days as long as they feel better.” B. “If your child develops nausea or vomiting, contact the healthcare provider immediately.” C. “Ensure your child is eating a normal diet within 24 hours.” D. “Check the surgical site every day for swelling, redness, and drainage.”

Answer 40

B. “If your child develops nausea or vomiting, contact the healthcare provider immediately.” Rationale: Nausea or vomiting after appendectomy may indicate complications such as infection or bowel obstruction. Parents should contact the healthcare provider if these symptoms occur.

Question 41

A nurse is caring for a 7-year-old child with appendicitis who is awaiting surgery. The child is anxious about the procedure. Which of the following is the best way to address the child’s anxiety? A. Tell the child that the surgery will be quick and painless B. Provide a detailed explanation of the surgery and recovery process C. Offer a distraction such as a favorite toy or video during the wait D. Reassure the child that everything will be fine without further discussion

Answer 41

C. Offer a distraction such as a favorite toy or video during the wait Rationale: Providing a distraction helps reduce anxiety and keeps the child calm. Reassurance and distraction are more effective than focusing on the surgical procedure in a detailed manner.

Question 42

A 10-year-old child is being evaluated for suspected appendicitis. The nurse notes the child is guarding their abdomen and has difficulty moving. What should the nurse do next? A. Administer pain medication and allow the child to rest B. Encourage the child to drink fluids to prevent dehydration C. Palpate the abdomen further to assess for tenderness D. Prepare the child for an ultrasound or CT scan to confirm the diagnosis

Answer 42

D. Prepare the child for an ultrasound or CT scan to confirm the diagnosis Rationale: Guarding and difficulty moving are signs of severe abdominal pain, which is typical in appendicitis. The next step is to confirm the diagnosis using imaging studies such as an ultrasound or CT scan.

Question 43

Which of the following nursing interventions is most important for a child recovering from appendectomy to promote comfort and prevent complications? A. Encouraging the child to cough and deep breathe every hour B. Ensuring the child maintains a strict bed rest regimen C. Limiting fluid intake to prevent abdominal distention D. Encouraging the child to avoid movement to reduce abdominal pain

Answer 43

A. Encouraging the child to cough and deep breathe every hour Rationale: Encouraging coughing and deep breathing helps prevent atelectasis and promotes lung expansion. It is important for the child to move, as tolerated, to prevent complications such as pneumonia.

Question 44

A nurse is caring for a child with appendicitis who is undergoing surgery. Which of the following interventions is a priority immediately after surgery? A. Monitor for signs of infection at the surgical site B. Administer prescribed antibiotics to prevent infection C. Encourage the child to ambulate early D. Ensure the child is receiving adequate pain management

Answer 44

D. Ensure the child is receiving adequate pain management Rationale: Pain management is crucial after appendectomy to promote comfort and reduce stress on the child. Although other interventions are important, managing pain takes priority initially to help the child recover comfortably.

Question 45

A 10-year-old child with Crohn’s disease is experiencing frequent episodes of diarrhea and abdominal cramping. Which of the following interventions should the nurse prioritize to manage the child’s symptoms? A. Administering antidiarrheal medications as prescribed B. Encouraging high-fiber foods to promote bowel regularity C. Providing oral rehydration solutions to prevent dehydration D. Limiting fluid intake to decrease bowel movements

Answer 45

C. Providing oral rehydration solutions to prevent dehydration Rationale: Dehydration is a significant risk in children with Crohn’s disease due to frequent diarrhea. Oral rehydration solutions can help replace lost fluids and electrolytes. Antidiarrheals are typically avoided in Crohn’s disease because they can worsen inflammation.

Question 46

A nurse is teaching the parents of a child with Crohn’s disease about the importance of medication adherence. Which of the following statements by the parent indicates the need for further teaching? A. “I understand that corticosteroids are used to control inflammation.” B. “We should discontinue medications when the child feels better.” C. “Immunosuppressants are used to reduce immune system activity.” D. “The goal of treatment is to maintain remission and prevent flare-ups.”

Answer 46

B. “We should discontinue medications when the child feels better.” Rationale: Discontinuing medications without a healthcare provider’s guidance can lead to disease flare-ups. Medication adherence is important for maintaining remission and preventing relapses.

Question 47

A 12-year-old child with Crohn’s disease presents with significant weight loss and poor growth. Which of the following interventions should the nurse prioritize to address these concerns? A. Encourage the child to eat a low-fat, high-protein diet B. Restrict caloric intake to promote weight loss C. Ensure the child receives supplemental vitamins and minerals D. Recommend an elimination diet to identify food triggers

Answer 47

C. Ensure the child receives supplemental vitamins and minerals Rationale: Malnutrition is common in children with Crohn’s disease due to malabsorption, so providing vitamin and mineral supplements is essential. A high-calorie, high-protein diet should be encouraged rather than restricting intake.

Question 48

A nurse is caring for a child who has been newly diagnosed with Crohn’s disease. The nurse should be most concerned about which of the following complications? A. Hypoglycemia due to corticosteroid therapy B. Risk for infection from immunosuppressive therapy C. Risk for fluid overload from intravenous fluids D. Risk for bleeding due to anticoagulant use

Answer 48

B. Risk for infection from immunosuppressive therapy Rationale: Immunosuppressive therapy can increase the risk of infections by suppressing the immune system. Monitoring for signs of infection is crucial in these children.

Question 49

A 9-year-old child with Crohn’s disease is receiving total parenteral nutrition (TPN) due to malnutrition. Which of the following is the most important intervention for the nurse to implement during TPN administration? A. Monitor for signs of hypoglycemia B. Check the child’s temperature every 4 hours C. Assess the child’s blood pressure for hypotension D. Verify that the child’s weight remains stable

Answer 49

A. Monitor for signs of hypoglycemia Rationale: Hypoglycemia is a potential complication of TPN therapy, especially when it is started or discontinued abruptly. Monitoring glucose levels regularly and assessing for signs of hypoglycemia are key nursing interventions.

Question 50

A 6-year-old child with Crohn’s disease is experiencing an exacerbation of symptoms, including diarrhea, abdominal pain, and fever. The nurse should prioritize which of the following assessments? A. Assessing the child’s level of pain using a pain scale B. Monitoring the child’s body temperature every 2 hours C. Measuring the child’s abdominal girth and tenderness D. Observing for signs of dehydration

Answer 50

D. Observing for signs of dehydration Rationale: Diarrhea and fever in Crohn’s disease can lead to dehydration, which should be assessed immediately. Monitoring for dehydration signs is critical to prevent complications such as renal failure.

Question 51

A nurse is providing discharge teaching to the parents of a child with Crohn’s disease. Which of the following statements by the parent indicates an understanding of the discharge instructions? A. “My child can eat whatever they want as long as we avoid dairy products.” B. “I should contact the healthcare provider if my child develops a fever or stomach pain.” C. “We can stop the medication if my child feels better.” D. “It’s okay for my child to skip meals if they don’t feel hungry.”

Answer 51

B. “I should contact the healthcare provider if my child develops a fever or stomach pain.” Rationale: A fever and abdominal pain can indicate a flare-up or infection in children with Crohn’s disease, requiring prompt medical attention. Stopping medication or skipping meals is not advisable.

Question 52

A 14-year-old with Crohn’s disease has been prescribed a corticosteroid for an acute flare-up. The nurse should monitor the child for which of the following potential side effects of corticosteroid therapy? A. Bradycardia and hypothermia B. Weight loss and fatigue C. Hyperglycemia and increased appetite D. Hypokalemia and muscle weakness

Answer 52

C. Hyperglycemia and increased appetite Rationale: Corticosteroids can cause hyperglycemia, increased appetite, and weight gain. Monitoring blood glucose levels is essential during corticosteroid therapy.

Question 53

A child with Crohn’s disease is admitted to the hospital with a severe flare-up. The nurse should anticipate that the child may require which of the following interventions? A. Intravenous fluids and electrolytes for hydration B. A low-protein, low-fat diet to reduce symptoms C. A full liquid diet to reduce inflammation D. Antibiotics to prevent bacterial overgrowth

Answer 53

A. Intravenous fluids and electrolytes for hydration Rationale: During a flare-up, dehydration and electrolyte imbalances are common due to diarrhea and vomiting. Intravenous fluids and electrolytes help maintain hydration and prevent complications.

Question 54

A 13-year-old child with Crohn’s disease is reporting increased abdominal pain and fatigue after starting a new medication. The nurse should ask the child and parents which of the following questions to determine the cause of these symptoms? A. “Has your child been following a strict diet?” B. “Is your child drinking enough water each day?” C. “Is your child getting enough sleep at night?” D. “Has your child been taking their medication as prescribed?”

Answer 54

D. “Has your child been taking their medication as prescribed?” Rationale: Non-adherence to medications, such as immunosuppressants or corticosteroids, can lead to exacerbations of symptoms. It is important to assess medication adherence when new symptoms occur.

Question 55

A 10-year-old child with ulcerative colitis is admitted with abdominal cramping, diarrhea, and fever. The nurse should prioritize which of the following assessments to monitor the child’s condition? A. Assessing the child’s weight loss and nutritional intake B. Monitoring the child’s temperature every 4 hours C. Observing for signs of dehydration D. Measuring the child’s abdominal girth every 8 hours

Answer 55

C. Observing for signs of dehydration Rationale: Dehydration is a significant concern in pediatric patients with ulcerative colitis due to diarrhea and fluid loss. Early detection of dehydration allows for prompt intervention to prevent complications.

Question 56

A nurse is teaching the parents of a child with ulcerative colitis about dietary modifications. Which of the following statements by the parent indicates the need for further teaching? A. “We should provide a low-fiber diet during flare-ups.” B. “My child can eat spicy foods as long as they tolerate them.” C. “We should offer small, frequent meals to help with digestion.” D. “High-protein foods are essential to support growth during flare-ups.”

Answer 56

B. “My child can eat spicy foods as long as they tolerate them.” Rationale: Spicy foods can irritate the gastrointestinal tract and worsen symptoms of ulcerative colitis, especially during flare-ups. The child should avoid spicy foods to prevent exacerbation of symptoms.

Question 57

A 12-year-old child with ulcerative colitis is prescribed corticosteroids to manage an acute flare-up. Which of the following side effects should the nurse monitor for while the child is on corticosteroid therapy? A. Weight loss and dehydration B. Hyperglycemia and increased appetite C. Hypotension and fatigue D. Hypokalemia and muscle weakness

Answer 57

B. Hyperglycemia and increased appetite Rationale: Corticosteroids can increase blood glucose levels and lead to increased appetite and weight gain. Regular monitoring of blood glucose levels is important in patients on corticosteroids.

Question 58

A child with ulcerative colitis presents with severe abdominal pain, bloody diarrhea, and a low-grade fever. Which of the following actions should the nurse take first? A. Administer pain medication as prescribed B. Obtain a stool sample for culture and analysis C. Provide oral rehydration solutions to prevent dehydration D. Assess the child’s vital signs, including blood pressure and heart rate

Answer 58

D. Assess the child’s vital signs, including blood pressure and heart rate Rationale: Severe symptoms such as abdominal pain, bloody diarrhea, and fever can indicate an acute exacerbation or complication, such as toxic megacolon. Vital sign assessment is critical to assess for signs of hypovolemic shock or sepsis.

Question 59

A nurse is providing discharge teaching to the parents of a child with ulcerative colitis. Which of the following statements by the parent indicates an understanding of the teaching? A. “I should contact the doctor if my child develops a fever, weight loss, or blood in the stool.” B. “My child should avoid all fiber-rich foods to prevent flare-ups.” C. “It’s okay to stop medication once the symptoms improve.” D. “My child can return to normal activities as soon as symptoms subside.”

Answer 59

A. “I should contact the doctor if my child develops a fever, weight loss, or blood in the stool.” Rationale: Fever, weight loss, and blood in the stool can indicate a flare-up or complications, such as infection or bleeding, and should prompt medical evaluation. Stopping medications or resuming normal activities too soon can result in symptom relapse.

Question 60

A 15-year-old adolescent with ulcerative colitis is hospitalized for an acute exacerbation. The nurse should anticipate which of the following interventions to manage the child’s care? A. Administering intravenous fluids for hydration and electrolytes B. Restricting all oral intake to a clear liquid diet C. Placing the child on bed rest to conserve energy D. Administering corticosteroids as prescribed

Answer 60

D. Administering corticosteroids as prescribed Rationale: Corticosteroids are commonly used to manage acute exacerbations of ulcerative colitis by reducing inflammation. IV fluids for hydration may also be indicated, but the primary intervention is corticosteroid therapy.

Question 61

A nurse is assessing a child with ulcerative colitis during a flare-up. Which of the following findings should the nurse expect? A. Increased appetite and weight gain B. Vomiting and severe abdominal distention C. Bloody diarrhea and abdominal cramping D. Yellowing of the skin and sclera

Answer 61

C. Bloody diarrhea and abdominal cramping Rationale: Bloody diarrhea and abdominal cramping are characteristic symptoms of ulcerative colitis, especially during flare-ups. Vomiting and abdominal distention may occur in severe cases but are less common.

Question 62

A 7-year-old child with ulcerative colitis is prescribed a medication regimen that includes sulfasalazine. The nurse should provide which of the following instructions to the parents? A. “Make sure your child takes this medication on an empty stomach.” B. “This medication should be stopped immediately if your child develops a rash.” C. “Sulfasalazine may cause increased appetite, so be sure to monitor your child’s weight.” D. “Sulfasalazine can cause yellowing of the skin and eyes, so notify the doctor if this occurs.”

Answer 62

B. “This medication should be stopped immediately if your child develops a rash.” Rationale: Sulfasalazine is a medication used to treat ulcerative colitis, but it can cause allergic reactions, including rash, which may indicate a severe reaction. If a rash occurs, the medication should be stopped and the healthcare provider notified.

Question 63

A 13-year-old child with ulcerative colitis is admitted to the hospital due to dehydration from diarrhea. The nurse should monitor for which of the following complications related to severe dehydration? A. Hypertension and tachycardia B. Decreased urinary output and poor skin turgor C. Increased bowel sounds and bloating D. Hyperthermia and increased perspiration

Answer 63

B. Decreased urinary output and poor skin turgor Rationale: Dehydration leads to a reduction in urine output and poor skin turgor, both indicators of fluid volume deficit. Monitoring for these signs helps guide rehydration therapy and prevent further complications.

Question 64

A 9-year-old child is diagnosed with a peptic ulcer and is prescribed a combination of a proton pump inhibitor (PPI), amoxicillin, and clarithromycin for 10 days. Which of the following is the most important teaching point for the nurse to emphasize to the parents regarding this medication regimen? A. “The medications should be taken with food to prevent nausea.” B. “Discontinue the medications as soon as the symptoms improve.” C. “If your child misses a dose, double the dose the next time to make up for it.” D. “It is important to complete the full course of antibiotics, even if your child feels better.”

Answer 64

D. “It is important to complete the full course of antibiotics, even if your child feels better.” Rationale: Completing the full course of antibiotics is crucial to ensure that the H. pylori infection is fully eradicated and to prevent antibiotic resistance.

Question 65

A child with peptic ulcer disease is prescribed ranitidine for the treatment of gastric acid secretion. The nurse explains to the parents that the medication works by: A. Decreasing the production of gastric acid B. Increasing the production of gastric acid C. Neutralizing the acid in the stomach D. Enhancing the mucosal defense of the stomach

Answer 65

A. Decreasing the production of gastric acid Rationale: Ranitidine is an H2 receptor antagonist that reduces gastric acid production, thereby helping to heal the ulcer and prevent further damage.

Question 66

A 7-year-old child with peptic ulcer disease presents with burning abdominal pain that worsens when the stomach is empty and awakens the child at night. Which of the following interventions should the nurse prioritize in the child’s care plan? A. Administering antacids to relieve the pain B. Encouraging the child to eat small, frequent meals C. Restricting fluid intake to prevent nausea D. Limiting the child’s physical activity to reduce stress

Answer 66

B. Encouraging the child to eat small, frequent meals Rationale: Eating small, frequent meals helps to neutralize stomach acid and prevent irritation, reducing abdominal pain and promoting healing of the ulcer.

Question 67

The nurse is caring for a child with peptic ulcer disease who is being treated with proton pump inhibitors (PPIs). Which of the following side effects should the nurse educate the parents to watch for while the child is on this medication? A. Diarrhea and abdominal cramping B. Headache and dizziness C. Increased appetite and weight gain D. Cough and sore throat

Answer 67

B. Headache and dizziness Rationale: Headache and dizziness are common side effects of proton pump inhibitors. The nurse should educate the parents to monitor for these symptoms and report them if they become bothersome.

Question 68

A nurse is caring for a child with peptic ulcer disease who has a history of H. pylori infection. The nurse assesses the child for which of the following signs of possible gastrointestinal bleeding? A. Vomiting of blood or coffee-ground material B. Sudden weight gain and bloating C. Increased abdominal tenderness and guarding D. Sudden increase in appetite and irritability

Answer 68

A. Vomiting of blood or coffee-ground material Rationale: Vomiting blood or coffee-ground material indicates gastrointestinal bleeding, a potential complication of peptic ulcers. Immediate medical attention is required.

Question 69

The nurse is teaching a child with peptic ulcer disease and their parents about diet modifications. Which of the following foods should the nurse recommend the family avoid to minimize ulcer symptoms? A. Yogurt and cheese B. Fruits and vegetables C. Spicy foods and citrus fruits D. Whole grains and nuts

Answer 69

C. Spicy foods and citrus fruits Rationale: Spicy foods and citrus fruits can irritate the gastric mucosa and exacerbate ulcer symptoms, so they should be avoided, especially during flare-ups.

Question 70

A 10-year-old child with peptic ulcer disease has been prescribed acetaminophen for pain management. The nurse should emphasize which of the following instructions to the parents? A. “Administer acetaminophen with food to minimize stomach irritation.” B. “Give the child acetaminophen every 4 hours, as needed.” C. “Avoid giving acetaminophen if your child develops a fever.” D. “Ensure your child takes no more than 5 doses per day.”

Answer 70

D. “Ensure your child takes no more than 5 doses per day.” Rationale: Acetaminophen is generally safe for pain relief in children with peptic ulcer disease; however, it should be used within recommended dosages to avoid toxicity, especially in children with liver concerns.

Question 71

The nurse is assessing a child with peptic ulcer disease who reports nausea, vomiting, and a feeling of fullness. The nurse notes the child’s abdomen is distended. Which of the following complications is the child at greatest risk for? A. Gastrointestinal perforation B. Biliary colic C. Intestinal obstruction D. Peritonitis

Answer 71

A. Gastrointestinal perforation Rationale: A distended abdomen, nausea, and vomiting may indicate gastrointestinal perforation, a serious complication of peptic ulcers, which can lead to peritonitis and requires emergency intervention.

Question 72

A nurse is discussing stress reduction techniques with the parents of a child with peptic ulcer disease. Which of the following interventions is most appropriate to help reduce stress in the child? A. Encouraging the child to engage in physical activities that they enjoy B. Teaching the child deep breathing exercises and relaxation techniques C. Limiting the child’s social interactions to minimize stimulation D. Restricting the child’s screen time to reduce anxiety

Answer 72

B. Teaching the child deep breathing exercises and relaxation techniques Rationale: Stress can exacerbate peptic ulcer disease. Teaching stress reduction techniques, such as deep breathing exercises and relaxation, can help reduce anxiety and minimize stress-related triggers.

Question 73

A nurse is caring for a child with peptic ulcer disease who is receiving long-term proton pump inhibitor therapy. Which of the following assessments is most important for the nurse to monitor in this child? A. Blood pressure for signs of hypotension B. Liver function tests for signs of liver damage C. Weight for signs of fluid retention D. Electrolyte levels for possible hypokalemia

Answer 73

D. Electrolyte levels for possible hypokalemia Rationale: Proton pump inhibitors can cause electrolyte imbalances, including hypokalemia. The nurse should regularly monitor electrolyte levels, especially potassium, to prevent complications.

Question 74

A 10-year-old child with a history of irritable bowel syndrome (IBS) presents with abdominal cramping, bloating, and alternating diarrhea and constipation. The nurse anticipates the healthcare provider may order which of the following to help manage the child’s symptoms? A. Broad-spectrum antibiotics B. Probiotics and fiber supplements C. Nonsteroidal anti-inflammatory drugs (NSAIDs) D. Corticosteroids for inflammation

Answer 74

B. Probiotics and fiber supplements Rationale: Probiotics can help restore the balance of gut bacteria, and fiber supplements can help regulate bowel movements in children with IBS. NSAIDs and corticosteroids are not typically used for IBS management.

Question 75

The nurse is educating the parents of a child diagnosed with IBS. Which of the following statements by the parent indicates a need for further teaching? A. “We should encourage our child to eat smaller, more frequent meals.” B. “I should monitor my child’s fluid intake to prevent dehydration.” C. “We should eliminate all fruits and vegetables from my child’s diet.” D. “It’s important to keep track of foods that trigger my child’s symptoms.”

Answer 75

C. “We should eliminate all fruits and vegetables from my child’s diet.” Rationale: While some fruits and vegetables may exacerbate symptoms, completely eliminating all fruits and vegetables is not necessary. A balanced diet with careful monitoring of triggers is key in managing IBS.

Question 76

A nurse is caring for a child with IBS. Which of the following interventions should the nurse prioritize when providing care for this child? A. Administering prescribed antidiarrheal medications to prevent dehydration B. Encouraging regular physical activity to promote gastrointestinal motility C. Limiting dietary fiber to prevent excessive stool formation D. Promoting a high-fat diet to help ease bowel irritation

Answer 76

B. Encouraging regular physical activity to promote gastrointestinal motility Rationale: Regular physical activity helps promote normal bowel motility and can alleviate some IBS symptoms, such as constipation and bloating.

Question 77

A 9-year-old child with IBS reports episodes of diarrhea followed by constipation. The nurse should assess for which of the following red flags that would suggest a more serious condition, such as inflammatory bowel disease (IBD)? A. Blood in stools B. A pattern of alternating diarrhea and constipation C. Abdominal bloating after meals D. Mild cramping relieved by defecation

Answer 77

A. Blood in stools Rationale: Blood in the stool is a red flag that could indicate a more serious condition, such as IBD, rather than IBS, and requires further investigation.

Question 78

The nurse is preparing to teach the family of a child diagnosed with IBS about dietary modifications. Which of the following foods should the nurse recommend the family avoid to reduce symptoms of IBS? A. Whole grain bread and pasta B. Apples and citrus fruits C. White rice and boiled potatoes D. Low-fat dairy products

Answer 78

B. Apples and citrus fruits Rationale: Certain fruits, such as apples and citrus fruits, can trigger IBS symptoms due to their high fiber content and acidity, respectively. These foods should be limited in the diet.

Question 79

A child with IBS has been prescribed a low-dose tricyclic antidepressant to help manage pain associated with IBS. The nurse should educate the parents on which of the following potential side effects of this medication? A. Diarrhea B. Drowsiness C. Increased appetite D. Dry mouth and constipation

Answer 79

D. Dry mouth and constipation Rationale: Tricyclic antidepressants can cause dry mouth and constipation, which may worsen IBS symptoms. Parents should be educated to monitor for these side effects and report them to the healthcare provider.

Question 80

A 12-year-old child with IBS presents to the clinic with complaints of fatigue and difficulty concentrating. The nurse suspects these symptoms may be related to the child’s IBS. Which of the following is the most appropriate initial intervention for the nurse to implement? A. Provide the child with a prescription for a stimulant medication B. Encourage the child to keep a food diary to identify potential triggers C. Recommend an increase in caffeine intake to improve energy levels D. Advise the child to reduce water intake to minimize bloating

Answer 80

B. Encourage the child to keep a food diary to identify potential triggers Rationale: A food diary helps identify specific foods that may be contributing to the child’s IBS symptoms, enabling targeted dietary changes to alleviate symptoms.

Question 81

The nurse is reviewing the lab results of a child diagnosed with IBS. Which of the following findings would suggest the need for further evaluation of another potential gastrointestinal condition? A. Normal stool cultures B. Negative blood tests for H. pylori infection C. Elevated C-reactive protein (CRP) level D. Normal liver function tests

Answer 81

C. Elevated C-reactive protein (CRP) level Rationale: An elevated CRP level may indicate an inflammatory process, such as inflammatory bowel disease (IBD), rather than IBS, and warrants further evaluation.

Question 82

The nurse is preparing a care plan for a child with IBS. Which of the following interventions is most important to include in the care plan to address the child’s psychosocial needs? A. Encourage regular counseling sessions to help cope with stress B. Recommend a high-protein diet to support growth and development C. Limit the child’s social activities to reduce stress and triggers D. Provide frequent reminders to the child to take medications as prescribed

Answer 82

A. Encourage regular counseling sessions to help cope with stress Rationale: Psychological stress is a common trigger for IBS symptoms. Counseling can help the child develop effective coping strategies and reduce stress, improving symptom management.

Question 83

A nurse is educating the parents of an infant diagnosed with GERD about the use of medications. Which of the following instructions is appropriate for the nurse to provide? A. “You may give over-the-counter antacids without consulting the healthcare provider.” B. “It is important to administer medications with every feeding, even if symptoms improve.” C. “Monitor for side effects such as irritability, dizziness, and constipation.” D. “You can discontinue the medication once your infant’s symptoms resolve.”

Answer 83

C. “Monitor for side effects such as irritability, dizziness, and constipation.”

Question 84

A 2-month-old infant diagnosed with GER is prescribed a proton pump inhibitor. The nurse should educate the parents to administer the medication in which of the following ways? A. With a meal to improve absorption. B. In the evening before bedtime. C. With water, immediately after feedings. D. On an empty stomach, in the morning.

Answer 84

D. On an empty stomach, in the morning. Rationale: Proton pump inhibitors should be administered in the morning on an empty stomach to maximize their effect.

Question 85

A 4-year-old child with GERD is experiencing frequent coughing and choking during meals. Which of the following actions should the nurse recommend to the child’s parents to help alleviate these symptoms? A. Give the child larger, less frequent meals. B. Use a special high-calorie formula to increase weight. C. Encourage the child to eat in a prone position. D. Elevate the head of the bed and feed the child in an upright position.

Answer 85

D. Elevate the head of the bed and feed the child in an upright position. Rationale: Elevating the head of the bed and feeding the child in an upright position reduces the likelihood of aspiration and alleviates choking and coughing.

Question 86

An infant with GERD is not gaining weight as expected. Which of the following interventions should the nurse recommend to address this concern? A. Increase the volume of each feeding. B. Provide feedings less frequently to reduce irritation. C. Introduce solid foods earlier than usual. D. Offer smaller, more frequent feedings.

Answer 86

D. Offer smaller, more frequent feedings. Rationale: Offering smaller, more frequent feedings helps ensure the infant receives adequate nutrition without exacerbating reflux symptoms.

Question 87

A 3-month-old infant is diagnosed with GERD and is prescribed thickened formula. Which of the following is the most appropriate action for the nurse to take? A. Administer the thickened formula with a regular nipple to encourage feeding. B. Increase the volume of each feeding to reduce reflux. C. Use a special nipple with a smaller opening for the thickened formula. D. Introduce solid foods to the infant’s diet to improve reflux symptoms.

Answer 87

C. Use a special nipple with a smaller opening for the thickened formula. Rationale: A smaller nipple opening slows the flow of the thickened formula, reducing the risk of aspiration.

Question 88

A nurse is providing discharge instructions to the parents of an infant diagnosed with GER. Which of the following recommendations is appropriate for the parents to help reduce the infant’s symptoms? A. Feed the infant large, infrequent meals to avoid overfeeding. B. Position the infant in a semisupine position during feedings. C. Hold the infant in an upright position for 20 to 30 minutes after feedings. D. Administer antacids before each feeding to reduce acid reflux.

Answer 88

C. Hold the infant in an upright position for 20 to 30 minutes after feedings. Rationale: Holding the infant upright after feedings helps reduce reflux and the risk of aspiration.

Question 89

A 2-year-old child with GERD is prescribed Prevacid (lansoprazole). Which of the following side effects should the nurse monitor for in this child? A. Abdominal pain and diarrhea B. Fatigue and headache C. Constipation and nausea D. Rash and confusion

Answer 89

A. Abdominal pain and diarrhea Rationale: PPIs like lansoprazole can cause abdominal pain and diarrhea as side effects.

Question 90

A child with severe GERD is scheduled for fundoplication surgery. Which of the following postoperative nursing interventions should be prioritized? A. Monitor for signs of infection at the incision site. B. Provide education on the long-term use of proton pump inhibitors (PPIs). C. Assess for complications related to the gastrostomy tube. D. Encourage the child to begin oral feedings immediately after surgery.

Answer 90

C. Assess for complications related to the gastrostomy tube. Rationale: After fundoplication surgery, a gastrostomy tube may be placed to provide nutrition. Monitoring for complications, such as infection or tube dislodgement, is critical.

Question 91

The nurse is educating the parents of a child with GERD about avoiding foods that trigger reflux. Which of the following foods should the nurse advise the parents to eliminate from the child’s diet? A. Chocolate and peppermint B. Apples and pears C. Milk and dairy products D. Whole grains and rice

Answer 91

A. Chocolate and peppermint Rationale: Chocolate and peppermint can relax the lower esophageal sphincter and increase reflux symptoms.

Question 92

A nurse is caring for a 6-month-old infant with GERD. Which of the following positions should the nurse recommend for sleep to reduce the risk of aspiration? A. Place the infant in a prone position for sleep. B. Place the infant in a supine position with the head elevated. C. Place the infant in a side-lying position. D. Place the infant in a semi-reclining position on their back.

Answer 92

B. Place the infant in a supine position with the head elevated. Rationale: A supine position with the head elevated reduces the risk of aspiration and is the safest sleeping position for an infant with GERD.

Question 93

An infant with GERD has been prescribed proton pump inhibitors (PPIs). The nurse should educate the parents to administer the medication at which of the following times? A. With meals to help reduce reflux. B. Immediately after feedings to maximize effectiveness. C. In the morning, on an empty stomach. D. At bedtime to avoid nighttime symptoms.

Answer 93

C. In the morning, on an empty stomach. Rationale: PPIs should be administered in the morning on an empty stomach to maximize their effect on acid suppression.

Question 94

A 7-year-old child with GERD presents with chest pain and dysphagia. Which of the following actions should the nurse take first? A. Assess the child’s respiratory status for signs of aspiration. B. Provide antacids to relieve the child’s pain. C. Instruct the child to eat smaller, more frequent meals. D. Teach the child how to use a proton pump inhibitor (PPI).

Answer 94

A. Assess the child’s respiratory status for signs of aspiration. Rationale: Respiratory symptoms and dysphagia are concerning for possible aspiration and should be addressed immediately.

Question 95

A nurse is caring for an infant diagnosed with gastroesophageal reflux (GER). Which of the following interventions would be most appropriate to help prevent aspiration during feedings? A. Place the infant in a prone position during feedings. B. Keep the infant in an upright position for 20 to 30 minutes after feedings. C. Feed the infant in a semi-reclined position with the head lowered. D. Hold the infant in a completely supine position during feedings.

Answer 95

B. Keep the infant in an upright position for 20 to 30 minutes after feedings. Rationale: Keeping the infant upright helps reduce the risk of aspiration by allowing gravity to prevent reflux.

Question 96

A 4-month-old infant with GERD is being prescribed thickened formula. Which of the following is a correct nursing implication when administering thickened formula? A. Always mix the formula in a bottle with a regular nipple. B. Use a nipple with a smaller opening to slow the flow of the thickened formula. C. Feed the infant large volumes at each feeding to avoid dehydration. D. Discontinue thickened formula once the infant reaches 6 months of age.

Answer 96

B. Use a nipple with a smaller opening to slow the flow of the thickened formula. Rationale: A smaller opening in the nipple helps prevent aspiration and ensures the formula flows at a manageable rate.

Question 97

An infant with GERD is prescribed Zantac (ranitidine) to manage symptoms. The nurse should educate the parents to monitor for which of the following potential side effects? A. Bradycardia and irritability B. Diarrhea and rash C. Constipation and headache D. Vomiting and abdominal bloating

Answer 97

A. Bradycardia and irritability Rationale: Ranitidine can cause bradycardia and irritability, which should be monitored in the infant.