The Child with Respiratory Health Problems

Question 1

The Client with Tonsillitis
1. The nurse is inspecting the child’s throat (see figure). The nurse should:
1. Remove the tongue blade from the child’s hands after he has experienced what it feels like in
his mouth.
2. Ask the child to hold the tongue blade with both hands in his lap while the nurse uses another
tongue blade.
3. Have the parent hold the child with arms restrained.
4. Guide the tongue blade while the child is holding it to depress the tongue to visualize the
throat.

Answer 1

The Client with Tonsillitis
1. 4. If the child does not stick out his tongue so the nurse can visualize the throat, it is appropriate
to use a tongue blade. Having the child participate by holding the tongue blade while the nurse guides
it to facilitate visualization of the throat is appropriate technique. It is not useful to remove the tongue
blade or have the child hold it because the nurse will need to use the tongue blade to depress the
tongue. It is preferable to engage the child’s cooperation before asking the parent to restrain the child.
CN: Health promotion and maintenance; CL: Apply

Question 2

2. The nurse has identified a problem of anxiety for a 4-year-old preparing for a tonsillectomy.
   The nurse should tell the child:
3. “You won’t have so many sore throats after your tonsils are removed.”
4. “The doctor will put you to sleep so you don’t feel anything.”
5. “Show me how to give the doll an IV.”
6. “When it is done you will get to see your mommy and get a Popsicle.”

Answer 2

2. 4. When preparing a child for a procedure the nurse should use neutral words, focus on sensory
      experiences, and emphasize the positive aspects at the end. Being reunited with parents and having an
      ice pop would be considered pleasurable events. Children this age fear bodily harm. To reduced
      anxiety, the nurse should use the word “fixed” instead of “removed” to describe what is being done to
      the tonsils. Using the terms “put to sleep” and “IV” may be threatening. Additionally, directing a play
      experience to focus on IV insertion may be counterproductive as the child may have little recollection
      of this aspect of the procedure.
      CN: Psychosocial integrity; CL: Synthesize

Question 3

3. After a tonsillectomy and adenoidectomy, which of the following findings should alert the
   nurse to suspect early hemorrhage in a 5-year-old child?
4. Drooling of bright red secretions.
5. Pulse rate of 95 bpm.
6. Vomiting of 25 mL of dark brown emesis.
7. Blood pressure of 95/56 mm Hg.

Answer 3

3. 1. After a tonsillectomy and adenoidectomy, drooling bright red blood is considered an early
      sign of hemorrhage. Often, because of discomfort in the throat, children tend to avoid swallowing;
      instead, they drool. Frequent swallowing would also be an indication of hemorrhage because the
      child attempts to clear the airway of blood by swallowing. Secretions may be slightly blood-tinged
      because of a small amount of oozing after surgery. However, bright red secretions indicate bleeding.
      A pulse rate of 95 bpm is within the normal range for a 5-year-old child, as is a blood pressure of
      95/56 mm Hg. A small amount of blood that is partially digested, and therefore dark brown, is often
      present in postoperative emesis.
      CN: Reduction of risk potential; CL: Analyze

Question 4

4. After teaching the parents of a preschooler who has undergone a tonsillectomy and
   adenoidectomy about appropriate foods to give the child after discharge, which of the following, if
   stated by the parents as appropriate foods, indicates successful teaching?
5. Meat loaf and uncooked carrots.
6. Pork and noodle casserole.
7. Cream of chicken soup and orange sherbet.
8. Hot dog and potato chips

Answer 4

4. 3. For the first few days after a tonsillectomy and adenoidectomy, liquids and soft foods are
      best tolerated by the child while the throat is sore. Children typically do not chew their food
      thoroughly, and solid foods are to be avoided because they are difficult to swallow. Although meat
      loaf would be considered a soft food, uncooked carrots would not be. Pork is frequently difficult to
      chew. Foods that have sharp edges, such as potato chips, are contraindicated because they are hard to
      chew and may cause more throat discomfort.
      CN: Basic care and comfort; CL: Evaluate

Question 5

5. A nurse is teaching the parents of a preschooler about the possibility of postoperative
   hemorrhage after a tonsillectomy and adenoidectomy. The nurse should explain that the risk is greatest
   at which of the following times?
6. 1 to 3 days after surgery.
7. 4 to 6 days after surgery.
8. 7 to 10 days after surgery.
9. 11 to 14 days after surgery.

Answer 5

5. 3. The risk of hemorrhage from a tonsillectomy is greatest when the tissue begins sloughing andthe scabs fall off. This typically happens 7 to 10 days after a tonsillectomy.
      CN: Safety and infection control; CL: Apply

Question 6

The Client with Otitis Media
6. An adolescent female is prescribed amoxicillin (Amoxil) for an ear infection. The nurse
should teach the adolescent about the risks associated with her concurrent use of:
1. Antacids.
2. Oral contraceptives.
3. Multiple vitamins.
4. Protein shakes.

Answer 6

The Client with Otitis Media
6. 2. When a person is taking amoxicillin as well as an oral contraceptive it renders the
contraceptive less effective. Because pregnancy can occur in such a situation, the nurse should advise
the client to use additional means of birth control during the time she is taking the antibiotic. There
are no risks associated with the concurrent use of amoxicillin and antacids, vitamins, or food.
CN: Psychosocial integrity; CL: Apply

Question 7

7. A toddler is scheduled to have tympanostomy tubes inserted. When approaching the toddler for
   the first time, which of the following should the nurse do?
8. Talk to the mother first so that the toddler can get used to the new person.
9. Hold the toddler so that the toddler becomes more comfortable.
10. Walk over and pick the toddler up right away so that the mother can relax.
11. Pick up the toddler and take the child to the play area so that the mother can rest.

Answer 7

7. 1. Toddlers should be approached slowly, because they are wary of strangers and need time to
      get used to someone they do not know. The best approach is to ignore them initially and to focus on
      talking to the parents. The child will likely resist being held by a stranger, so the nurse should not
      pick up or hold the child until the child indicates a readiness to be approached or the mother indicates
      that it is okay.
      CN: Health promotion and maintenance; CL: Synthesize

Question 8

8. After insertion of bilateral tympanostomy tubes in a toddler, which of the following
   instructions should the nurse include in the child’s discharge plan for the parents?
9. Insert ear plugs into the canals when the child bathes.
10. Blow the nose forcibly during a cold.
11. Administer the prescribed antibiotic while the tubes are in place.
12. Disregard any drainage from the ear after 1 week.

Answer 8

8. 1. Placing ear plugs in the ears will prevent contaminated bathwater from entering the middle
      ear through the tympanostomy tube and causing an infection. Blowing the nose forcibly during a cold
      causes organisms to ascend through the eustachian tube, possibly leading to otitis media. It is not
      necessary to administer antibiotics continuously to a child with a tympanostomy tube. Antibiotics are
      appropriate only when an ear infection is present. Drainage from the ear may be a sign of middle ear
      infection and should be reported to the health care provider.
      CN: Reduction of risk potential; CL: Create

Question 9

The Client with Foreign Body Aspiration
9. After teaching the parents of a toddler about commonly aspirated foods, which of the following
foods, if identified by the parents as easily aspirated, would indicate the need for additional teaching?
1. Popcorn.
2. Raw vegetables.
3. Round candy.
4. Crackers.

Answer 9

The Client with Foreign Body Aspiration
9. 4. Crackers, because they crumble and easily dissolve, are not commonly aspirated. Because
children commonly eat popcorn hulls or pieces that have not popped, popcorn can be easily
aspirated. Toddlers frequently do not chew their food well, making raw vegetables a commonly
aspirated food. Round candy is often difficult to chew and comes in large pieces, making it easily
aspirated.
CN: Health promotion and maintenance; CL: Evaluate

Question 10

10. A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the
    parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler
    home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse
    interprets this behavior as indicating separation anxiety involving which of the following?
11. Protest.
12. Despair.
13. Regression.
14. Detachment.

Answer 10

10. 1. Young children have specific reactions to separation and hospitalization. In the protest
       stage, the toddler physically and verbally attacks anyone who attempts to provide care. Here, the
       child is fussing and crying and visibly pushes the nurse away. In the despair stage, the toddler
       becomes withdrawn and obviously depressed (eg, not engaging in play activities and sleeping more
       than usual). Regression is a return to a developmentally earlier phase because of stress or crisis (eg,
       a toddler who could feed himself before this event is not doing so now). Denial or detachment occurs
       if the toddler’s stay in the hospital without the parent is prolonged because the toddler settles in to the
       hospital life and denies the parents’ existence (eg, not reacting when the parents come to visit).
       CN: Psychosocial integrity; CL: Analyze

Question 11

11. After teaching the parents of an 18-month-old who was treated for a foreign body obstruction
    about the three cardinal signs indicative of choking, the nurse determines that the teaching has been
    successful when the parents state that a child is choking when he or she cannot speak, turns blue, and
    does which of the following?
12. Vomits.
13. Gasps.
14. Gags.
15. Collapses.

Answer 11

11. 4. The three cardinal signs indicating that a child is truly choking and requires immediate life-
       saving interventions include inability to speak, blue color (cyanosis), and collapse. Vomiting does notoccur while a child is unable to breathe. Once the object is dislodged, however, vomiting may occur.
       Gasping, a sudden intake of air, indicates that the child is still able to inhale. When a child is choking,
       air is not being exchanged, so gagging will not occur.
       CN: Reduction of risk potential; CL: Evaluate

Question 12

12. The father of a 2-year-old phones the emergency room on a Sunday evening and informs the
    nurse that his son put a bead in his nose. What is the most appropriate recommendation made by the
    nurse?
13. “Try to remove the bead at home as soon as possible; you might try using a pair of tweezers.”
14. “Be sure to take your child to the pediatrician in the morning so the pediatrician can remove
    the bead in the office.”
15. “You should bring your child to the emergency room tonight so the bead can be removed as
    soon as possible.”
16. “Ask your child to blow his nose several times; this should dislodge the bead.”

Answer 12

12. 3. The bead should be removed by a health care professional as soon as possible to prevent
       the risk of aspiration and tissue necrosis. Unskilled individuals should not attempt to remove an
       object from the nose as they may push the object further increasing the risk for aspiration. Two-year-
       old children are not skilled at blowing their nose and may breathe in, further increasing the risk of
       aspiration.
       CN: Management of care; CL: Analyze

Question 13

The Client with Asthma
13. An 11-year-old is admitted for treatment of an asthma attack. Which of the following
indicates immediate intervention is needed?
1. Thin, copious mucous secretions.
2. Productive cough.
3. Intercostal retractions.
4. Respiratory rate of 20 breaths/minute.

Answer 13

The Client with Asthma
13. 3. Intercostal retractions indicate an increase in respiratory effort, which is a sign of
respiratory distress. During an asthma attack, secretions are thick, the cough is tight, and respiration is
difficult (and shortness of breath may occur). If mucous secretions are copious but thin, the client can
expectorate them, which indicates an improvement in the condition. If the cough is productive it
means the bronchospasms and the inflammation have been resolved to the extent that the mucus can be
expectorated. A respiratory rate of 20 breaths/min would be considered normal and no intervention
would be needed.
CN: Physiological adaptation; CL: Analyze

Question 14

14. A 12-year-old with asthma wants to exercise. Which of the following activities should the
nurse suggest to improve breathing?
1. Soccer.
2. Swimming.
3. Track.
4. Gymnastics.

Answer 14

14. 2. Swimming is appropriate for this child because it requires controlled breathing, assists in
       maintaining cardiac health, enhances skeletal muscle strength, and promotes ventilation and perfusion.
       Stop-and-start activities, such as soccer, track, and gymnastics, commonly trigger symptoms in
       asthmatic clients.
       CN: Health promotion and maintenance; CL: Synthesize

Question 15

15. When preparing the teaching plan for the mother of a child with asthma, which of the
    following should the nurse include as signs to alert the mother that her child is having an asthma
    attack?
16. Secretion of thin, copious mucus.
17. Tight, productive cough.
18. Wheezing on expiration.
19. Temperature of 99.4°F (37.4°C).

Answer 15

15. 3. The child who is experiencing an asthma attack typically demonstrates wheezing on
       expiration initially. This results from air moving through narrowed airways secondary to
       bronchoconstriction. The child’s expiratory phase is normally longer than the inspiratory phase.
       Expiration is passive as the diaphragm relaxes. During an asthma attack, secretions are thick and are
       not usually expelled until the bronchioles are more relaxed. At the beginning of an asthma attack the
       cough will be tight but not productive. Fever is not always present unless there is an infection that
       may have triggered the attack.
       CN: Physiological adaptation; CL: Analyze

Question 16

16. Which assessment findings should lead the nurse to suspect that a toddler is experiencing
respiratory distress? Select all that apply.
1. Coughing.
2. Respiratory rate of 35 breaths/min.
3. Heart rate of 95 beats/min.
4. Restlessness.
5. Malaise.
6. Diaphoresis.

Answer 16

16. 1, 2, 4, 6. Coughing, especially at night and in the absence of an infection, is a common
    symptom of asthma. Early signs of respiratory distress include restlessness, tachypnea, tachycardia,
    and diaphoresis. Other signs also include hypertension, nasal flaring, grunting, wheezing, and
    intercostal retractions. A heart rate of 95 bpm is normal for a toddler. Malaise typically does not
    indicate respiratory distress.
    CN: Physiological adaptation; CL: Analyze

Question 17

17. A 10-year-old child who is 5′ 4′′ (138 cm) tall with a history of asthma uses an inhaled
    bronchodilator only when needed. He/she takes no other medications routinely. His/her best peak
    expiratory flow rate is 270 L/min. The child’s current peak flow reading is 180 L/min. The nurse
    interprets this reading as indicating which of the following?
18. The child’s asthma is under good control, so the routine treatment plan should continue.
19. The child needs to use his/her short-acting inhaled beta 2 -agonist medication.
20. This is a medical emergency requiring a trip to the emergency department for treatment.
21. The child needs to use his/her inhaled cromolyn sodium (Intal).

Answer 17

17. 2. The peak flow of 180 L/min is in the yellow zone, or 50% to 80% of the child’s personal
       best. This means that the child’s asthma is not well controlled, thereby necessitating the use of a short-acting beta 2 -agonist medication to relieve the bronchospasm. A peak flow reading greater than 80%
       of the child’s personal best (in this case, 220 L/min or better) would indicate that the child’s asthma is
       in the green zone or under good control. A peak flow reading in the red zone, or less than 50% of the
       child’s personal best (135 L/min or less), would require notification of the health care provider or a
       trip to the emergency department. Cromolyn sodium (Intal) is not used for short-term treatment of
       acute bronchospasm. It is used as part of a long-term therapy regimen to help desensitize mast cells
       and thereby help to prevent symptoms.
       CN: Reduction of risk potential; CL: Evaluate

Question 18

18. An adolescent with chest pain goes to the school nurse. The nurse determines that the
    teenager has a history of asthma but has had no problems for years. Which of the following should the
    nurse do next?
19. Call the adolescent’s parent.
20. Have the adolescent lie down for 30 minutes.3. Obtain a peak flow reading.
21. Give two puffs of a short-acting bronchodilator.

Answer 18

18. 3. Problems of chest pain in children and adolescents are rarely cardiac. With a history of
       asthma, the most likely cause of the chest pain is related to the asthma. Therefore, the nurse should
       check the adolescent’s peak flow reading to evaluate the status of the air flow. Calling the
       adolescent’s parent would be appropriate, but this would be done after the nurse obtains the peak
       flow reading and additional assessment data. Having the adolescent lie down may be an option, but
       more data need to be collected to help establish a possible cause. Because the adolescent has not
       experienced any asthma problems for a long time, it would be inappropriate for the nurse to
       administer a short-acting bronchodilator at this time.
       CN: Reduction of risk potential; CL: Synthesize

Question 19

19. A 7-year-old child with a history of asthma controlled without medications is referred to the
    school nurse by the teacher because of persistent coughing. Which of the following should the nurse
    do first?
20. Obtain the child’s heart rate.
21. Give the child a nebulizer treatment.
22. Call a parent to obtain more information.
23. Have a parent come and pick up the child.

Answer 19

19. 3. Because persistent coughing may indicate an asthma attack and a 7-year-old child would be
       able to provide only minimal history information, it would be important to obtain information from
       the parent. Although determining the child’s heart rate is an important part of the assessment, it would
       be done after the history is obtained. More information needs to be obtained before giving the child a
       nebulizer treatment. Although it may be necessary for the parent to come and pick up the child, a
       thorough assessment including history information should be obtained first.
       CN: Reduction of risk potential; CL: Synthesize

Question 20

20. When developing a teaching plan for the mother of an asthmatic child concerning measures to
    reduce allergic triggers, which of the following suggestions should the nurse include?
21. Keep the humidity in the home between 50% and 60%.
22. Have the child sleep in the bottom bunk bed.
23. Use a scented room deodorizer to keep the room fresh.
24. Vacuum the carpet once or twice a week.

Answer 20

20. 1. To help reduce allergic triggers in the home, the nurse should recommend that the humidity
       level be kept between 50% and 60%. Doing so keeps the air moist and comfortable for breathing.
       When air is dry, the risk for respiratory infections increases. Too high a level of humidity increases
       the risk for mold growth. Typically, the child with asthma should sleep in the top bunk bed to
       minimize the risk of exposure to dust mites. The risk of exposure to dust mites increases when the
       child sleeps in the bottom bunk bed because dust mites fall from the top bed, settling in the bottom
       bed. Scented sprays should be avoided because they may trigger an asthmatic episode. Ideally,
       carpeting should be avoided in the home if the child has asthma. However, if it is present, carpeting in
       the child’s room should be vacuumed often, possibly daily, to remove dust mites and dust particles.
       CN: Reduction of risk potential; CL: Create

Question 21

21. After discussing asthma as a chronic condition, which of the following statements by the
    father of a child with asthma best reflects the family’s positive adjustment to this aspect of the child’s
    disease?
22. “We try to keep him happy at all costs; otherwise, he has an asthma attack.”
23. “We keep our child away from other children to help cut down on infections.”
24. “Although our child’s disease is serious, we try not to let it be the focus of our family.”
25. “I’m afraid that when my child gets older, he won’t be able to care for himself like I do.”

Answer 21

21. 3. Positive adjustment to a chronic condition requires placing the child’s illness in its proper
       perspective. Children with asthma need to be treated as normally as possible within the scope of the
       limitations imposed by the illness. They also need to learn how to manage exacerbations and then
       resume as normal a life as possible. Trying to keep the child happy at all costs is inappropriate and
       can lead to the child’s never learning how to accept responsibility for behavior and get along with
       others. Although minimizing the child’s risk for exposure to infections is important, the child needs to
       be with his or her peers to ensure appropriate growth and development. Children with a chronic
       illness need to be involved in their care so that they can learn to manage it. Some parents tend tooverprotect their child with a chronic illness. This overprotectiveness may cause a child to have an
       exaggerated feeling of importance or later, as an adolescent, to rebel against the overprotectiveness
       and the parents.
       CN: Psychosocial integrity; CL: Evaluate

Question 22

22. An 8-year-old child with asthma states, “I want to play some sports like my friends. What can
    I do?” The nurse responds to the child based on the understanding of which of the following?
23. Physical activities are inappropriate for children with asthma.
24. Children with asthma must be excluded from team sports.
25. Vigorous physical exercise frequently precipitates an asthmatic episode.
26. Most children with asthma can participate in sports if the asthma is controlled.

Answer 22

22. 4. Physical activities are beneficial to asthmatic children, physically and psychosocially.
       Most children with asthma can engage in school and sports activities that are geared to the child’s
       condition and within the limits imposed by the disease. The coach and other team members need to be
       aware of the child’s condition and know what to do in case an attack occurs. Those children who have
       exercise-induced asthma usually use a short-acting bronchodilator before exercising.
       CN: Health promotion and maintenance; CL: Apply

Question 23

The
Client
with
Bronchopneumonia
Cystic
Fibrosis
and
23. A 9-month-old child with cystic fibrosis does not like taking pancreatic enzyme supplement
with meals and snacks. The mother does not like to force the child to take the supplement. The most
important reason for the child to take the pancreatic enzyme supplement with meals and snacks is:
1. The child will become dehydrated if the supplement is not taken with meals and snacks.
2. The child needs these pancreatic enzymes to help the digestive system absorb fats,
carbohydrates, and proteins.
3. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear.
4. The child will experience severe diarrhea if the supplement is not taken as prescribed.

Answer 23

The Client with Cystic Fibrosis and Bronchopneumonia
23. 2. The child must take the pancreatic enzyme supplement with meals and snacks to help
absorb nutrients so he can grow and develop normally. In cystic fibrosis, the normally liquid mucus is
tenacious and blocks three digestive enzymes from entering the duodenum and digesting essential
nutrients. Without the supplemental pancreatic enzyme, the child will have voluminous, foul, fatty
stools due to the undigested nutrients and may experience developmental delays due to malnutrition.
Dehydration is not a problem related to cystic fibrosis. The pancreatic enzymes have no effect on the
viscosity of the tenacious mucus. Diarrhea is not caused by failing to take the pancreatic enzyme
supplement.
CN: Pharmacological and parenteral therapies; CL: Apply

Question 24

24. A client’s diagnosis of cystic fibrosis was made 13 years ago, and he/she has since been
    hospitalized several times. On the latest admission, the client has labored respirations, fatigue,
    malnutrition, and failure to thrive. Which nursing actions are most important initially?
25. Placing the client on bed rest and prescribing a blood gas analysis.
26. Prescribing a high-calorie, high-protein, low-fat, vitamin-enriched diet and pancreatic
    granules.
27. Applying an oximeter and initiating respiratory therapy.
28. Inserting an IV line and initiating antibiotic therapy.

Answer 24

24. 3. Clients with cystic fibrosis commonly die from respiratory problems. The mucus in the
       lungs is tenacious and difficult to expel, leading to lung infections and interference with oxygen and
       carbon dioxide exchange. The client will likely need supplemental oxygen and respiratory treatments
       to maintain adequate gas exchange, as identified by the oximeter reading. The child will be on bed
       rest due to respiratory distress. However, although blood gases will probably be prescribed, the
       oximeter readings will be used to determine oxygen deficit and are, therefore, more of a priority. A
       diet high in calories, proteins, and vitamins with pancreatic granules added to all foods ingested will
       increase nutrient absorption and help the malnutrition; however, this intervention is not the priority at
       this time. Inserting an IV to administer antibiotics is important, and can be done after ensuring
       adequate respiratory function.
       CN: Physiological adaptation; CL: Synthesize

Question 25

25. A child with cystic fibrosis is receiving gentamicin. Which of the following nursing actions is
    most important?
26. Monitoring intake and output.
27. Obtaining daily weights.
28. Monitoring the client for indications of constipation.
29. Obtaining stool samples for hemoccult testing.

Answer 25

25. 1. Monitoring intake and output is the most important nursing action when administering an
       aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage.
       Daily weight monitoring is not indicated when the client is receiving an aminoglycoside. Constipation
       and bleeding are not adverse effects of aminoglycosides.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 26

26. When developing the plan of care for a child with cystic fibrosis (CF) who is scheduled to
    receive postural drainage, the nurse should anticipate performing postural drainage at which of the
    following times?
27. After meals.
28. Before meals.
29. After rest periods.
30. Before inhalation treatments.

Answer 26

26. 2. Postural drainage, which aids in mobilizing the thick, tenacious secretions commonly
       associated with CF, is usually performed before meals to avoid the possibility of vomiting or
       regurgitating food. Although the child with CF needs frequent rest periods, this is not an important
       factor in scheduling postural drainage. However, the nurse would not want to interrupt the child’s rest
       period to perform the treatment. Inhalation treatments are usually given before postural drainage tohelp loosen secretions.
       CN: Reduction of risk potential; CL: Apply

Question 27

27. When teaching the parents of an older infant with cystic fibrosis (CF) about the type of diet
    the child should consume, which of the following would be appropriate?
28. Low-protein diet.
29. High-fat diet.
30. Low-carbohydrate diet.
31. High-calorie diet.

Answer 27

27. 4. CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the
       pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion
       and absorption, a high-calorie, high-protein, high-carbohydrate, moderate-fat diet is indicated.
       CN: Physiological adaptation; CL: Apply

Question 28

28. At a follow-up appointment after being hospitalized, an adolescent with a history of cystic
    fibrosis (CF) describes his stools to the nurse. Which of the following descriptions should the nurse
    interpret as indicative of continued problems with malabsorption?1. Soft with little odor.
29. Large and foul-smelling.
30. Loose with bits of food.
31. Hard with streaks of blood.

Answer 28

28. 2. In children with CF, poor digestion and absorption of foods, especially fats, results in
       frequent bowel movements that are bulky, large, and foul-smelling. The stools also contain
       abnormally large quantities of fat, which is called steatorrhea. An adolescent experiencing good
       control of the disease would describe soft stools with little odor. Stool described as loose with bits
       of food indicates diarrhea. Stool described as hard with streaks of blood may indicate constipation.
       CN: Physiological adaptation; CL: Analyze

Question 29

29. When developing a recreational therapy plan of care for a 3-year-old child hospitalized with
    pneumonia and cystic fibrosis, which of the following toys would be appropriate?
30. 100-piece jigsaw puzzle.
31. Child’s favorite doll.
32. Fuzzy stuffed animal.
33. Scissors, paper, and paste.

Answer 29

29. 2. The child’s favorite doll would be a good choice of toys. The doll provides support and is
       familiar to the child. Although a 3-year-old may enjoy puzzles, a 100-piece jigsaw puzzle is too
       complicated for an ill 3-year-old child. In view of the child’s lung pathology, a fuzzy stuffed animal
       would not be advised because of its potential as a reservoir for dust and bacteria, possibly
       predisposing the child to additional respiratory problems. Scissors, paper, and paste are not
       appropriate for a 3-year-old unless the child is supervised closely.
       CN: Health promotion and maintenance; CL: Create

Question 30

30. Which of the following, if described by the parents of a child with cystic fibrosis (CF),
    indicates that the parents understand the underlying problem of the disease?
31. An abnormality in the body’s mucus-secreting glands.
32. Formation of fibrous cysts in various body organs.
33. Failure of the pancreatic ducts to develop properly.
34. Reaction to the formation of antibodies against streptococcus.

Answer 30

30. 1. CF is characterized by a dysfunction in the body’s mucus-producing exocrine glands. The
       mucus secretions are thick and sticky rather than thin and slippery. The mucus obstructs the bronchi,
       bronchioles, and pancreatic ducts. Mucus plugs in the pancreatic ducts can prevent pancreatic
       digestive enzymes from reaching the small intestine, resulting in poor digestion and poor absorption
       of various food nutrients. Fibrous cysts do not form in various organs. Cystic fibrosis is an autosomal
       recessive inherited disorder and does not involve any reaction to the formation of antibodies against
       streptococcus.
       CN: Physiological adaptation; CL: Evaluate

Question 31

31. Which of the following outcome criteria would the nurse develop for a child with cystic
    fibrosis who has ineffective airway clearance related to increased pulmonary secretions and inability
    to expectorate?
32. Respiratory rate and rhythm within expected range.
33. Absence of chills and fever.
34. Ability to engage in age-related activities.
35. Ability to tolerate usual diet without vomiting.

Answer 31

31. 1. After treatment, the client outcome would be that respiratory status would be within normal
       limits, as evidenced by a respiratory rate and rhythm within expected range. Absence of chills and
       fever, although related to an underlying problem causing the respiratory problem (eg, the infection),
       do not specifically relate to the respiratory problem of ineffective airway clearance. The child’s
       ability to engage in age-related activities may provide some evidence of improved respiratory status.
       However, this outcome criterion is more directly related to activity intolerance. Although the child’s
       ability to tolerate his or her usual diet may indirectly relate to respiratory function, this outcome is
       more specifically related to an imbalanced nutrition that may or may not be related to the child’s
       respiratory status.
       CN: Physiological adaptation; CL: Evaluate

Question 32

32. A school-age child with cystic fibrosis asks the nurse what sports she can become involved
    in as she becomes older. Which of the following activities would be appropriate for the nurse to
    suggest?
33. Swimming.
34. Track.
35. Baseball.
36. Javelin throwing.

Answer 32

32. 1. Swimming would be the most appropriate suggestion because it coordinates breathing and
       movement of all muscle groups and can be done on an individual basis or as a team sport. Because
       track events, baseball, and javelin throwing usually are performed outdoors, the child would be
       breathing in large amounts of dust and dirt, which would be irritating to her mucous membranes andpulmonary system. The strenuous activity and increased energy expenditure associated with track
       events, in conjunction with the dust and possible heat, would play a role in placing the child at risk
       for an upper respiratory tract infection and compromising her respiratory function.
       CN: Health promotion and maintenance; CL: Synthesize

Question 33

The Client with Sudden Infant Death Syndrome
33. When explaining to parents how to reduce the risk of Sudden Infant Death Syndrome (SIDS)
the nurse should teach about which of the following measures? Select all that apply.
1. Maintain a smoke-free environment.
2. Use a wedge for side-lying positions.
3. Breast-feed the baby.
4. Place the baby on his back to sleep.
5. Use bumper pads over the bed rails.
6. Have the baby sleep in the parent’s bed.

Answer 33

The Client with Sudden Infant Death Syndrome
33. 1, 3, 4. Exposure to environmental tobacco increases the risk for SIDS. Sleeping on the back
and breast-feeding both decrease the risk of SIDS. The side-lying position is not recommended for
sleep. It is recommended that babies be dressed in sleepers and that cribs are free of blankets,
pillows, bumper pads, and stuffed animals. Co-bedding with parents is not recommended as parents
may roll on the child.
CN: Safety and infection control; CL: Create

Question 34

34. Which one of the following children is at most risk for sudden infant death syndrome (SIDS)?
35. Infant who is 3 months old.
36. 2-year-old who has apnea lasting up to 5 seconds.
37. First-born child whose parents are in their early forties.
38. 6-month-old who has had two bouts of pneumonia.

Answer 34

34. 1. The highest incidence of SIDS occurs in infants between ages 2 and 4 months. About 90%
       of SIDS occurs before the age of 6 months. Apnea lasting longer than 20 seconds has also been
       associated with a higher incidence of SIDS. SIDS occurs with higher frequency in families where a
       child in the family has already died of SIDS, but the age of the parents has not been shown to
       contribute to SIDS. A respiratory infection such as pneumonia has not been shown to cause a higher
       incidence of SIDS.
       CN: Health promotion and maintenance; CL: Analyze

Question 35

35. Parents bring their child to the emergency department because the child has stopped
    breathing. A nurse obtains a brief history of events occurring before and after the parents found the
    infant not breathing. Which of the following questions should the nurse ask the parents first?
36. “Was the infant sleeping while wrapped in a blanket?”
37. “Was the infant lying on his stomach?”
38. “What did the infant look like when you found him?”
39. “When had you last checked on the infant?”

Answer 35

35. 3. Because this is an especially disturbing and upsetting time for the parents, they must be
       approached in a sensitive manner. Asking what the infant looked like when found allows the parents
       to verbalize what they saw and felt, thereby helping to minimize their feelings of guilt without
       implying any blame, neglect, wrongdoing, or abuse. Asking if the child was wrapped in a blanket or
       lying on his stomach, or when the parents last checked on the infant, implies that the parents did
       something wrong or failed in their care of the infant, thus blaming them for the event.
       CN: Physiological adaptation; CL: Analyze

Question 36

36. When planning a visit to the parents of an infant who died of sudden infant death syndrome
    (SIDS) at home, the nurse should visit the parents at which of the following times?
37. A few days after the funeral.
38. Two weeks after the funeral.
39. As soon as the parents are ready to talk.
40. As soon after the infant’s death as possible.

Answer 36

36. 4. The community health nurse should visit as soon after the death as possible, because the
       parents may need help to deal with the sudden, unexpected death of their infant. Parents often have a
       great deal of guilt in these situations and need to express their feelings to someone who can provide
       counseling.
       CN: Psychosocial integrity; CL: Synthesize

Question 37

37. When developing the ongoing plan of care for the parents whose infant died of sudden infant
    death syndrome (SIDS), the nurse should plan to accomplish which of the following on the second
    home visit?
38. Allow the parents to express their feelings.
39. Have the parents gain an understanding of the disease.
40. Assess the impact of the infant’s death on their other children.
41. Deal with issues such as having other children.

Answer 37

37. 1. The goal of the second home visit is to help the parents express their feelings more openly.
       Many parents are reluctant to express their grief and need help. The goal of the first visit is to help the
       parents understand the disease and what happened. The first visit also provides time to help the
       parents understand that they are not to blame. Although it is important to assess the impact of SIDS on
       siblings, this is not the primary goal for the second visit. However, the nurse must be flexible in case
       problems involving this area arise. Typically, parents are unable to deal with decisions such as
       having other children during the second visit because they are grieving for the child that they lost.
       This topic may be discussed later in the course of care.
       CN: Psychosocial integrity; CL: Synthesize

Question 38

The Client Who Requires Immediate Care and
Cardiopulmonary Resuscitation
38. A child has just ingested about 10 adult-strength acetaminophen (Tylenol) pills. The mother
brings the child to the emergency department. What should the nurse do? Place the interventions in the
order of priority from first to last.
1. Administer activated charcoal.
2. Assess the airway.
3. Reassure the mother.
4. Check serum acetaminophen levels.
5. Obtain a history of the incident.
6. Complete a physical examination.

Answer 38

The
Client
Who
Requires
Immediate
Care
andCardiopulmonary Resuscitation
38.
2. Assess the airway.
1. Administer activated charcoal.
3. Reassure the mother.
6. Perform a physical exam.
5. Obtain a history of the incident.
4. Check serum acetaminophen levels.
Immediate care of the child who has ingested acetaminophen is to ensure airway, breathing, and
circulation. Next, the nurse should administer activated charcoal. Acetylcysteine (Mucomyst) may
also be used as an antidote. When the child is stable, the nurse should reassure the mother. Next, the
nurse should perform a physical exam to assess the child for other health problems, and then obtain
further information about how the child obtained the aspirin. The serum acetaminophen level should
be obtained 4 hours after ingestion.
CN: Safety and infection control; CL: Synthesize

Question 39

39. On finding a child who is not breathing, the nurse has someone activate the emergency
    medical system and then does which of the following first?
40. Clear the airway.
41. Begin mouth-to-mouth resuscitation.
42. Initiate oxygen therapy.
43. Start chest compressions.

Answer 39

39. 4. The 2010 CPR guidelines call for a CAB approach. When breathlessness is determined, the
       priority nursing action is checking a pulse and beginning compressions. After 30 compressions, the
       nurse opens the airway and gives 2 breaths. Oxygen therapy would not be initiated at this time,
       because the child is not breathing. Also, administering oxygen therapy would interfere with providing
       mouth-to-mouth resuscitation.
       CN: Physiological adaptation; CL: Synthesize

Question 40

40. Which of the following breathing rates should the nurse use when performing rescue
    breathing during cardiopulmonary resuscitation for a 5-year-old?
41. 10 breaths/min.
42. 12 breaths/min.3. 15 breaths/min.
43. 20 breaths/min.

Answer 40

40. 1. Rescue breaths should be delivered slowly at a volume that makes the chest rise and fall.
       For a 5-year-old child, the rate is 10 breaths per minute. If the nurse is also administering chest
       compressions, the rate is 2 breaths for every 15 compressions.
       CN: Physiological adaptation; CL: Apply

Question 41

41. The nurse begins CPR on a 5-year-old unresponsive client. When the emergency response
    team arrives, the child continues to have no respiratory effort but has a heart rate of 50 with cyanotic
    legs. The team should next:
42. Discontinue compressions but continue administering breaths with a bag-mask device.
43. Establish an intravenous line with a large bore needle while preparing the defibrillator.
44. Begin 2-person CPR at a ratio of 2 breaths to 15 compressions.
45. Begin 2-person CPR at a ratio of 2 breaths to 30 compressions.

Answer 41

41. 3. CPR is done on children for heart rate of less than 60 with signs of poor perfusion.
       Rescuers should use a 15:2 compression to ventilation ratio for 2-rescuer CPR for a child. Breaths
       without compressions are indicated only for respiratory arrests where the heart rate remains above
42. The AED/defibrillator should be used as soon as it is ready, but rescuers should not discontinue
    compressions until the device is ready for use. The ratio for 2-person CPR in adults is 30:2.
    CN: Physiological adaptation; CL: Synthesize

Question 42

42. As part of a health education program, the nurse teaches a group of parents CPR. The nurse
    determines that the teaching had been effective when a parent states:
43. “If I am by myself, I should call for help before starting CPR.”
44. “I should compress the chest using 2 to 3 fingers.”
45. “I should deliver chest compression at a rate of 100 per minute.”
46. “If I can’t get the breaths to make the chest rise, I should administer abdominal thrusts.”

Answer 42

42. 3. To maintain the best perfusion, it is recommended that compressions be given at a rate of
       100 per minute in a ratio of 30 compressions to 2 breaths for 1-rescuer CPR. Children still are more
       likely to have had a respiratory arrest than a cardiac arrest and are more likely to respond to opening
       the airway and rescue breaths. Therefore, it is recommended that unless the collapse was witnessed,
       a sole rescuer should attempt 5 cycles of CPR before leaving to call for help. Using 2 to 3 fingers for
       chest compressions is recommended for infant CPR only. Abdominal thrusts are no longer
       recommended for unconscious victims.
       CN: Physiological adaptation; CL: Evaluate

Question 43

43. When performing cardiopulmonary resuscitation (CPR), which of the following indicates that
    external chest compressions are effective?
44. Mottling of the skin.
45. Pupillary dilation.
46. Palpable pulse.
47. Cool, dry skin.

Answer 43

43. 3. With CPR, effectiveness of external chest compressions is indicated by palpable peripheral
       pulses, the disappearance of mottling and cyanosis, the return of pupils to normal size, and warm, dry
       skin. To determine whether the victim of cardiopulmonary arrest has resumed spontaneous breathing
       and circulation, chest compressions must be stopped for 5 seconds at the end of the first minute and
       every few minutes thereafter.
       CN: Physiological adaptation; CL: Evaluate

Question 44

44. A nurse walks into the room just as a 10-month-old infant places an object in his mouth and
    starts to choke. After opening the infant’s mouth, which of the following should the nurse do next to
    clear the airway?
45. Use blind finger sweeps.
46. Deliver back slaps and chest thrusts.
47. Apply four subdiaphragmatic abdominal thrusts.
48. Attempt to visualize the object.

Answer 44

44. 2. The nurse should use mechanical force—back slaps and chest thrusts—in an attempt to
       dislodge the object. Blind finger sweeps are not appropriate in infants and children because the
       foreign body may be pushed back into the airway. Subdiaphragmatic abdominal thrusts are not used
       for infants aged 1 year or younger because of the risk of injury to abdominal organs. If the object is
       not visible when opening the mouth, time is wasted in looking for it. Action is required to dislodge
       the object as quickly as possible.
       CN: Reduction of risk potential; CL: Apply

Question 45

45. When preparing to deliver back slaps to an infant who is choking on a foreign body, in which
    of the following positions should the nurse position the infant?
46. Head down and lower than the trunk.
47. Head up and raised above the trunk.
48. Head to one side and even with the trunk lower than the head.
49. Head parallel to the nurse and supported at the buttocks.

Answer 45

45. 1. To deliver back slaps, the nurse should place the infant face down, straddled over the
       nurse’s arm, with the head lower than the trunk and the head supported. This position, together with
       the back slaps, facilitates dislodgment and removal of a foreign object and minimizes aspiration if
       vomiting occurs. Placing the infant with the head up and raised above the trunk would not aid in
       dislodging and removing the foreign object. In addition, this position places the infant at risk for
       aspiration should vomiting occur. Placing the head to one side may minimize the risk of aspiration.
       However, it would not help with removal of an object that is dislodged by the back slaps. Placing the
       infant with the head parallel to the nurse and supported at the buttocks is more appropriate for burping
       the infant.
       CN: Physiological adaptation; CL: Apply

Question 46

46. A 6-month-old infant has had a cardiac arrest and the rapid response team has been paged.
    The nurse arrives in the client’s room and observes a licensed practical nurse (LPN) administering
    CPR to an infant (see figure). To assist the LPN with CPR, the nurse should:1. Take over rescue breaths with a rate of 1 breath per 5 compressions using a bag-mask device
    while the LPN continues compressions.
47. Take over compressions using one hand while the LPN uses a mask device to administer
    rescue breaths.
48. Take over rescue breaths using a rate of 2 breaths per 15 compressions using a bag-mask
    device while the LPN delivers compressions.
49. Take over compressions at 80 compressions a minute while the LPN uses a bag-mask device to
    administer rescue breaths.

Answer 46

46. 2. The nurse should first obtain a bag-mask device and assist with CPR by giving breaths at 2
       breaths/15 compressions. The LPN is using correct technique by using two to three fingers on the
       chest to administer chest compressions. The encircling hand technique may also be used during two-
       person infant CPR. The heel of both hands is used for older children and adolescents. The
       compression rate is at least 100/min.
       CN: Management of care; CL: Apply

Question 47

47. When teaching the parents of an infant how to perform back slaps to dislodge a foreign body,
    which of the following should the nurse tell the parents to use to deliver the blows?
48. Palm of the hand.
49. Heel of the hand.
50. Fingertips.
51. Entire hand.

Answer 47

47. 2. Back slaps are delivered rapidly and forcefully with the heel of the hand between the
       infant’s shoulder blades. Slowly delivered back slaps are less likely to dislodge the object. Using the
       heel of the hand allows more force to be applied than when using the palm or the whole hand,
       increasing the likelihood of loosening the object. The fingertips would be used to deliver chest
       compressions to an infant younger than 1 year of age.CN: Physiological adaptation; CL: Apply

Question 48

48. While the nurse is delivering abdominal thrusts to a 6-year-old who is choking on a foreign
    body, the child begins to cry. Which of the following should the nurse do next?
49. Tap or gently shake the shoulders.
50. Deliver back slaps.
51. Perform a blind finger sweep of the mouth.
52. Observe the child closely.

Answer 48

48. 4. Crying indicates that the airway obstruction has been relieved. No additional thrusts are
       needed. However, the child needs to be observed closely for complications, including respiratory
       distress. Tapping or shaking the shoulders is used initially to determine unresponsiveness in someone
       who appears unconscious. Delivering chest or back slaps could jeopardize the child’s now-patent
       airway. Because the obstruction has been relieved, there is no need to sweep the child’s mouth.
       Additionally, blind finger sweeps are contraindicated because the object may be pushed further back,
       possibly causing a complete airway obstruction.
       CN: Physiological adaptation; CL:Synthesize

Question 49

The Client with Croup
49. A 3-year-old is brought into the emergency department in her mother’s arms. The child’s
mouth is open and she is drooling and lethargic. Her mother states that she became ill suddenly within
the past 2 hours. What should the nurse do first?
1. Draw blood cultures for complete blood count.
2. Start an intravenous line.
3. Inspect the child’s throat with a tongue blade.
4. Maintain the child in an undisturbed, upright position.

Answer 49

The Client with Croup
49. 4. This child is in severe respiratory distress with the potential for complete airway
obstruction. The nurse should refrain from disturbing the child at this time to avoid irritating the
epiglottis and causing it to completely obstruct the child’s airway. The child may be intubated or
undergo a tracheotomy. However, initially, the child should be kept as calm as possible with as little
disruption as possible. Any attempt to restrain the child, draw blood, insert an IV, or examine her
throat could result in total airway obstruction.
CN: Physiological adaptation; CL: Synthesize

Question 50

50. The father of a 16-month-old child calls the clinic because the child has a low-grade fever,
    cold symptoms, and a hoarse cough. Which of the following should the nurse suggest that the father
    do?
51. Offer extra fluids frequently.
52. Bring the child to the clinic immediately.
53. Count the child’s respiratory rate.
54. Use a hot air vaporizer.

Answer 50

50. 1. The toddler is exhibiting cold symptoms. A hoarse cough may be part of the upper
       respiratory tract infection. The best suggestion is to have the father offer the child additional fluids at
       frequent intervals to help keep secretions loose and membranes moist. There is no evidence presented
       to suggest that the child needs to be brought to the clinic immediately. Although having the father count
       the child’s respiratory rate may provide some additional information, it may lead the father to suspect
       that something is seriously wrong, possibly leading to undue anxiety. A hot air vaporizer is not
       recommended. However, a cool mist vaporizer would cause vasoconstriction of the respiratory
       passages, making it easier for the child to breathe and loosening secretions.
       CN: Physiological adaptation; CL: Synthesize

Question 51

51. A 21-month-old child admitted with the diagnosis of croup now has a respiratory rate of 48
    breaths/minute, a heart rate of 120 bpm, and a temperature of 100.8°F (38.2°C) rectally. The nurse is
    having difficulty calming the child. Which of the following should the nurse do next?
52. Administer acetaminophen (Tylenol).
53. Notify the primary care provider immediately.
54. Allow the toddler to continue to cry.
55. Offer clear fluids every few minutes.

Answer 51

51. 2. The nurse may be having difficulty calming the child because the child is experiencing
       increasing respiratory distress. The normal respiratory rate for a 21-month-old is 25 to 30
       breaths/min. The child’s respiratory rate is 48 breaths/min. Therefore the primary care provider needs
       to be notified immediately. Typically, acetaminophen is not given to a child unless the temperature is
       101°F (38.6°C) or higher. Letting the toddler cry is inappropriate with croup because crying
       increases respiratory distress. Offering fluids every few minutes to a toddler experiencing increasing
       respiratory distress would do little, if anything, to calm the child. Also, the child would have
       difficulty coordinating breathing and swallowing, possibly increasing the risk of aspiration.
       CN: Physiological adaptation; CL: Synthesize

Question 52

The Client with Bronchiolitis or Pharyngitis
52. A child has viral pharyngitis. The nurse should advise the parents to do which of the
following? Select all that apply.
1. Use a cool mist vaporizer.
2. Offer a soft-to-liquid diet.
3. Administer amoxicillin.
4. Administer acetaminophen.
5. Place the child on secretion precautions

Answer 52

The Client with Bronchiolitis or Pharyngitis
52. 1, 2, 4. Viral pharyngitis is treated with symptomatic, supportive therapy. Treatment includes
use of a cool mist vaporizer, feeding a soft or liquid diet, and administration of acetaminophen for
comfort. Viral infections do not respond to antibiotic administration. The child does not need to be on
secretion precautions because viral pharyngitis is not contagious.CN: Psychosocial integrity; CL: Synthesize

Question 53

53. A father brings his 3-month-old infant to the clinic, reporting that the infant has a cold, is
    having trouble breathing, and “just doesn’t seem to be acting right.” Which of the following actions
    should the nurse do first?
54. Check the infant’s heart rate.
55. Weigh the infant.
56. Assess the infant’s oxygen saturation.
57. Obtain more information from the father.

Answer 53

53. 3. In an infant with these symptoms, the first action by the nurse would be to obtain an oxygen
       saturation reading to determine how well the infant is oxygenating, which is valuable information for
       an infant having trouble breathing. Because the father probably can provide no other information,
       checking the heart rate would be the second action done by the nurse. Then the nurse would obtain the
       infant’s weight.
       CN: Reduction of risk potential; CL: Synthesize

Question 54

54. While the nurse is working in a homeless shelter, assessment of a 6-month-old infant reveals
    a respiratory rate of 52 breaths/min, retractions, and wheezing. The mother states that her infant was
    doing fine until yesterday. Which of the following actions would be most appropriate?
55. Administer a nebulizer treatment.
56. Send the infant for a chest radiograph.
57. Refer the infant to the emergency department.
58. Provide teaching about cold care to the mother.

Answer 54

54. 3. Based on the assessment findings of increased respiratory rate, retractions, and wheezing,
       this infant needs further evaluation, which could be obtained in an emergency department. Without a
       definitive diagnosis, administering a nebulizer treatment would be outside the nurse’s scope of
       practice unless there was a prescription for such a treatment. Sending the infant for a radiograph may
       not be in the nurse’s scope of practice. The findings need to be reported to a primary care provider
       who can then determine whether or not a chest radiograph is warranted. The infant is exhibiting signs
       and symptoms of respiratory distress and is too ill to send out with just instructions on cold care for
       the mother.
       CN: Physiological adaptation; CL: Synthesize

Question 55

55. An infant is being treated at home for bronchiolitis. Which of the following should the nurse
    teach the parent about home care? Select all that apply.
56. Offering small amounts of fluids frequently.
57. Allowing the infant to sleep prone.
58. Calling the clinic if the infant vomits.
59. Writing down how much the infant drinks.
60. Performing chest physiotherapy every 4 hours.
61. Watching for difficulty breathing.

Answer 55

55. 1, 6. An infant with bronchiolitis will have increased respirations and will tire more quickly,
    so it is best and easiest for the infant to take fluids more often in smaller amounts. The parents also
    would be instructed to watch for signs of increased difficulty breathing, which signal possible
    complications. Healthy infants and even those with bronchiolitis should sleep in the supine position.
    Calling the clinic for an episode of vomiting would not be necessary. However, the parents would be
    instructed to call if the infant cannot keep down any fluids for a period of more than 4 hours. Parents
    would not need to record how much the infant drinks. Chest physiotherapy is not indicated because it
    does not help and further irritates the infant.
    CN: Basic care and comfort; CL: Create

Question 56

56. In preparation for discharge, the nurse teaches the mother of an infant diagnosed with
    bronchiolitis about the condition and its treatment. Which of the following statements by the mother
    indicates successful teaching?
57. “I need to be sure to take my child’s temperature every day.”
58. “I hope I don’t get a cold from my child.”
59. “Next time my child gets a cold I need to listen to the chest.”
60. “I need to wash my hands more often.”

Answer 56

56. 4. Handwashing is the best way to prevent respiratory illnesses and the spread of disease.
       Bronchiolitis, a viral infection primarily affecting the bronchioles, causes swelling and mucus
       accumulation of the lumina and subsequent hyperinflation of the lung with air trapping. It is
       transmitted primarily by direct contact with respiratory secretions as a result of eye-to-hand or nose-
       to-hand contact or from contaminated fomites. Therefore, handwashing minimizes the risk for
       transmission. Taking the child’s temperature is not appropriate in most cases. As long as the child is
       getting better, taking the temperature will not be helpful. The mother’s statement that she hopes she
       doesn’t get a cold from her child does not indicate understanding of what to do after discharge. For
       most parents, listening to the child’s chest would not be helpful because the parents would not know
       what they were listening for. Rather, watching for an increased respiratory rate, fever, or evidence of
       poor eating or drinking would be more helpful in alerting the parent to potential illness.
       CN: Physiological adaptation; CL: Evaluate

Question 57

57. The nurse observes an 18-month-old who has been admitted with a respiratory tract infection
    (see figure). The nurse should first:1. Position the child supine.
58. Call the rapid response team.
59. Offer the child a carbonated drink.
60. Place the child in a croup tent.

Answer 57

57. 4. The child is in respiratory distress and is sitting in a position to relieve the airway
       obstruction; the nurse should provide a humidified environment with a croup tent with cool mist to
       facilitate breathing and liquefy secretions. The child should remain sitting to facilitate breathing; the
       nurse should allow the child to determine the most comfortable position. After the child is breathing
       normally, the nurse can offer fluids; the primary care provider also may prescribe intravenous fluids.The nurse can call the rapid response team if the respiratory distress is not relieved by using a croup
       tent or changes in other vital signs indicate further distress.
       CN: Reduction of risk potential; CL: Synthesize

Question 58

58. A teaching care plan to prevent the transmission of respiratory syncytial virus (RSV) should
    include which of the following? Select all that apply.
59. The virus can be spread by direct contact.
60. The virus can be spread by indirect contact.
61. Palivizumab (Synagis) is recommended to prevent RSV for all toddlers in day care.
62. The virus is typically contagious for 3 weeks.
63. Older children seldom spread RSV.
64. Frequent handwashing helps reduce the spread of RSV.

Answer 58

58. 1, 2, 6. RSV can be spread through direct contact such as kissing the face of an infected
    person, and it can be spread through indirect contact by touching surfaces covered with infected
    secretions. Handwashing is one of the best ways to reduce the risk of disease transmission.
    Palivizumab can prevent severe RSV infections but is only recommended for the most at-risk infants
    and children. RSV is typically contagious for 3 to 8 days. RSV frequently manifests in older children
    as cold-like symptoms. Infected school-age children frequently spread the virus to other family
    members.
    CN: Safety and infection control; CL: Create

Question 59

Managing Care Quality and Safety
59. A charge nurse is making assignments for a group of children on a pediatric unit. The nurse
should most avoid assigning the same nurse to care for a 2-year-old with respiratory syncytial virus
(RSV) and:
1. An 18-month-old with RSV.
2. A 9-year-old 8 hours post-appendectomy.
3. A 1-year-old with a heart defect.
4. A 6-year-old with sickle cell crisis.

Answer 59

members.
CN: Safety and infection control; CL: Create
Managing Care Quality and Safety
59. 3. RSV may be spread through both direct and indirect contact. While contact and standard
precautions should be employed, a measure to further decrease the risk of nosocomial infections is to
avoid assigning the same nurse caring for an RSV client to a client at risk for infection. A private
room is preferred, but if this is not an option the nurse should understand that children 2 years of age
and younger are most at risk for RSV, especially if they have other chronic problems such as a heart
defect. From an infection control perspective, pairing two clients with RSV is ideal. RSV infections
are less likely to pose a serious problem in older children.
CN: Safety and infection control; CL: Synthesize

Question 60

60. The nurse is preparing to administer the last dose of ceftriaxone (Rocephin) before discharge
    to a 1-year-old but finds the IV has occluded. The nurse should:
61. Restart the IV.
62. Administer the medication intramuscularly.
63. Arrange for early discharge.
64. Contact the prescriber to request a prescription change.

Answer 60

60. 4. Restarting an IV for one dose of a medication may not be in the infant’s best interest when
       the medication can be given in an alternate form. The prescriber should be contacted to determine IM
       or PO options. Rocephin may be given IM, but changing the route of a medication administration
       requires a prescription. Failing to complete an entire course of antibiotics contributes to the
       emergence of antibiotic resistance and would rarely be the best option.
       CN: Management of care; CL: Synthesize

Question 61

61. A nurse administers cefazolin instead of ceftriaxone to an 8-year-old with pneumonia. The
    client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears
    disciplinary action from reporting the error. The charge nurse should tell the nurse:
62. “If you do not report the error, I will have to.”
63. “Reporting the error helps to identify system problems to improve client safety.”
64. “Notify the client’s primary care provider to see if she wants this reported.”
65. “This is not a serious mistake so reporting it will not affect your position.”

Answer 61

61. 2. Client safety is enhanced when the emphasis on medication errors is to determine the root
       cause. All errors should be reported so systems can identify patterns that contribute to errors. Here,
       the similar names probably contributed to the error. The nurse who commits the error knows all the
       relevant information and is in the best position to report it. While the primary care provider should be
       notified, it is a nursing responsibility to report errors, not a primary care provider choice. Relating
       mistakes to a nurse’s position focuses on personal blame.
       CN: Safety and infection control; CL: Synthesize

Question 62

62. A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The primary
    care provider is calling in a telephone prescription for ampicillin. The nurse should do which of the
    following? Select all that apply.
63. Ask the unit clerk to listen on the speaker phone with the nurse and write down the
    prescription.
64. Ask the primary care provider to come to the hospital and write the prescription on the chart.
65. Repeat the prescription to the primary care provider.
66. Ask the primary care provider to confirm that the prescription is correct as understood by the
    nurse.
67. Ask the nursing supervisor to cosign the telephone prescription as transcribed by the nurse.

Answer 62

62. 3, 4. To ensure client safety in obtaining telephone prescriptions, the prescription must be
    received by a registered nurse. The nurse should write the prescription, read the prescription back to
    the primary care provider, and receive confirmation from the primary care provider that the
    prescription is correct. It is not necessary to ask the unit clerk to listen to the prescription, to require
    the primary care provider to come to the hospital to write the prescription on the chart, or to have the
    nursing supervisor cosign the telephone prescription.
    CN: Safety and infection control; CL: Synthesize

Question 63

63. The triage nurse in the emergency room must prioritize the children waiting to be seen. Which
    of the following children is in the greatest need of emergency medical treatment?
64. A 6-year-old with a fever of 104°F (40°C), a muffled voice, no spontaneous cough, and
    drooling.
65. A 3-year-old with a fever of 100°F (37.8°C), a barky cough, and mild intercostal retractions.
66. A 4-year-old with a fever of 101°F (38.3°C), a hoarse cough, inspiratory stridor, and
    restlessness.
67. A 13-year-old with a fever of 104°F (40°C), chills, and a cough with thick yellow secretions.

Answer 63

63. 1. This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency
       due to the risk of complete airway obstruction. The 3- and 4-year-olds are exhibiting signs and
       symptoms of croup. Symptoms often diminish after the child has been taken out in the cool night air. If
       symptoms do not improve, the child may need a single dose of dexamethasone. Fever should also be
       treated with antipyretics. The 13-year-old is exhibiting signs and symptoms of bronchitis. Treatment
       includes rest, antipyretics, and hydration.
       CN: Management of care; CL: Analyze

Question 64

64. A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions,
    and oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and isrestless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for
    communication, the nurse calls the primary health care provider with the recommendation for:
65. Starting oxygen.
66. Providing sedation.
67. Transferring to PICU.
68. Prescribing a chest CT scan.

Answer 64

64. 1. The infant is experiencing signs and symptoms of respiratory distress indicating the need
       for oxygen therapy. Sedation will not improve the infant’s respiratory distress and would likely cause
       further respiratory depression. If the infant’s respiratory status continues to decline, she may need to
       be transferred to the PICU. Oxygen should be the priority as it may improve the infant’s respiratory
       status. A chest CT is not indicated. However, a CXR would be another appropriate recommendation
       for this infant.
       CN: Safety and infection control; CL: Apply