TEST 4: The Child with Health Problems of the Upper Gastrointestinal Tract

Question 1

The Client with Cleft Lip and Palate
1. When developing the plan of care for an infant with a cleft lip before corrective surgery is
performed, which of the following should be a priority?
1. Maintaining skin integrity in the oral cavity.
2. Using techniques to minimize crying.
3. Altering the usual method of feeding.
4. Preventing the infant from putting fingers in the mouth

Answer 1

The Client with Cleft Lip and Palate
1. 3. Before corrective surgery for a cleft lip, the infant needs to consume formula or breast milk.
Methods for feeding may need to be adjusted to fit the infant’s needs, because the infant with a cleft
lip experiences a decreased ability to suck, which interferes with the infant’s ability to compress the
nipple. A special feeder may be used to feed the infant to ensure adequate caloric intake. Problems
with infection and skin integrity in the mouth are uncommon because the areas of the defect are not
open areas. Although crying may cause the infant to swallow more air because of the defect, crying
poses no harm to the infant. There is no need to keep the infant’s fingers out of the mouth
preoperatively. The fingers will not harm the defect or cause an infection.
CN: Reduction of risk potential; CL: Synthesize

Question 2

2. Which of the following measures would be most effective in helping the infant with a cleft lip
   and palate to retain oral feedings?
3. Burp the infant at frequent intervals.
4. Feed the infant small amounts at one time.
5. Place the end of the nipple far to the back of the infant’s tongue.
6. Maintain the infant in a lying position while feeding.

Answer 2

2. 1. An infant with a cleft lip and palate typically swallows large amounts of air while being fed
      and therefore should be burped frequently. The soft palate defect allows air to be drawn into the
      pharynx with each swallow of formula. The stomach becomes distended with air, and regurgitation,
      possibly with aspiration, is likely if the infant is not burped frequently. Feeding frequently, even in
      small amounts, would not prevent swallowing of large amounts of air. A nipple placed in the back of
      the mouth is likely to cause the infant to gag and aspirate. Holding the infant in a lying position during
      feedings can also lead to regurgitation and aspiration of formula. The infant should be fed in an
      upright position.
      CN: Basic care and comfort; CL: Synthesize

Question 3

3. After teaching the parent of an infant who has had a surgical repair for a cleft lip about the use
   of elbow restraints at home, the nurse determines that the teaching has been successful when the
   parent states which of the following?
4. “We will keep the restraints on continuously except when checking the skin under them for
   redness.”
5. “We will keep the restraints on during the day while he is awake, but take them off when we
   put him to bed at night.”
6. “After we get home, we won’t have to use the restraints because our child does not suck on his
   hands or fingers.”
7. “We will be sure to keep the restraints on all the time until we come to see the primary care
   provider for a follow-up visit.”

Answer 3

3. 1. To keep the infant from disturbing the suture line by placing fingers or other objects in the
      mouth, either intentionally or accidentally, the restraints should be in place at all times. They should
      be removed for a short period, however, so that the underlying skin can be checked for any redness or
      breakdown. While the restraints are removed, the parents should be instructed to manually restrain the
      hands and arms.
      CN: Safety and infection control; CL: Evaluate

Question 4

4. The parent of an infant with a cleft lip and palate asks the nurse when the infant’s cleft palate
   will be repaired. The nurse responds by stating that the first repair of a cleft palate is usually done at
   which of the following times?
5. Before the eruption of teeth.
6. When the child weighs approximately 10 kg (22 lb).
7. Before the development of speech.
8. After the child learns to drink from a cup.

Answer 4

4. 3. The optimal time for cleft palate repair depends on many factors. However, it is best done
      before speech develops and the child learns faulty speech habits as a result of the defect, usually
      before 12 to 15 months of age. Tooth eruption usually begins at about 6 months of age. The child
      should weigh about 10 kg (22 lb) at 6 months, but the important consideration is to schedule surgery
      before speech patterns begin to develop. An infant may learn to start drinking from a cup as early as 6
      to 7 months of age, possibly up to the first birthday.
      CN: Physiological adaptation; CL: Apply

Question 5

5. On the second postoperative day after repair of a cleft palate, which of the following should
the nurse use to feed a toddler?
1. Cup.
2. Straw.
3. Rubber-tipped syringe.
4. Large-holed nipple.

Answer 5

5. 1. A cup is the preferred drinking or eating utensil after repair of a cleft palate. At the age when
      repair is done, the child is ordinarily able to drink from a cup. Use of a cup avoids having to place a
      utensil in the mouth, which would increase the potential for injury to the suture lines.
      CN: Physiological adaptation; CL: Synthesize

Question 6

The Client with Tracheoesophageal Fistula
6. The parents report that their 1-day-old is drooling and having choking episodes with excessive
amounts of mucus and color changes, especially during feedings. The nurse should contact the primary
care provided to further assess the baby and request a prescription for:
1. A lactation consultation.
2. A blood gas.
3. An x-ray with orogastric catheter placement.
4. A serum blood glucose.

Answer 6

The Client with Tracheoesophageal Fistula
6. 3. The drooling and excessive mucus production is highly suggestive of a tracheoesophageal
fistula (TEF). The initial diagnosis is made when an orogastric catheter cannot be passed to the
stomach. A lactation consult would be warranted only after determining feedings were safe to
continue. While cyanosis can be a sign of sepsis and hypoglycemia, the cyanosis is most likely related
to the excessive secretions and airway patency. A blood gas may be needed, but only after ruling out a
TEF.
CN: Management of care; CL: Synthesize

Question 7

7. The parents of a child with a tracheoesophageal fistula express feelings of guilt about their
   baby’s anomaly. Which of the following approaches by the nurse would best support the parents?
8. Helping the parents accept their feelings as a normal reaction.
9. Explaining that the parents did nothing to cause the newborn’s defect.
10. Encouraging the parents to concentrate on planning their baby’s care.
11. Urging the parents to visit their newborn as often as possible.

Answer 7

7. 1. The parents of children born with defects often have feelings of guilt and ask what they might
      have done to cause the condition or how they might have avoided it. It is important to allow parents to
      express their feelings and to accept these feelings as normal reactions. Explaining that the parents are
      not at fault would not be appropriate until they have dealt with their feelings of guilt. Encouraging
      long-term planning generally is of little benefit to parents who are emotionally distraught.
      Additionally, the parents may interpret this as ignoring their feelings and confirming that they played a
      role in causing their child’s anomaly. Urging the parents to visit their infant as often as possible would
      generally be of little help and could appear to the parents as though they are being “talked out” of
      their feelings.
      CN: Psychosocial integrity; CL: Synthesize

Question 8

8. After teaching the parents of a neonate diagnosed with a tracheoesophageal fistula (TEF) about
   this anomaly, the nurse determines that the teaching was successful when the father describes the
   condition as which of the following?
9. “The muscle below the stomach is too tight, causing the baby to vomit forcefully.”
10. “There is a blind upper pouch and an opening from the esophagus into the airway.”
11. “The lower bowel is lacking certain nerves to allow normal function.”
12. “A part of the bowel is on the outside without anything covering it.”

Answer 8

8. 2. Although a TEF can include several different structural anomalies, the most common type
      involves a blind upper pouch and a fistula from the esophagus into the trachea. Other types include a
      blind pouch at the end of the esophagus with no connection to the trachea and a normal trachea and
      esophagus with an opening that connects them. A tightened muscle below the stomach and projectile
      vomiting of normal amounts of formula are characteristic of pyloric stenosis. Aganglionic megacolon
      is a lack of autonomic parasympathetic ganglion cells in a portion of the lower intestine.
      Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall and no
      membrane covers the exposed bowel.
      CN: Physiological adaptation; CL: Evaluate

Question 9

9. Which of the following would indicate that an infant with a tracheoesophageal fistula (TEF)
needs suctioning?
1. Brassy cough.
2. Substernal retractions.
3. Decreased activity level.
4. Increased respiratory rate.

Answer 9

9. 2. With a TEF, overflow of secretions into the larynx leads to laryngospasm. This obstruction to
      inspiration stimulates the strong contraction of accessory muscles of the thorax to assist the diaphragm
      in breathing. This produces substernal retractions. The laryngospasm that occurs with a TEF resolves
      quickly when secretions are removed from the oropharynx area. A brassy cough is related to a
      relatively constant laryngeal narrowing, usually caused by edema. It is not an indication of the need to
      suction. A decreased activity level and an increased respiratory rate in an infant with a TEF are
      usually the result of hypoxia, a relatively long-term and constant phenomenon in infants with a TEF.
      CN: Physiological adaptation; CL: Analyze

Question 10

10. The nurse is administering gastrostomy feedings to an infant after surgery to correct a
    tracheoesophageal fistula (TEF). To prevent air from entering the stomach once the syringe barrel is
    attached to the gastrostomy tube the nurse should:
11. Unclamp the tube after pouring the complete amount of formula to be administered into the
    syringe barrel.
12. Pour all of the formula to be administered into the syringe barrel after opening the clamp.
13. Maintain a continuous flow of formula down the side of the syringe barrel once the clamp is
    opened.
14. Allow a small amount of formula to enter the stomach before pouring more formula into the
    syringe barrel.

Answer 10

10. 1. The best way to prevent air from entering the stomach when feeding an infant through a
       gastrostomy tube is to open the clamp after all the formula has been placed in the syringe barrel.Doing so prevents air from mixing with the formula and thus being introduced into the stomach.
       Pouring all the formula into the barrel after opening the clamp, maintaining a continuous flow of
       formula down the side of the barrel after unclamping the tube, and allowing a small amount of formula
       to enter the stomach before adding more formula to the barrel permit air to enter the stomach.
       CN: Reduction of risk potential; CL: Apply

Question 11

11. After surgery to repair a tracheoesophageal fistula, an infant receives gastrostomy tube
    feedings. After feeding the infant by this method, the nurse cradles and rocks the infant for about 15
    minutes, primarily to help accomplish which of the following?
12. Promote intestinal peristalsis.2. Prevent regurgitation of formula.
13. Relieve pressure on the surgical site.
14. Associate eating with a pleasurable experience.

Answer 11

11. 4. The nurse can help meet the psychological needs of an infant being fed through a
       gastrostomy tube by rocking the infant after a feeding. The infant soon learns to associate eating with a
       pleasurable experience and learns to trust the caregiver. Rocking the infant will not promote
       peristalsis or prevent regurgitation. Holding the baby will not relieve pressure on the surgical site.
       However, holding the child right after feeding promotes comfort and pleasure.
       CN: Psychosocial integrity; CL: Apply

Question 12

12. A newborn who had a surgical repair of a tracheoesophageal fistula (TEF) is started on oral
    feedings. Which of the following should the nurse include in the teaching plan for the mother about
    oral feedings?
13. They are better tolerated when larger, but less frequent feedings are offered.
14. They should be offered on a feeding schedule to help the infant accept the feedings more
    readily.
15. They are best accepted by the infant when offered by the same nurse or by the infant’s mother.
16. They are best planned in conjunction with observations of the infant’s behavior.

Answer 12

12. 4. When initiating oral feedings after surgical repair of a TEF, it is best to follow a plan of
       care in conjunction with observation of the infant’s needs and behavior. When the infant’s needs and
       behavior are overlooked, plans are likely to be unsatisfactory and are more likely to meet the nurse’s
       needs rather than the infant’s needs. After a surgical procedure, infants initially tolerate small amounts
       of fluids offered more frequently better than larger amounts offered less often. Smaller amounts cause
       less bloating as the infant becomes used to feeding again. Although infants accept feedings more
       readily from their mother or from someone who feeds the infant repeatedly, the priority is to meet the
       infant’s nutritional needs based on the infant’s behavior.
       CN: Basic care and comfort; CL: Create

Question 13

The Client with an Anorectal Anomaly
13. After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis
of an imperforate anus for surgery the next day. The infant’s parents are Catholic and do not want the
surgery to take place unless the infant has first been baptized. The nurse asks the parents:
1. “Are you worried your baby might die?”
2. “Do you want me to help arrange the baptism?”
3. “Do you want to speak with the social worker?”
4. “Would you prefer to wait for the surgery?”

Answer 13

The Client with an Anorectal Anomaly
13. 2. The nurse should honor the parent’s belief system and help arrange to have the infant
baptized. This may be done through the hospital’s chaplaincy department or by the family’s clergy. The
parents may indeed be worried that the infant may die during surgery. Having the infant baptized
would help address the family’s spiritual needs. At this time there is an immediate need for
chaplaincy, not social service. While surgery may be postponed briefly, the infant cannot begin
feeding until an outlet for stool as been established. Therefore, it is not advisable to postpone the
surgery for a prolonged period of time.
CN: Psychosocial integrity; CL: Analyze

Question 14

14. Which of the following should the nurse assess in a newborn diagnosed with an anorectal
malformation? Select all that apply.
1. Abdominal distension.
2. Loose stools.
3. Vomiting.
4. Meconium in the urine.
5. Meconium stools.

Answer 14

14. 1,3,4. Anorectal malformations present with lack of stool or evidence of meconium in the
    urine through a fistula. Meconium is not found in the stool. Because stool does not pass, abdominal
    distension and vomiting occur.
    CN: Physiological adaptation; CL: Analyze

Question 15

15. After teaching the mother of a neonate who has successfully undergone surgery to repair a
    low anorectal anomaly, the mother indicates that she understands her child’s prognosis when she
    states which of the following?
16. “My child will need to wear protective pads until puberty.”
17. “My child will need extra fluids to prevent constipation.”
18. “My child will probably always need a high-fiber diet.”
19. “My child has a good chance of being potty trained.”

Answer 15

15. 4. Children who undergo surgical correction for low anorectal anomalies as infants usually
       are continent. Fecal continence can be expected after successful correction of anal membrane atresia.
       Therefore, this child probably has a good chance of being potty trained and will not need to wear
       protective pads. Extra fluids and a high-fiber diet are not required to prevent constipation. Children
       with high anorectal anomalies may or may not achieve continence.
       CN: Physiological adaptation; CL: Evaluate

Question 16

16. When the infant returns to the unit after imperforate anus repair, the nurse should place the
    infant in which of the following positions?
17. On the abdomen, with legs pulled up under the body.
18. On the back, with legs extended straight out.
19. Lying on the side with the hips elevated.
20. Lying on the back in a position of comfort.

Answer 16

16. 3. After surgical repair for an imperforate anus, the infant should be positioned either supinewith the legs suspended at a 90-degree angle or on either side with the hips elevated to prevent
       pressure on the perineum. A neonate who is placed on the abdomen pulls the legs up under the body,
       which puts tension on the perineum, as does positioning the neonate on the back with the legs
       extended straight out.
       CN: Basic care and comfort; CL: Synthesize

Question 17

17. The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns
    respond to painful stimuli. Which of the following should be the nurse’s best response?
18. “Newborns cry and cannot be distracted to stop crying.”
19. “When faced with a pain, newborns try to roll away from it.”
20. “Newborns typically move their whole body in response to pain.”
21. “Pain causes the newborn to withdraw the affected part.”

Answer 17

17. 3. The neonate responds to pain with total body movement and brief, loud crying that ceases
       with distraction. After the age of 6 months, an infant reacts to pain with intense physical resistance
       and tries to escape by rolling away. A toddler reacts to pain by withdrawing the affected part.
       CN: Basic care and comfort; CL: Apply

Question 18

18. When developing the plan of care for a neonate who was diagnosed with an anorectal
    malformation and who subsequently underwent surgery, which of the following would be most
    helpful in facilitating parent-infant bonding?
19. Explaining to the parents that they can visit at any time.
20. Encouraging the parents to hold their infant.
21. Asking the parents to help monitor the infant’s intake and output.
22. Helping the parents plan for their infant’s discharge.

Answer 18

18. 2. Encouraging the parents to hold their neonate promotes parent-infant attachment. Parent-
       infant bonding is based on a relationship that begins when the parent first touches the infant. Both the
       parents and the infant have predictable steps that they go through in this process. Explaining that the
       parents can visit at any time promotes bonding only if they do visit with, talk to, and hold the
       newborn. Asking the parents to help monitor intake and output at this time may be too anxiety-
       producing, thus interfering with bonding. Helping the parents plan for the infant’s discharge involves
       them in the newborn’s care and is important. However, it is not the first step in the development of
       bonding.
       CN: Psychosocial integrity; CL: Synthesize

Question 19

The Client with Pyloric Stenosis
19. A 4-week-old infant admitted with the diagnosis of hypertrophic pyloric stenosis presents
with a history of vomiting. The nurse should anticipate that the infant's vomitus would contain gastric
contents and which of the following?
1. Bile and streaks of blood.
2. Mucus and bile.
3. Mucus and streaks of blood.
4. Stool and bile.

Answer 19

The Client with Pyloric Stenosis
19. 3. The vomitus of an infant with hypertrophic pyloric stenosis contains gastric contents,
mucus, and streaks of blood. The vomitus does not contain bile or stool because the pyloric
constriction is proximal to the ampulla of Vater.
CN: Physiological adaptation; CL: Analyze

Question 20

20. When an infant with pyloric stenosis is admitted to the hospital, which of the following
    should the nurse do first?
21. Weigh the infant.
22. Begin an intravenous infusion.
23. Switch the infant to an oral electrolyte solution.
24. Orient the mother to the hospital unit.

Answer 20

20. 1. Unless the infant is in hypovolemic shock, obtaining a baseline weight is an important first
       action because the weight is used to calculate the child’s fluid and electrolyte needs. The intravenous
       fluid rate and the amounts of electrolytes to be added to the fluid are based on the infant’s weight. The
       weight also helps determine the infant’s degree of dehydration. The intravenous infusion is initiated
       once the weight has been obtained. The child with pyloric stenosis typically experiences vomiting
       and is at risk for fluid volume deficit and metabolic acidosis. As a result, oral food and fluids are
       withheld and the infant is allowed nothing by mouth. Fluid replacement is given intravenously.
       Orientation can wait until treatment is under way.
       CN: Physiological adaptation; CL: Synthesize

Question 21

21. After teaching the mother of an infant with pyloric stenosis about the disease, which of the
    following, if stated by the mother as a cause, indicates effective teaching?
22. “An enlarged muscle below the stomach sphincter.”
23. “A telescoping of the large bowel into the smaller bowel.”
24. “A result of giving the baby more formula than is necessary.”
25. “A result of my baby taking the formula too quickly.”

Answer 21

21. 1. Pyloric stenosis involves hypertrophy of the pylorus muscle distal to the stomach and
       obstruction of the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration.
       Telescoping of the bowel is called intussusception. Overfeeding, feeding too quickly, or underfeeding
       is not associated with pyloric stenosis.
       CN: Physiological adaptation; CL: Evaluate

Question 22

22. A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary
    care provider has prescribed IV fluids of dextrose water with sodium and potassium. The baby’s
    admission potassium level is 3.4 mEq/L (3.4 mmol/L). The nurse should:
23. Notify the primary care provider.
24. Administer the prescribed fluids.
25. Verify that the infant has urinated.
26. Have the potassium level redrawn.

Answer 22

22. 3. Normal serum potassium levels are 3.5 to 4.5 mEq/L (3.5 to 4.5 mmol/L). Elevated
       potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client
       has the ability to clear potassium through urination before administering the drug. Infants with pyloricstenosis frequently have low potassium levels due to vomiting. A level of 3.4 mEq/L (3.4 mmol/L) is
       not unexpected and should be corrected with the prescribed fluids. The lab value does not need to be
       redrawn as the findings are consistent with the infant’s condition.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 23

23. After undergoing surgical correction of pyloric stenosis, an infant is returned to the room in
    stable condition. While standing by the crib, the mother says, “Perhaps if I had brought my baby to the
    hospital sooner, the surgery could have been avoided.” Which of the following should be the nurse’s
    best response?
24. “Surgery is the most effective treatment for pyloric stenosis.”
25. “Try not to worry; your baby will be fine.”
26. “Do you feel that this problem indicates that you are not a good mother?”
27. “Do you think that earlier hospitalization could have avoided surgery?”

Answer 23

23. 4. Restating or rephrasing a mother’s response provides the opportunity for clarification and
       validation. It also helps to focus on what the mother is saying and address her concerns and feelings.
       Although surgery is the most effective treatment for pyloric stenosis, stating this ignores the mother’s
       feelings and does not give her an opportunity to express them. Telling the mother not to worry also
       ignores the mother’s feelings. Additionally, this type of statement gives the mother premature
       reassurance, which may turn out to be false. Asking the mother if she thinks the problem indicates that
       she is not a good mother implies such an idea. It does not allow her to express her concerns and
       feelings and therefore is not a therapeutic response.
       CN: Psychosocial integrity; CL: Synthesize

Question 24

24. After surgery to correct pyloric stenosis, the nurse instructs the parents about the
    postoperative feeding schedule for their infant. The parents exhibit understanding of these instructions
    when they state that they can start feeding the child within which of the following time frames?
25. 6 hours.
26. 8 hours.
27. 10 hours.4. 12 hours.

Answer 24

24. 1. Clear liquids containing glucose and electrolytes are usually prescribed 4 to 6 hours after
       surgery. If vomiting does not occur, formula or breast milk then can be gradually substituted for clear
       liquids until the infant is taking normal feedings.
       CN: Physiological adaptation; CL: Evaluate

Question 25

25. Immediately after the first oral feeding after corrective surgery for pyloric stenosis, a 4-
    week-old infant is fussy and restless. Which of the following actions would be most appropriate at
    this time?
26. Encourage the parents to hold the infant.
27. Hang a mobile over the infant’s crib.
28. Give the infant more to eat.
29. Give the infant a pacifier to suck on.

Answer 25

25. 4. Giving the infant a pacifier would help meet nonnutritive sucking needs and ensure oral
       gratification. Additionally, sucking aids in calming the infant. Holding the infant to decrease fussiness
       and restlessness is more effective in an older infant. Also, the reason for the infant’s fussiness needs
       to be explored. Hanging a mobile over the crib frequently does not decrease fussiness. After surgery
       to correct pyloric stenosis, feeding the infant more formula would lead to vomiting, putting additional
       stress on the operative site.
       CN: Reduction of risk potential; CL: Synthesize

Question 26

26. Which of the following behaviors exhibited by the parents of an infant with pyloric stenosis
    should the nurse correctly interpret as a positive indication of parental coping?
27. Telling the nurse that they have to get away for a while.
28. Discussing the infant’s care realistically.
29. Repeatedly asking if their child is normal.
30. Exhibiting fear that they will disturb the infant.

Answer 26

26. 2. The parents’ ability to verbalize the infant’s care realistically indicates that they are
       working through their fears and concerns. This behavior demonstrates an understanding of the infant’s
       condition and needs. Without further data, the fact that the parents have to get away could be
       interpreted as ineffective coping, possibly suggesting that they are unable to handle the situation.
       Continuing to ask about the child’s general condition even after answers have been given does not
       suggest effective coping. The parents are demonstrating that they are unsure of themselves as parents
       or are hoping for positive information. Exhibiting fear that they will disturb the infant does not suggest
       effective coping. This behavior indicates that they are uncertain or lack knowledge about infants.
       CN: Psychosocial integrity; CL: Analyze

Question 27

27. A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after
    surgery, the parents have placed their infant in his own infant seat (see figure). The nurse should do
    which of the following?
28. Reposition the infant to the left side.
29. Ask the parents to put the infant back in his crib.
30. Remind the parents that the infant cannot use a pacifier now.
31. Tell the parents they have positioned their infant correctly.

Answer 27

27. 4. Following pyloromyotomy the infant should be positioned with the head elevated and
       slightly on the right side to promote gastric emptying; the parents have positioned their infant
       correctly. The infant should be positioned on the right side, not the left side. When the child is in a
       crib, the head can be elevated and the infant can be propped on the right side. The infant can use a
       pacifier if needed.
       CN: Basic care and comfort; CL: Evaluate

Question 28

The Client with Intussusception
28. When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse
should expect the mother to relate which of the following about the infant’s crying and episodes of
pain?
1. Constant accompanied by leg extension.
2. Intermittent with knees drawn to the chest.
3. Shrill during ingestion of solids.
4. Intermittent while being held in the mother’s arms.

Answer 28

The Client with Intussusception28. 2. The infant with intussusception experiences acute episodes of colic-like abdominal pain.
Typically, the infant screams and draws the knees to the chest. Between these episodes of acute
abdominal pain, the infant appears comfortable and normal. Feeding does not precipitate episodes of
pain. Additionally, a 4-month-old infant typically would not be ingesting solid foods. Pain exhibited
by crying that occurs when the infant is placed in a reclining position, as in the mother’s arms, is not
associated with intussusception. This type of cry may indicate that the infant wants attention, wants to
be held, or needs to have a diaper change.
CN: Physiological adaptation; CL: Analyze

Question 29

29. When obtaining the nursing history from the mother of an infant with suspected
    intussusception, which of the following questions would be most helpful?
30. “What do the stools look like?”
31. “When was the last time your child urinated?”
32. “Is your child eating normally?”
33. “Has your child had any episodes of vomiting?”

Answer 29

29. 1. For the infant with intussusception, stools characteristically have the appearance of currant
       jelly because of the intestinal inflammation and hemorrhage resulting from intestinal obstruction.
       These stools occur later in the course of the disease process. Questions that focus on urination,
       vomiting, and food intake do not elicit information about the effects of intussusception.
       CN: Physiological adaptation; CL: Analyze

Question 30

30. A nasogastric tube inserted during surgery to correct an infant’s intussusception is no longer
    freely removing gastric secretions. Which of the following should the nurse do next?
31. Aspirate the tube with a syringe.
32. Irrigate the tube with distilled water.
33. Increase the level of suction.
34. Rotate the tube.

Answer 30

30. 1. The first action is to check the placement of the tube to ensure that it is in the correct
       position. To check tube position, the nurse should aspirate the tube with a syringe. A return of gastric
       contents indicates that the end of the tube is in the stomach. Another method is to inject a small amount
       of air while auscultating with a stethoscope over the epigastric area. The tube is irrigated with normal
       saline, not distilled water, and only after the position of the tube is confirmed. The suction level
       should not be increased, because doing so could damage the mucosa. Rotating the tube could irritate
       or traumatize the nasal mucosa.
       CN: Reduction of risk potential; CL: Synthesize

Question 31

31. Which of the following assessments should be the priority for an infant who has had surgery
    to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?
32. Measurement of urine specific gravity.
33. Auscultation of bowel sounds.
34. Inspection of the first stool passed.
35. Measurement of gastric output.

Answer 31

31. 2. Development of a paralytic ileus postoperatively is a functional obstruction of the bowel.
       Bowel sounds initially may be hyperactive, but then they diminish and cease. Measurement of urine
       specific gravity provides information about fluid and electrolyte status. The first stool and the amount
       of gastric output provide information about the return of gastric function.
       CN: Physiological adaptation; CL: Analyze

Question 32

32. An infant is to be discharged after surgery for intussusception. In developing the discharge
    teaching plan, the nurse should tell the mother:
33. The infant will experience a change in the normal home routine.
34. The infant can return to the prehospital routine immediately.
35. The infant needs to ingest more calories at home than what was consumed in the hospital.
36. The infant will continue to experience abdominal cramping for a few days.

Answer 32

32. 1. Infants who have had an interruption in their normal routine and experiences, such as
       hospitalization and surgery, typically manifest behavior changes when discharged. The infant’s normal
       routine has been significantly altered, so it will take time to reestablish another routine. Calorie
       requirements at home will continue to be the same as those in the hospital. The infant does not need
       more calories at home. The surgical procedure corrected the problems, so the infant should not
       continue to have abdominal cramping.
       CN: Physiological adaptation; CL: Create

Question 33

The Client with Inguinal Hernia
33. When assessing an infant with suspected inguinal hernia, which of the following findings
would be most significant?
1. The inguinal swelling is reddened, and the abdomen is distended.
2. The infant is irritable, and a thickened spermatic cord is palpable.
3. The inguinal swelling can be reduced, and the infant has a stool in the diaper.
4. The infant’s diaper is wet with urine, and the abdomen is nontender.

Answer 33

The Client with Inguinal Hernia
33. 1. Abdominal distention and a redness of the inguinal swelling are significant findings. Their
presence in conjunction with area tenderness and inability to reduce the hernia indicate an
incarcerated hernia. An incarcerated hernia can lead to strangulation, necrosis, and gangrene of the
bowel. Other findings associated with strangulation include irritability, anorexia, and difficulty in
defecation. Irritability is nonspecific and could be caused by various factors. A palpable, thickened
spermatic cord on the affected side is diagnostic of inguinal hernia and would be an expected finding.
A wet diaper indicates that urine is being excreted, a finding unrelated to inguinal hernia.CN: Physiological adaptation; CL: Analyze

Question 34

34. The primary care provider is able to reduce an infant’s hernia and schedules the infant for a
    herniorrhaphy in 2 days. The mother asks the nurse why the surgery is not performed now. Which of
    the following responses indicates that the nurse understands the rationale for delaying the surgery?
35. “Delaying the surgery ensures that your infant will receive the proper preoperative
    preparation.”
36. “We need to make sure that your infant receives nothing by mouth for at least 24 hours before
    the surgery.”
37. “Waiting these 2 days helps to allow any edema and inflammation in the area to subside.”
38. “Your infant needs to wear a truss for at least 24 hours before any surgery can be attempted.”

Answer 34

34. 3. If nonoperative reduction is successful, delaying surgery for 2 to 3 days allows the edema
       and inflammation in the inguinal area to subside. Thus, the area to be operated will appear more
       normal, helping to decrease the risk of complications. The preoperative preparation for a
       herniorrhaphy is minimal and is not the reason for delaying the surgery. Typically, the infant is fed
       until a few hours before surgery to prevent dehydration. Trusses do not prevent incarceration, and
       there is no reason to use a truss preoperatively.
       CN: Physiological adaptation; CL: Apply

Question 35

35. Preoperatively, the nurse develops a plan to prepare a 7-month-old infant psychologically for
    a scheduled herniorrhaphy the next day. Which of the following should the nurse expect to implement
    to accomplish this goal?
36. Explaining the preoperative and postoperative procedures to the mother.
37. Having the mother stay with the infant.
38. Making sure the infant’s favorite toy is available.
39. Allowing the infant to play with surgical equipment.

Answer 35

35. 2. The best way to prepare a 7-month-old infant psychologically for surgery is to have the
       primary caretaker stay with the child. Infants in the second 6 months of life commonly develop
       separation anxiety. Therefore, the priority in this case is to support the child by having the parent
       present. Teaching the mother what to expect may decrease her anxiety; this is important because
       infants sense anxiety and distress in parents, but the priority in this case is to have the parent present.
       Actual play and acting out life experiences are appropriate for preschool-age children. Allowing an
       infant to play with surgical equipment would be inappropriate and dangerous.
       CN: Psychosocial integrity; CL: Synthesize

Question 36

36. Which of the following instructions should the nurse expect to include in the discharge
    teaching plan for the parent of an infant who has had an inguinal herniorrhaphy?
37. Change diapers as soon as they become soiled.
38. Apply an abdominal binder.
39. Keep the incision covered with a sterile dressing.
40. Restrain the infant’s hands.

Answer 36

36. 1. Changing a diaper as soon as it becomes soiled helps prevent wound infection, the most
       common complication after inguinal hernia repair in an infant secondary to possible wound
       contamination with urine and stool. Because the surgical wound is unlikely to separate, an abdominal
       binder is unnecessary. The incision may or may not be covered with a dressing. If a dressing is not
       used, the primary care provider may apply a topical spray to protect the wound. Restraining the
       infant’s hands is unnecessary if the diaper is applied snugly. The infant would be unable to get the
       hands into the diaper close to the surgical site.
       CN: Safety and infection control; CL: Create

Question 37

37. A mother asks, “How should I bathe my baby now that he’s had surgery for his inguinal
    hernia?” Which of the following instructions should the nurse give the mother?
38. “Clean his face and diaper area for 2 weeks.”
39. “Use sterile sponges to cleanse the inguinal incision.”
40. “Give him a sponge bath daily for 1 week.”
41. “Give the infant full tub baths every day.”

Answer 37

37. 3. The incision must be kept as clean and dry as possible. Therefore, daily sponge baths are
       given for about 1 week postoperatively. Cleaning the infant’s face and diaper area should occur at
       least daily and continuously, not limited to a 2-week period. Because this type of surgery results in a
       wound that heals through primary intention, the skin will heal and cover the wound in 2 to 3 days.
       Therefore, it is not necessary to use sterile gauze to cleanse the incision; clean technique is
       acceptable. Because the incision must be kept as clean and dry, full tub baths are inappropriate.
       CN: Reduction of risk potential; CL: Synthesize

Question 38

38. A male adolescent who underwent repair of an inguinal hernia earlier today and is getting
ready to go home receives instructions about resuming physical activities. Which of the following
statements would indicate that he has understood the instructions?
1. “I can start riding my bike next week.”
2. “I have to skip physical education classes for 2 weeks.”
3. “I can start wrestling again in 3 weeks.”4. “I can return to my weight-lifting class in 2 weeks.”

Answer 38

38. 3. Because of possible stress on the suture line, physical activities such as bicycle riding,
       physical education classes, weight lifting, and wrestling are contraindicated for about 3 weeks.
       CN: Basic care and comfort; CL: Evaluate

Question 39

The Client with Hirschsprung’s Disease
39. During physical assessment of a 4-month-old infant with Hirschsprung’s disease, the nurse
should most likely note which of the following?
1. Scaphoid-shaped abdomen.
2. Weight less than expected for height and age.
3. Cyanosis of the fingers and toes.
4. Hyperactive deep tendon reflexes.

Answer 39

The Client with Hirschsprung’s Disease
39. 2. Infants with Hirschsprung’s disease typically display failure to thrive, with poor weight
gain due to malabsorption of nutrients. Therefore, the nurse would expect to see a child who weighs
less than that which is expected for height and age. A distended, rather than a scaphoid-shaped,
abdomen would be noted. Cyanosis of fingers and toes is associated with congenital heart disease.
Hyperactive deep tendon reflexes are associated with upper motor neuron problems, such as cerebralpalsy.
CN: Physiological adaptation; CL: Analyze

Question 40

40. An infant diagnosed with Hirschsprung’s disease is scheduled to receive a temporary
    colostomy. When initially discussing the diagnosis and treatment with the parents, which of the
    following would be most appropriate?
41. Assessing the adequacy of their coping skills.
42. Reassuring them that their child will be fine.
43. Encouraging them to ask questions.
44. Giving them printed material on the procedure.

Answer 40

40. 3. By encouraging parents to ask questions during information-sharing sessions, the nurse can
       clarify misconceptions and determine the parents’ understanding of information. A better
       understanding of what is happening allows the parents to feel some control over the situation.
       Assessing the adequacy of the parents’ coping skills is important but secondary to encouraging them to
       express their concerns. The questions they ask and their interactions with the nurse may provide clues
       to the adequacy of their coping skills. The nurse should never give false reassurance to parents. At
       this point, there is no way for the nurse to know whether the child will be fine. Written materials are
       appropriate for augmenting the nurse’s verbal communication. However, these are secondary to
       encouraging questions.
       CN: Psychosocial integrity; CL: Synthesize

Question 41

41. After teaching the parents of an infant diagnosed with Hirschsprung’s disease, the nurse
    determines that the parents understand the diagnosis when the father states which of the following?
42. “There is no rectal opening for stool to pass.”
43. “There is a tube between the trachea and esophagus.”
44. “The nerves at the end of the large colon are missing.”
45. “The muscle below the stomach is too tight.”

Answer 41

41. 3. The primary defect in Hirschsprung’s disease is an absence of autonomic parasympathetic
       ganglion cells in the distal portion of the colon. Thus, the nerves at the end of the large colon are
       missing. Absence of a rectal opening refers to an imperforate anus. A tube between the trachea and
       esophagus refers to a tracheoesophageal fistula. Presence of a tight muscle below the stomach refers
       to pyloric stenosis.
       CN: Physiological adaptation; CL: Evaluate

Question 42

42. When developing the preoperative plan of care for an infant with Hirschsprung’s disease,
    which of the following should the nurse include?
43. Administering a tap water enema.
44. Inserting a gastrostomy tube.
45. Restricting oral intake to clear liquids.
46. Using povidone-iodine solution to prepare the perineum.

Answer 42

42. 3. Before intestinal surgery, dietary intake is limited to clear liquids for 24 to 48 hours. A
       clear liquid diet meets the child’s fluid needs and avoids the formation of fecal material in the
       intestine. Typically, repeated saline enemas, not tap water enemas, are given to empty the bowel.
       Soapsuds enemas are contraindicated for infants, as are tap water enemas. A nasogastric tube may be
       inserted for gastric decompression. Insertion of a gastrostomy tube is outside the scope of nursing
       practice. Because the perineal area is not involved in the surgery, it does not need to be prepared.
       CN: Physiological adaptation; CL: Create

Question 43

43. The nurse is showing the parent of a child with Hirschsprung’s disease where the aganglionic
    area is located. Identify the area the nurse should point out as being aganglionic.

Answer 43

43. In most instances, the absence of ganglionic innervation occurs in the lower portion of the
    sigmoid colon just above the anus.
    CN: Physiological adaptation; CL: Apply

Question 44

44. An infant diagnosed with Hirschsprung’s disease undergoes surgery with the creation of a
    temporary colostomy. Which of the following statements by the parent regarding the colostomy
    indicates the need for further teaching?
45. “The colostomy is only temporary.”
46. “The colostomy will give time for the nerves to return to normal.”
47. “The colostomy may include two separate abdominal openings.”
48. “Right after the procedure the stoma may appear purple.”

Answer 44

44. 2. The goal of the surgery is to remove the aganglionic portion of the intestine. The remaining
       intestines should have normal innervation. Colostomies are used to relieve the obstruction and allow
       the remaining intestines to return to normal size. A temporary loop or double-barreled colostomy has
       stomas for both the proximal and distal portion of the bowel. The final surgical repair is usually done
       when the infant is around 20 lb (9.1 kg). A new stoma is frequently swollen and bruised after surgery.
       CN: Physiological adaptation; CL: Evaluate

Question 45

45. When teaching the mother of an infant who has received a temporary colostomy for treatment
    of Hirschsprung’s disease about how the stoma should normally appear, which of the following
    descriptions about the stoma’s appearance should the nurse include in the teaching?
46. Becoming dark brown in 2 months.
47. Staying deep red in color.
48. Changing to several shades of pink.
49. Turning almost purple in color.

Answer 45

45. 2. Typically, the stoma should remain deep red in color as long as the infant has the colostomy.
       A dark red to purplish color may indicate impaired circulation to the stoma.
       CN: Physiological adaptation; CL: Create

Question 46

46. When teaching the parent of an infant with Hirschsprung’s disease who received a temporary
    colostomy about the types of foods the infant will be able to eat, which of the following would the
    nurse recommend?
47. High-fiber diet.
48. Low-fat diet.
49. High-residue diet.
50. Regular diet.

Answer 46

46. 4. A regular diet would be recommended for the child with a colostomy; no special diet is
       needed. High-fiber foods, such as fruits and vegetables, should be minimized because they increase
       the bulk in the stool. Fat is necessary for brain growth in the first year of life. A high-residue diet
       would result in bulkier stools and increased gas production, which will collect in the colostomy bag.
       Therefore, a high-residue diet is not indicated.
       CN: Basic care and comfort; CL: Apply

Question 47

47. An infant with Hirschsprung’s disease is to be discharged 1 or 2 days after surgery to create a
    colostomy. After teaching the infant’s parents about the overall effects of their infant’s surgery, the
    nurse determines that the teaching has been effective when the parents state which of the following?
48. “His abdomen will be large for awhile.”
49. “When he’s ready, toilet training may be difficult.”3. “We need to limit his intake of dairy products.”
50. “We will give him vitamin supplements until he is an adolescent.”

Answer 47

47. 2. Toilet-training is commonly more difficult for children who have undergone surgery for
       Hirschsprung’s disease than it is for other children. This is because of the trauma to the area and the
       associated psychological implications. Abdominal distention is an early sign of infection and
       therefore the parents need to report it to the primary care provider. Typically, dietary restrictions are
       not required. Usually the infant is placed on an age-appropriate diet. Vitamin supplementation is not
       necessary if the infant’s dietary intake is adequate.
       CN: Physiological adaptation; CL: Evaluate

Question 48

The Client with Diarrhea, Gastroenteritis, or
Dehydration
48. A nurse is caring for a 10-month-old, weighing 8.0 kg, who was admitted for dehydration.
The infant has vomited five times in the last 3 hours and has had no wet diapers in the last 8 hours.
The nurse informs the primary health care provider. Which of the following prescriptions should the
nurse question?
1. Begin an intravenous line of D5W .45% normal saline at 40 mL/h.
2. NPO except for medication administration while vomiting persists.
3. Begin an intravenous line and administer a fluid bolus of dextrose 25%.
4. Strict intake and output; weighing all diapers.

Answer 48

The Client with Diarrhea, Gastroenteritis, or Dehydration
48. 3. The infant is in need of a fluid bolus. A fluid bolus should consist of an isotonic fluid suchas normal saline or lactated ringers. Dextrose 25% is not an appropriate bolus for dehydrated
children because it could cause a fluid shift that may result in cerebral edema and death. D5 .45%
normal saline is an appropriate IV fluid for infants. The rate is 1.5 times maintenance for this child
and is appropriate for the first 24 hours if the child is dehydrated. Once hydration is adequate, the
infant’s IV rate should be reduced to a maintenance rate. Vomiting is persistent, so it is appropriate for
the child to be NPO. Strict I and O is an appropriate prescription for all dehydrated children.
CN: Safety and infection control; CL: Analyze

Question 49

49. A mother brings her 3-month-old child into the emergency department. The child is listless
    with dry mucous membranes, tenting of the skin on the forehead, a depressed fontanel, and a history of
    vomiting and diarrhea for the last 36 hours. In what order from first to last should the nurse implement
    the primary care provider’s prescriptions?
50. Obtain vital signs and weight.
51. Insert an IV and infuse fluids.
52. Apply a urine collection bag.
53. Draw blood for laboratory tests.

Answer 49

49.
1. Obtain vital signs and weight.
3. Apply a urine collection bag.
2. Insert an IV and infuse fluids as prescribed.
4. Draw blood for laboratory tests.
The nurse should first obtain vital signs and evaluate the child for signs of shock or cardiac
arrhythmias. The weight can also be obtained at this time to estimate the amount of fluid lost. The
nurse should next apply the urine collection bag. As soon as possible after these steps, the nurse
should insert an IV to replace lost fluids, electrolytes, and sugar to reduce the incidence of metabolic
acidosis created by the lack of calorie intake and the loss of electrolytes. Blood should be drawn to
assess the severity of electrolyte imbalance and other possible causes for the diarrhea and vomiting.
CN: Physiological adaptation; CL: Synthesize

Question 50

50. A child is admitted with a tentative diagnosis of shigella. The nurse should do which of the
    following? Select all that apply.
51. Assess the child for nausea and vomiting.
52. Collect a stool specimen for white blood cells (WBCs).
53. Place the child on airborne precautions.
54. Monitor the child for signs and symptoms of dehydration.
55. Initiate an intake and output record.

Answer 50

50. 1,2,4,5. Shigella is caused by the Shigella organism. Clinical manifestations of shigella
    include fever, nausea and vomiting, some cramping, headache, seizures, rectal prolapse, and loose,
    watery stools containing pus, mucus, and blood. The nurse should assess the child for these symptoms
    on an ongoing basis. Shigella is spread via direct contact with the organism, which is found in the
    stool. A stool specimen will show increased numbers of WBCs, blood, and mucus. Vomiting and
    loose stools can result in severe dehydration and electrolyte imbalance. Thus, the nurse should record
    intake, output, and daily weights. There is no need for strict isolation; masks are not needed as
    shigella is not transmitted by airborne methods.
    CN: Physiological adaptation; CL: Synthesize

Question 51

51. Which of the following would most likely alert the nurse to the possibility that a preschooler
    is experiencing moderate dehydration?1. Deep, rapid respirations.
52. Diaphoresis.
53. Absence of tear formation.
54. Decreased urine specific gravity.

Answer 51

51. 3. The absence of tears is typically found when moderate dehydration is observed as the body
       attempts to conserve fluids. Other typical findings associated with moderate dehydration include a
       dry mouth, sunken eyes, poor skin turgor, and an increased pulse rate. Deep, rapid respirations are
       associated with severe dehydration. Decreased perspiration, not diaphoresis, would be seen with
       moderate dehydration. The specific gravity of urine increases with decreased output in the presence
       of dehydration.
       CN: Reduction of risk potential; CL: Analyze

Question 52

52. Which of the following would be an important assessment finding for an 8-month-old infant
admitted with severe diarrhea?
1. Bowel sounds every 5 seconds.
2. Pale yellow urine.
3. Normal skin elasticity.
4. Depressed anterior fontanel.

Answer 52

52. 4. An infant with severe diarrhea will experience some degree of dehydration. In an 8-month-
       old child, the anterior fontanel has not closed. Therefore, a depressed anterior fontanel would be an
       important finding. Additionally, the infant would exhibit dry mucous membranes, lethargy, hyperactive
       bowel sounds, dark urine, and sunken eyeballs. Skin turgor would be decreased or delayed (eg, slow
       to return when pinched). Bowel sounds every 5 seconds would not be considered abnormal for an
       infant.
       CN: Reduction of risk potential; CL: Analyze

Question 53

53. Which of the following would be the best activity for the nurse to include in the plan of care
    for an infant experiencing severe diarrhea?
54. Monitoring the total 8-hour formula intake.
55. Weighing the infant each day.
56. Checking the anterior fontanel every shift.
57. Monitoring abdominal skin turgor every shift.

Answer 53

53. 2. Because an infant experiencing severe diarrhea is at high risk for a fluid volume deficiency,
       the nurse needs to evaluate the infant’s fluid balance status by weighing the infant at least every day.
       Body weight is the best indicator of hydration status because a higher proportion of an infant’s body
       weight is water, compared with an adult. Initially, the infant with severe diarrhea is not allowed
       liquids but is given fluids intravenously. Therefore, monitoring the oral intake of formula is
       inappropriate. Although checking the anterior fontanel for depression or bulging provides information
       about hydration status, this method is not considered the best indicator of the infant’s fluid balance.
       Monitoring skin turgor can provide information about fluid volume status. The abdomen is commonly
       used to assess skin turgor in an infant because it is a large surface area and can be accessed quickly.
       However, weight is the best indicator of fluid balance.
       CN: Physiological adaptation; CL: Synthesize

Question 54

54. The primary care provider prescribes an intravenous infusion of 5% dextrose in 0.45 normal saline to
    be infused at 2 mL/kg/h in an infant who weighs 9 lb (4.1 kg). How many milliliters per hour of the
    solution should the nurse infuse? Round to one decimal.
    ________________________ mL/h.

Answer 54

54. 8.2 mL/h

CN: Pharmacological and parenteral therapies; CL: Apply

Question 55

55. A 3-year old with dehydration has vomited three times in the last hour and continues to have
    frequent diarrhea stools. The child was admitted 2 days ago with gastroenteritis caused by rotavirus.
    The child weighs 22 kg, has a normal saline lock in his right hand, and has had 30 mL of urine output
    in the last four hours. Using the SBAR (Situation-Background-Assessment-Recommendation)
    technique for communication, the nurse calls the primary health care provider with the
    recommendation for:
56. Giving a dose of loperamide (Imodium).
57. Starting a fluid bolus of normal saline.
58. Beginning an IV antibiotic.
59. Establishing a Foley catheter.

Answer 55

55. 2. The child is dehydrated, is not able to retain oral fluids, and continues to have diarrhea. A
       normal saline bolus should be given followed by maintenance of IV fluids. Antidiarrheal medications
       are not recommended for children and will prolong the illness. The child has gastroenteritis caused
       by a viral illness. IV antibiotics are not indicated for viral illnesses. Strict I&O is important in all
       children with gastroenteritis.
       CN: Reduction of risk potential; CL: Apply

Question 56

56. Which of the following would be most appropriate for the nurse to teach the mother of a 6-
    month-old infant hospitalized with severe diarrhea to help her comfort her infant who is fussy?
57. Offering a pacifier.
58. Placing a mobile above the crib.
59. Sitting at crib side talking to the infant.
60. Turning the television on to cartoons.

Answer 56

56. 1. Typically, an infant hospitalized with severe diarrhea receives fluid replacement
       intravenously rather than orally. Oral fluids and food are usually withheld. Although activities such as
       placing a mobile over the crib, speaking to the infant, or turning on the television may provide
       distraction for or help in calming the infant, a fussy infant receiving nothing by mouth is usually best
       comforted by providing a pacifier to satisfy sucking needs.
       CN: Health promotion and maintenance; CL: Synthesize

Question 57

57. Which of the following would be appropriate for the nurse to identify as a priority nursing
    problem for an infant just admitted to the hospital with a diagnosis of gastroenteritis?
58. Pain related to repeated episodes of vomiting.
59. Deficient fluid volume related to excessive losses from severe diarrhea.
60. Impaired parenting related to infant’s loss of fluid.
61. Impaired urinary elimination related to increased fluid intake feeding pattern.

Answer 57

57. 2. Given this infant’s history of gastroenteritis, the priority problem would be fluid volume
       deficit. With gastroenteritis, vomiting and diarrhea occur, leading to the loss of fluids. This loss of
       fluids is problematic in infants because a higher proportion of their body weight is water. Pain is not
       a priority problem, although the nurse should continue to assess the infant for pain. There are no data
       to indicate impaired parenting. Impaired urinary elimination is related to the infant’s fluid volume
       deficit resulting from vomiting and diarrhea associated with gastroenteritis. If the infant’s fluid
       volume deficit is not corrected, then this nursing diagnosis may become the priority.
       CN: Physiological adaptation; CL: Analyze

Question 58

58. The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step
    of the treatment plan once the infant’s condition has been controlled. The nurse determines that the
    father understands when he explains which of the following will occur with his infant?
59. The infant will receive clear liquids for a period of time.
60. Formula and juice will be offered.
61. Blood will be drawn daily to test for anemia.
62. The infant will be allowed to go to the playroom.

Answer 58

58. 1. The usual way to treat an infant hospitalized with gastroenteritis is to keep the infantnothing-by-mouth status to rest the gastrointestinal tract. The resulting fluid volume deficit is treated
       with intravenous fluids. When the infant’s condition is controlled (eg, when vomiting subsides), clear
       liquids are then started slowly. Formula and juice will be started once the infant’s vomiting has
       subsided and the infant has demonstrated the ability to tolerate clear liquids for a period of time. In
       this situation, there is no need to test the infant’s blood every day for anemia. Most likely, the infant’s
       serum electrolyte levels would be monitored closely. Typically, an infant is placed in a private room
       because gastroenteritis is most commonly caused by a virus that is easily transmitted to others.
       CN: Physiological adaptation; CL: Evaluate

Question 59

59. The mother of a toddler who has just been admitted with severe dehydration secondary to
    gastroenteritis says that she cannot stay with her child because she has to take care of her other
    children at home. Which of the responses by the nurse would be most appropriate?
60. “You really shouldn’t leave right now. Your child is very sick.”
61. “I understand, but feel free to visit or call anytime to see how your child is doing.”
62. “It really isn’t necessary to stay with your child. We’ll take very good care of him.”
63. “Can you find someone to stay with your children? Your child needs you here.”

Answer 59

59. 2. The nurse’s best course of action would be to support the mother. This is best done by
       conveying understanding and encouraging the mother to visit or call. Telling the mother that she
       shouldn’t leave and that the child is very sick is critical and insensitive. Additionally, it implies guilt
       should the mother leave. Commenting that the child does not need anyone is not appropriate or true.
       Toddlers, in particular, need family members present because of the stresses associated with
       hospitalization. They experience separation anxiety, a normal aspect of development, and need
       constancy in their environment. Asking the mother to find someone else to stay with her children is
       inappropriate. The children at home also need the support of the mother and/or other family members
       to minimize the disruptions in family life resulting from the toddler’s hospitalization and to maintain
       consistency.
       CN: Psychosocial integrity; CL: Synthesize

Question 60

60. A 9-month-old is admitted because of dehydration. How should the nurse go about accurately
    monitoring fluid intake and output? Select all that apply.
61. Weighing and recording all wet diapers.
62. Change breast-feedings to bottle-feedings.
63. Obtaining an accurate daily weight.
64. Restricting fluids prior to weighing the child.
65. Obtaining an accurate stool count.

Answer 60

60. 1, 3, 5. Accurate intake and output recording includes noting all intake, including IV fluids;
    noting output, such as emesis and stool; weighing diapers; measuring weight daily; measuring urine
    specific gravity; monitoring serum electrolytes; and monitoring for signs of dehydration. Children
    who are dehydrated must receive sufficient fluid intake, but having a breast-feeding child switch to
    bottle-feeding will not promote intake. Restricting fluids just prior to weighing the child will not alter
    the accuracy of the weight, and the nurse should continue to encourage fluids for this dehydrated
    child.
    CN: Management of care; CL: Analyze

Question 61

61. The primary care provider prescribes intravenous fluid replacement therapy with potassium
    chloride to be added for a child with severe gastroenteritis. Before adding the potassium chloride to
    the intravenous fluid, which of the following assessments would be most important?
62. Ability to void.
63. Passage of stool today.
64. Baseline electrocardiogram.
65. Serum calcium level.

Answer 61

61. 1. Potassium chloride is readily excreted in the urine. Before adding potassium chloride to the
       IV fluid, the nurse should ascertain whether the child can void; if not, potassium chloride may build
       up in the serum and cause hyperkalemia. An electrocardiogram could be done during intravenous
       potassium replacement therapy to evaluate for these changes. Having a stool daily is important but,
       because potassium is primarily excreted in the urine, the child’s ability to void must be verified.
       Serum calcium levels do not indicate the child’s ability to tolerate potassium replacement.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 62

62. Which of the following would alert the nurse to suspect that a child with severe
    gastroenteritis who has been receiving intravenous therapy for the past several hours may be
    developing circulatory overload?
63. A drop in blood pressure.
64. Change to slow, deep respirations.
65. Auscultation of moist crackles.
66. Marked increase in urine output.

Answer 62

62. 3. An early sign of circulatory overload is moist rales or crackles heard when auscultating
       over the chest wall. Elevated blood pressure, engorged neck veins, a wide variation between fluid
       intake and output (with a higher intake than output), shortness of breath, increased respiratory rate,
       dyspnea, and cyanosis occur later.
       CN: Reduction of risk potential; CL: Analyze

Question 63

63. The stool culture of a child with profuse diarrhea reveals Salmonella bacilli. After teaching
    the mother about the course of Salmonella enteritidis, which of the following statements by the
    mother indicates effective teaching?
64. “Some people become carriers and stay infectious for a long time.”
65. “After the acute stage passes, the organism is usually not present in the stool.”
66. “Although the organism may be alive indefinitely, in time it will be of no danger to anyone.”
67. “If my child continues to have the organism in the stool, an antitoxin can help destroy theorganism.”

Answer 63

63. 1. After having S. enteritidis, some clients become chronic carriers of the causative organism
       and remain infectious for a long time as the organism continues to be shed from the body. During this
       time, the child is still considered infectious. No antitoxin is available to treat or prevent Salmonellainfections.
       CN: Physiological adaptation; CL: Evaluate

Question 64

64. A child is started on a soft diet after having been on clear liquids following an episode of
    severe gastroenteritis. When helping the mother choose foods for her child, which of the following
    foods would be most appropriate?
65. Muffins and eggs.
66. Bananas and rice cereal.
67. Bran cereal and a bagel.
68. Pancakes and sausage.

Answer 64

64. 2. After clear liquids, the foods of choice are soft foods. These foods should be easily
       digested and low in fat. Additionally, the foods should be nonbulk-forming. Bananas and rice cereal
       are low in fat and easy to digest. Muffins and eggs, as well as sausage and pancakes, are typically
       high in fat and would be avoided. Although a bagel is low in fat, bran cereal is high in fiber and
       would be avoided because it may cause more diarrhea.
       CN: Basic care and comfort; CL: Synthesize

Question 65

65. A child undergoes rehydration therapy after having diarrhea and dehydration. A nurse is
    teaching the child’s parents about dietary management. The nurse understands that the teaching plan
    has been successful when the parents tell the nurse that they will follow which type of diet?
66. Regular.
67. Clear liquid.
68. Full liquid.
69. Soft.

Answer 65

65. 1. Dietary management following rehydration for diarrhea and mild dehydration would
       include offering the child a regular diet. Following rehydration, there is no need for the child to be on
       a special diet, such as a clear liquid, full liquid, or soft diet.
       CN: Basic care and comfort; CL: Evaluate

Question 66

66. When obtaining a history from the parents of a child diagnosed with diarrhea due to
    Salmonella, the nurse should ask the parents if the child has been exposed to which of the following
    possible sources of infection?
67. Nonrefrigerated custard.
68. A pet canary.
69. Undercooked eggs.
70. Unwashed fruit.

Answer 66

66. 3. Diarrhea related to Salmonella bacilli is commonly spread by raw or undercooked fowl
       and eggs, pet turtles, and kittens. Food poisoning caused by Staphylococcus species is commonly
       spread by inadequately cooked or refrigerated custards, cream fillings, or mayonnaise. Psittacosis, a
       respiratory illness, may be spread by canaries. Contaminated, unwashed fruit is associated with
       typhoid fever (caused by Salmonella typhi), a disorder rarely seen in the United States.
       CN: Physiological adaptation; CL: Analyze

Question 67

67. On a home visit following discharge from the hospital after treatment for severe
    gastroenteritis, the mother tells the nurse that her toddler answers “No!” and is difficult to manage.
    After discussing this further with the mother, the nurse explains that the child’s behavior is most likely
    the result of which of the following?
68. Beginning leadership skills.
69. Inherited personality trait.
70. Expression of individuality.
71. Usual lack of interest in everything.

Answer 67

67. 3. The “no” behavior demonstrated by a toddler is typical of this age group as the child
       attempts to be self-assertive as an individual. The negativism does not demonstrate an inherited
       personality trait or disinterest. Rather, it reflects the developmental task of establishing autonomy.
       The toddler is attempting to exert control over the environment. It is too early to assess leadership
       qualities in a toddler.
       CN: Health promotion and maintenance; CL: Analyze

Question 68

68. The mother of a toddler hospitalized for episodes of diarrhea reports that when her toddler
    cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The
    mother says, “I don’t know what to do!” After teaching the mother about ways to manage this
    behavior, which of the following statements indicates that the nurse’s teaching was successful?
69. “Next time she screams and throws her legs, I’ll ignore the behavior.”
70. “I’ll allow her to have what she wants once in a while.”
71. “I’ll explain why she cannot have what she wants.”
72. “When she behaves like this, I’ll tell her that she is being a bad girl.”

Answer 68

68. 1. The child is demonstrating behavior associated with temper tantrums, which are relatively
       frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy.
       The development of autonomy requires opportunities for the child to make decisions and express
       individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the
       behavior and helps the child to learn limits, promoting the development of self-control. However, the
       mother should intervene in a temper tantrum if the child is likely to injure herself. Allowing the child
       to have what she wants occasionally would typically add to the problems associated with temper
       tantrums, because doing so rewards the behavior and prevents the child from developing self-control.
       Toddlers do not possess the capacity to understand explanations about behavior. Expressing
       disappointment in the child’s behavior or telling her that she is being a bad girl reinforces feelings of
       guilt and shame, thus interfering with the child’s ability to develop a sense of autonomy.
       CN: Health promotion and maintenance; CL: Evaluate

Question 69

69. The mother of a toilet-trained toddler who was admitted to the hospital for severe
    gastroenteritis and subsequent dehydration and is now at home asks the nurse why the child still wets
    the bed. Which of the following should be the nurse’s best response?
70. “Hospitalization is a traumatic experience for children. Regression is common and it takestime for them to return to their former behavior.”
71. “The stress of hospitalization is hard for many children, but usually they have no problems
    when they return home.”
72. “After returning home from being hospitalized, children still feel they should be the center of
    attention.”
73. “Children do not feel comfortable in their home surroundings once they return home from being
    hospitalized.”

Answer 69

69. 1. Hospitalization is a traumatic time for a child, and it takes some time to readjust to the
       home environment. The child may regress at home for a period until she feels comfortable. Children
       normally do not dislike their home environment; in fact, they usually are eager to get home to familiar
       surroundings where they feel safe.
       CN: Health promotion and maintenance; CL: Synthesize

Question 70

The Client with Appendicitis
70. An adolescent is being seen in the clinic for abdominal pain with a fever. In what order
should the nurse assess the abdomen?
1. Auscultate.
2. Inspect.
3. Palpate.
4. Percuss.

Answer 70

The Client with Appendicitis
70. 2,1,4,3. The nurse should first inspect the abdomen for abnormalities. Auscultation should be
done before percussion and palpation as vigorous touching may disturb the intestines. Percussion is
next. Palpation is the last step as it is most likely to cause pain.
CN: Basic care and comfort; CL: Apply

Question 71

71. A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain.
    Which of the following nursing interventions would be appropriate prior to surgery to decrease pain?
    Select all that apply.
72. Offer an ice pack.
73. Apply a heating pad.
74. Encourage the child to assume a position of comfort.
75. Limit the child’s activity.
76. Request a prescription for a cathartic

Answer 71

71. 1,3,4. Cold is a vasoconstrictor and supplies some degree of anesthesia. The child is usually
    more comfortable on his side with his legs flexed to take the strain off the inflamed appendix.
    Limiting the child’s activity puts less stress on the inflamed appendix and lessens the discomfort. Heat
    increases circulation to an area, causing more engorgement and pain and, possibly, rupture of the
    appendix. Heat is contraindicated in any situation where rupture or perforation is a possibility. A
    cathartic is contraindicated when appendicitis is suspected. Increasing peristalsis can cause the
    appendix to rupture.
    CN: Physiological adaptation; CL: Synthesize

Question 72

72. A 10-year old male is 24 hours postappendectomy. He is awake, alert, and oriented. He tells
    the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN pain. What
    is the priority nursing action in managing the child’s pain?
73. Change the child’s position in bed.
74. Obtain vital signs with a pain score.
75. Administer 1 mg morphine as prescribed.
76. Perform a head to toe assessment.

Answer 72

72. 2. The child is in pain and needs intervention but before the nurse can determine how to
       proceed, it is essential to know the client’s pain score to determine the appropriate morphine dose. In
       addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score
       prior to administering the medication. Changing the child’s position and administering pain
       medication may be helpful to relieve the child’s pain but the nurse must first know the severity of the
       pain before determining the appropriate intervention. The nurse must perform a head to toe
       assessment however it is not the priority in managing the child’s pain.
       CN: Basic care and comfort; CL: Analyze

Question 73

73. A 5-year-old child is experiencing pain after an appendectomy. Which data collection tool
should the nurse use to assess the pain?
1. Visual analog scale.
2. FLACC scale.
3. Numerical pain scale.
4. FACES pain rating scale.

Answer 73

73. 4. The nurse should use the FACES pain rating scale for children aged three or older. The
       visual analog and numerical scales are used with adults. The FLACC (faces-legs-activity-cry-
       consolability) scale is a behavioral scale that is appropriate for very small children or nonverbal
       children.
       CN: Basic care and comfort; CL: Analyze

Question 74

74. A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24
    hours. There is a prescription to administer Tylenol (acetaminophen) with Codeine every 3 to 4 hours
    as needed. The nurse is beginning the shift and the child is requesting pain medication. The nurse
    reviews the chart below for pain history. Based on the information in the chart, what should the nurse
    do next?
75. Administer the Tylenol with Codeine.
76. Distract the child by giving him breakfast.
77. Instruct the child to take deep breaths and blow his pain away.
78. Assess the child again in 1 hour.

Answer 74

74. 1. The nurse should administer the Tylenol with Codeine as the client indicates he is having
       pain. Although the child reports less severe pain, he is still experiencing pain. The nurse will also
       want the child to have less pain because he will need to be more active during the day. Assessing the
       child later will likely cause the pain to have increased and be more difficult to manage. While
       distraction is appropriate for short-term pain, such as from a needlestick or pain that the child might
       be able to manage himself, postoperative pain should be relieved with medication.
       CN: Basic care and comfort; CL: Synthesize

Question 75

75. When obtaining the initial health history from a 10-year-old child with abdominal pain and
    suspected appendicitis, which of the following questions would be most helpful in eliciting data to
    help support the diagnosis?
76. “Where did the pain start?”
77. “What did you do for the pain?”
78. “How often do you have a bowel movement?”
79. “Is the pain continuous, or does it let up?”

Answer 75

75. 1. The most helpful question would be to determine the location of the pain when it started.
       The pain associated with appendicitis usually begins in the periumbilical area, and then progresses to
       the right lower quadrant. After the nurse has determined the location of the pain, asking about what
       was done for the pain would be appropriate. Asking about the child’s usual bowel movement pattern
       is a general question unrelated to child’s condition. Children with appendicitis may have diarrhea or
       constipation. Additionally, knowledge about the child’s usual pattern would not be a priority because
       the child with appendicitis typically is not hospitalized long enough to reestablish the normal pattern.
       Although the characteristics of the pain are important, asking if the pain is continuous or intermittentis vague and general because the pain could be associated with numerous conditions. With
       appendicitis, the client’s pain may begin as intermittent, but it eventually becomes continuous.
       CN: Physiological adaptation; CL: Analyze

Question 76

76. When developing the plan of care for a school-age child with a suspected diagnosis of
    appendicitis who has severe abdominal pain, which of the following measures should the nurse
    expect to include in the child’s plan of care?
77. Application of a heating pad.
78. Insertion of a rectal tube.
79. Application of an ice bag.
80. Administration of an intravenous narcotic.

Answer 76

76. 3. Application of an ice bag may help to relieve pain by decreasing circulation to the area. A
       heating pad is contraindicated because heat may increase circulation to the appendix, possibly
       leading to rupture. Rectal tubes are contraindicated because they stimulate bowel motility and can
       exacerbate abdominal pain. Also, they would be ineffective because accumulation of gas in the lower
       bowel is not likely to be the cause of the child’s discomfort. Because narcotics can mask the child’s
       symptoms, such as pain and discomfort, and they also decrease bowel motility, they are not given
       until after a definitive diagnosis has been made.
       CN: Physiological adaptation; CL: Create

Question 77

77. Which of the following assessment findings should alert the nurse to suspect appendicitis in a
    male adolescent with severe abdominal pain?
78. Abdomen appears slightly rounded.
79. Bowel sounds are heard twice in 2 minutes.
80. All four abdominal quadrants reveal tympany.
81. The client demonstrates a cremasteric reflex

Answer 77

77. 2. Manifestations of appendicitis include decreased or absent bowel sounds. Normally, bowel
       sounds are heard every 10 to 30 seconds. Therefore, bowel sounds heard twice in 2 minutes suggests
       appendicitis. Normally, the contour of the male adolescent abdomen is flat to slightly rounded, and
       tympany is typically heard when auscultating over most of the abdomen. A cremasteric reflex is
       normal for male adolescents.
       CN: Physiological adaptation; CL: Analyze

Question 78

78. An adolescent male client scheduled for an emergency appendectomy is to be transferred
    directly from the emergency room to the operating room. Which of the following statements by the
    client should the nurse interpret as most significant?
79. “All of a sudden it doesn’t hurt at all.”2. “The pain is centered around my navel.”
80. “I feel like I’m going to throw up.”
81. “It hurts when you press on my stomach.”

Answer 78

78. 1. Sudden relief of pain in a client with appendicitis may indicate that the appendix has
       ruptured. Rupture relieves the pressure within the appendix but spreads the infection to the peritoneal
       cavity. Periumbilical pain (pain centered around the navel), vomiting, and abdominal tenderness on
       palpation are common findings associated with appendicitis.
       CN: Physiological adaptation; CL: Analyze

Question 79

79. Which of the following should be the priority assessment for an adolescent on return to the
nursing unit after an appendectomy?
1. The dressing on the surgical site.
2. Intravenous fluid infusion site.
3. Nasogastric (NG) tube function.
4. Amount of pain.

Answer 79

79. 1. The priority assessment after an appendectomy would be the dressing over the surgical site
       to determine whether there is any drainage or bleeding. The surgical dressing should be clean, dry,
       and intact. Once the dressing has been assessed, the nurse would assess the intravenous infusion site,
       assess the NG tube to be sure it is functioning, and finally, determine the degree of pain the client is
       experiencing.
       CN: Physiological adaptation; CL: Analyze

Question 80

80. An adolescent who has had an appendectomy and developed peritonitis has nausea. Which of
the following should the nurse do first?
1. Administer an antiemetic.
2. Irrigate the nasogastric (NG) tube.
3. Notify the surgeon.
4. Take the blood pressure.

Answer 80

80. 2. After an appendectomy, the client who develops peritonitis typically has an NG tube in
       place. When a client has nausea, the nurse would first check to ensure that the NG tube is functioning
       correctly, because the client’s nausea may be related to a blockage of the NG tube. If the tube is
       clogged, it can be irrigated with normal saline. An antiemetic may be given, but only after the nurse
       has determined that the NG tube is functioning properly. Postoperative prescriptions usually include
       an antiemetic. Typically, the nurse would notify the surgeon if the client did not obtain relief from
       irrigation of the NG tube or administration of a prescribed antiemetic. Although taking the client’s
       blood pressure is an important postoperative nursing activity, it is unrelated to relieving the client’s
       nausea.
       CN: Physiological adaptation; CL: Synthesize

Question 81

81. When developing the postoperative plan of care for an adolescent who has undergone an
    appendectomy for a ruptured appendix, in which of the following positions should the nurse expect to
    place the client during the early postoperative period?
82. The semi-Fowler’s position.
83. Supine.
84. Lithotomy position.
85. Prone.

Answer 81

81. 1. After an appendectomy for a ruptured appendix, assuming the semi-Fowler’s or a right side-
       lying position helps localize the infection. These positions promote drainage from the peritoneal
       cavity and decrease the incidence of subdiaphragmatic abscess.CN: Physiological adaptation; CL: Synthesize

Question 82

82. Which of the following is a normal response from an adolescent who has just returned to her
    room after an appendectomy?
83. “I’ll need plastic surgery for this scar.”
84. “I’m worried about the size of my scar.”
85. “I don’t want to have any pain.”
86. “What will my boyfriend say about the scar?”

Answer 82

82. 2. Adolescents are concerned about the immediate state and functioning of their bodies. The
       adolescent needs to know whether any changes (eg, illness, trauma, surgery) will alter her lifestyle or
       interfere with her quest for physical perfection. Having a scar may be devastating to the adolescent.
       The need for plastic surgery cannot be determined at this point. The adolescent has just returned from
       surgery and has yet to see the scar. Healing has yet to occur. Typically scars become smaller and fade
       over time. The desire for no pain is unrealistic. Although adolescents are worried about pain and how
       they will respond, they typically are discharged within 24 hours after an appendectomy with pain
       well controlled by oral analgesics. The immediate concern of adolescents is the state and functioning
       of their bodies. After concerns about themselves, then adolescents are concerned about their peer
       group and their responses. Although the boyfriend’s response will matter, this concern would be more
       common later in the course of the adolescent’s recovery.
       CN: Health promotion and maintenance; CL: Analyze

Question 83

83. Which of the following client actions should the nurse judge to be a healthy coping behavior
    for a male adolescent after an appendectomy?
84. Insisting on wearing a T-shirt and gym shorts rather than pajamas.
85. Avoiding interactions with other adolescents on the nursing unit.
86. Refusing to fill out the menu, and allowing the nurse to do so.
87. Not taking telephone calls from friends so he can rest.

Answer 83

83. 1. Adolescents struggle for independence and identity, needing to feel in control of situations
       and to conform to peers. Control and conformity are often manifested in appearance, including
       clothing, and this carries over into the hospital experience. The adolescent feels best when he is able
       to look and act as he normally does, for example, wearing a T-shirt and gym shorts. Adolescents
       normally want to interact with peers and commonly seek every opportunity to do so. Avoiding other
       adolescents on the nursing unit or not taking phone calls from friends might suggest ineffective coping
       behavior. Refusing to fill out the menu and allowing the nurse to do so demonstrate dependent
       behavior, not a healthy coping mechanism.
       CN: Psychosocial integrity; CL: Analyze

Question 84

84. The nurse prepares to teach an adolescent scheduled for an appendectomy about what to
    expect. The adolescent says, “I would rather look this up on the Internet.” The nurse should:
85. Explain that completing a teaching checklist is required by the hospital.
86. Help the client find information on the Internet.
87. Provide the client with written information instead.
88. Explain that information found on the Internet cannot be trusted.

Answer 84

84. 2. Part of providing client-centered care is to honor the client’s preferred method of learning.
       The nurse should help the adolescent find accurate information about the procedure. By assisting with
       the information search the nurse can verify learning. Teaching straight from a checklist does not
       encourage customization. If the client has requested to use the Internet, it is unlikely that written
       information will be read. While it is true that some information on the Internet is not accurate, the
       nurse can take this opportunity to help the client learn how to determine if a source is reliable.
       CN: Psychosocial integrity; CL: Synthesize

Question 85

Managing Care Quality and Safety
85. The health care team has noticed an increase in IV infiltrations on the pediatric floor. As part
of a Plan, Do, Study, Act quality improvement plan the team should do the following in which order?
1. Analyze the data.
2. Decide to monitor IV gauges.
3. Perform chart audits.
4. Write a new IV insertion policy.

Answer 85

Managing Care Quality and Safety
85.
2. Decide to monitor IV gauges.
3. Perform chart audits.
1. Analyze the data.
4. Write a new IV insertion policy.Deciding what to study and how to do it is part of the planning process. Collecting data through chart
audits is part of the “do” phase. Once the chart audits are complete the data may be “studied” or
analyzed. The final step of the process, or the “act” phase, is to determine what should be done,
which may include writing a new policy.
CN: Reduction of risk potential; CL: Synthesize

Question 86

86. The health care team wishes to establish a policy regarding sleep positions for infants with
    gastroesophageal reflux (GER). The first step should be to search for:
87. Policies from other hospitals.
88. Data from retrospective studies.
89. Published national standards.
90. Expert opinions.

Answer 86

86. 3. Published national standards are based on the best evidence and when available should
       serve as the foundation for nursing unit policies. Policies from other hospitals may or may not be
       evidence based. Retrospective studies and expert opinions should only be used to form policy when
       data from experimental studies or national standards are not available.
       CN: Reduction of risk potential; CL: Synthesize

Question 87

87. The nurse is assisting another member of the health care team who is placing a peripherally
    inserted catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in
    the treatment room to support the child. The nurse observes that the other team member has
    contaminated a sterile glove. The nurse should:
88. Discuss the incident with the team member after the event.
89. Report the incident to the nursing unit manager.
90. Tell the team member the glove is contaminated.
91. Ask the family to leave before confronting the team member.

Answer 87

87. 3. It is the responsibility of all health care members to protect the client. The provider may
       honestly not have realized that the glove was contaminated. Therefore, the nurse needs to alert the
       provider to the situation. Waiting until after the procedure to address the problem puts the child at
       unnecessary risk for infection. Asking the parents to leave could invoke anxiety in both the child and
       the parents. Alerting the provider does not need to be confrontational. If done with a calm approach,
       the result is most likely to be gratitude instead of embarrassment.
       CN: Reduction of risk potential; CL: Synthesize

Question 88

88. The hospital is responding to a mass casualty disaster with adult and pediatric victims. After
    reallocating staff, the charge nurse on the pediatric floor should:
89. Ask parents to leave to free up the parent sleep areas for incoming victims.
90. Review the census for clients that are candidates for early discharge.
91. Initiate paper charting back-up.
92. Change taking all vital signs to every 8 hours.

Answer 88

88. 2. The charge nurse can anticipate needing beds for incoming victims. Any client who can go
       home should go home. Parents are a child’s primary care givers and should not be asked to leave. If
       computers were not affected by the disaster, charting in the electronic health record is safer. Some
       routine procedures are altered during a disaster, but clients who are unstable will still need frequent
       assessments; reducing vital sign frequency must be considered on a case-to-case basis.
       CN: Management of care; CL: Synthesize

Question 89

89. Eight hours ago, an infant with Hirschsprung’s disease had surgery to create a colostomy.Which of the following findings should alert the nurse to notify the primary care provider
    immediately?
90. A 3-cm increase in abdominal circumference.
91. Periods of occasional fussiness.
92. Absence of bowel sounds since surgery.
93. Evidence of the infant’s returning appetite.

Answer 89

89. 1. Abdominal circumference is measured to monitor for abdominal distention. An increase of
       3 cm in 8 hours would require notification of the primary care provider; it would indicate a
       substantial degree of abdominal distention, possibly from fluid or gas accumulation. Normally, after
       surgery, an infant experiences occasional periods of fussiness. However, as long as the infant is able
       to be quiet by himself or with the aid of a pacifier, the primary care provider does not need to be
       contacted. Absence of bowel sounds would be expected after surgery because of the effects of
       anesthesia. It takes approximately 48 hours for gastric motility to resume. Even if the infant displays
       evidence that he is hungry, fluids will not be offered until bowel sounds are heard, indicating a
       functioning gastrointestinal tract.
       CN: Reduction of risk potential; CL: Synthesize