Pediatric Nursing (Wayne County Community College District)
Ques%on 1
The nurse is teaching parents of a child recently diagnosed with asthma how to interpret the results of
the peak expiratory flow meter at home. The nurse should tell them what level indicates the red
zone?
Answers Less than 50% of personal best
:
Less than 25% of personal best
Peak flow meters should never be used at home because they must be interpreted by a
health care provider
Less than 80% of personal best
Ra%onale: A peak expiratory flow rate of red (<50% of personal best) signals a medical
alert. Severe airway narrowing may be occurring. A short-acLng bronchodilator should be
administered. NoLfy health care provider if the peak rate does not return immediately
and stay in the yellow and green zones.
Ques%on 2
Which is the priority nursing intervenLon for an unconscious child aOer a fall?
Answers Assess for a neck injury
:
Monitor intracranial pressure
Perform neurologic assessment
, Establish adequate airway
Ra%onale: Respiratory effecLveness is the primary concern in the care of the unconscious
child. Establishment of an adequate airway is always the first priority. A neurologic
assessment and determinaLon of whether a neck injury is present will be performed aOer
breathing and circulaLon are stabilized. Intracranial, not intercranial, pressure is
monitored if indicated aOer airway, breathing, and circulaLon are maintained.
Ques%on 3
The nurse is conducLng discharge teaching about signs and symptoms of heart failure to parents of an
infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include?
( Select all that apply. )
Answers Swea%ng (inappropriate)
:
Warm flushed extremiLes
Decreased urinary output
Fa%gue
Weight loss
Ra%onale: The signs and symptoms of heart failure include decreased urinary output,
sweaLng, and faLgue. Other signs include pale, cool extremiLes, not warm and flushed,
and weight gain, not weight loss
Ques%on 4
The nurse is caring for a child with acute renal failure. Which clinical manifestaLon would the nurse
recognize as a sign of hyperkalemia?
Answers Dyspnea
:
Seizure
Cardiac arrhythmia
Oliguria
Ra%onale: Hyperkalemia is the most common threat to the life of the child. Signs of
hyperkalemia include electrocardiograph anomalies such as prolonged QRS complex,
depressed ST segments, peaked T waves, bradycardia, or heart block. Dyspnea, seizure,
and oliguria are not manifestaLons of hyperkalemia.
, Ques%on 5
Place in order, the intervenLons the nurse would implement starLng with the highest priority
intervenLon sequencing to the lowest priority intervenLon for a child experiencing a generalized
seizure. Chapter 27 last quesLon
Answers
1. Ease the child to the floor
2. Turn the child to the side
3. Take vital signs
4. Allow child to rest
5. Integrate child back into the school environment
Evaluate posLctal symptoms
Turn child to the side
Ease child to the floor
Note onset of seizure
Monitor vital sig
Ques%on 6
The nurse is teaching parents of a child recently diagnosed with asthma how to interpret the results of
the peak expiratory flow meter at home. The nurse should tell them what level indicates the red
zone?
Answers Less than 50% of personal best
:
Less than 25% of personal best
Peak flow meters should never be used at home because they must be interpreted by a
health care provider
Less than 80% of personal best
Ra%onale: A peak expiratory flow rate of red (<50% of personal best) signals a medical
alert. Severe airway narrowing may be occurring. A short-acLng bronchodilator should be
administered. NoLfy health care provider if the peak rate does not return immediately
and stay in the yellow and green zones.
Ques%on 8
, Which is the priority nursing intervenLon for an unconscious child aOer a fall?
Answers Assess for a neck injury
:
Monitor intracranial pressure
Perform neurologic assessment
Establish adequate airway
Ra%onale: Respiratory effecLveness is the primary concern in the care of the unconscious
child. Establishment of an adequate airway is always the first priority. A neurologic
assessment and determinaLon of whether a neck injury is present will be performed aOer
breathing and circulaLon are stabilized. Intracranial, not intercranial, pressure is
monitored if indicated aOer airway, breathing, and circulaLon are maintained.
Ques%on 9
The nurse is conducLng discharge teaching about signs and symptoms of heart failure to parents of an
infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include?
( Select all that apply. )
Answers Swea%ng (inappropriate)
:
Warm flushed extremiLes
Decreased urinary output
Fa%gue
Weight loss
Ra%onale: The signs and symptoms of heart failure include decreased urinary output,
sweaLng, and faLgue. Other signs include pale, cool extremiLes, not warm and flushed,
and weight gain, not weight loss
Ques%on 10
The nurse is caring for a child with acute renal failure. Which clinical manifestaLon would the nurse
recognize as a sign of hyperkalemia?
Answers Dyspnea
:
Seizure