PNR 204/PNR204 Exam 3 V2 | Pediatric Nursing
Q&A with Rationale | Fortis College
1. A 4-year-old is admitted with suspected epiglottitis. Which nursing intervention is the
highest priority?
A. Assess the child’s airway patency and respiratory status.
B. Obtain a throat culture to identify the causative organism.
C. Prepare the child for a chest radiograph to confirm diagnosis.
D. Administer intravenous antibiotics as prescribed.
Correct Answer: A
Explanation: In cases of suspected epiglottitis, the nurse’s priority is always maintaining a
patent airway. Assessing respiratory status helps identify signs of complete obstruction
early. Attempting a throat culture or using a tongue blade is contraindicated as it can cause
laryngospasm and immediate airway occlusion.
2. The nurse is caring for a child with Tetralogy of Fallot who suddenly becomes cyanotic and
tachypneic. What should be the nurse’s first action?
A. Administer 100% oxygen via non-rebreather mask.
B. Place the child in the knee-chest position.
C. Prepare to administer morphine sulfate intravenously.
D. Notify the healthcare provider immediately.
,Correct Answer: B
Explanation: The knee-chest position increases systemic vascular resistance, which
reduces the right-to-left shunt in Tetralogy of Fallot. This is the first-line intervention for a
hypercyanotic or ‘tet’ spell. Once the child is positioned, oxygen and medications like
morphine can be administered as needed.
3. A child with cystic fibrosis is being discharged. Which dietary instruction should the nurse
include in the teaching?
A. Provide a high-calorie, high-protein diet.
B. Restrict fat intake to prevent steatorrhea.
C. Decrease salt intake during the summer months.
D. Limit fluid intake to prevent pulmonary congestion.
Correct Answer: A
Explanation: Children with cystic fibrosis require a high-calorie, high-protein diet to
compensate for malabsorption issues. Fat intake should not be restricted but rather
managed with pancreatic enzyme replacement therapy. Increased salt intake is actually
necessary during hot weather due to excessive sodium loss in sweat.
4. A school-aged child is diagnosed with acute glomerulonephritis. Which clinical
manifestation should the nurse expect to observe?
A. Massive proteinuria and hypotension.
B. Increased urine output and weight loss.
, C. Periorbital edema and tea-colored urine.
D. Normal blood pressure and clear urine.
Correct Answer: C
Explanation: Acute glomerulonephritis is characterized by hematuria, which gives the
urine a tea-colored or smoky appearance. Periorbital edema is common due to fluid
retention and decreased glomerular filtration. Hypertension is also a hallmark sign of this
condition, not hypotension.
5. A nurse is assessing a child with a suspected vaso-occlusive sickle cell crisis. What is the
primary goal of nursing care for this patient?
A. Prevention of infection through isolation.
B. Promotion of physical exercise to improve circulation.
C. Correction of the genetic defect.
D. Management of pain and adequate hydration.
Correct Answer: D
Explanation: Pain management is critical in a vaso-occlusive crisis due to tissue ischemia
caused by sickled cells. Hydration is equally important to reduce blood viscosity and help
move the sickled cells through the vasculature. While infection prevention is important, it
is not the primary focus during an acute crisis.
Q&A with Rationale | Fortis College
1. A 4-year-old is admitted with suspected epiglottitis. Which nursing intervention is the
highest priority?
A. Assess the child’s airway patency and respiratory status.
B. Obtain a throat culture to identify the causative organism.
C. Prepare the child for a chest radiograph to confirm diagnosis.
D. Administer intravenous antibiotics as prescribed.
Correct Answer: A
Explanation: In cases of suspected epiglottitis, the nurse’s priority is always maintaining a
patent airway. Assessing respiratory status helps identify signs of complete obstruction
early. Attempting a throat culture or using a tongue blade is contraindicated as it can cause
laryngospasm and immediate airway occlusion.
2. The nurse is caring for a child with Tetralogy of Fallot who suddenly becomes cyanotic and
tachypneic. What should be the nurse’s first action?
A. Administer 100% oxygen via non-rebreather mask.
B. Place the child in the knee-chest position.
C. Prepare to administer morphine sulfate intravenously.
D. Notify the healthcare provider immediately.
,Correct Answer: B
Explanation: The knee-chest position increases systemic vascular resistance, which
reduces the right-to-left shunt in Tetralogy of Fallot. This is the first-line intervention for a
hypercyanotic or ‘tet’ spell. Once the child is positioned, oxygen and medications like
morphine can be administered as needed.
3. A child with cystic fibrosis is being discharged. Which dietary instruction should the nurse
include in the teaching?
A. Provide a high-calorie, high-protein diet.
B. Restrict fat intake to prevent steatorrhea.
C. Decrease salt intake during the summer months.
D. Limit fluid intake to prevent pulmonary congestion.
Correct Answer: A
Explanation: Children with cystic fibrosis require a high-calorie, high-protein diet to
compensate for malabsorption issues. Fat intake should not be restricted but rather
managed with pancreatic enzyme replacement therapy. Increased salt intake is actually
necessary during hot weather due to excessive sodium loss in sweat.
4. A school-aged child is diagnosed with acute glomerulonephritis. Which clinical
manifestation should the nurse expect to observe?
A. Massive proteinuria and hypotension.
B. Increased urine output and weight loss.
, C. Periorbital edema and tea-colored urine.
D. Normal blood pressure and clear urine.
Correct Answer: C
Explanation: Acute glomerulonephritis is characterized by hematuria, which gives the
urine a tea-colored or smoky appearance. Periorbital edema is common due to fluid
retention and decreased glomerular filtration. Hypertension is also a hallmark sign of this
condition, not hypotension.
5. A nurse is assessing a child with a suspected vaso-occlusive sickle cell crisis. What is the
primary goal of nursing care for this patient?
A. Prevention of infection through isolation.
B. Promotion of physical exercise to improve circulation.
C. Correction of the genetic defect.
D. Management of pain and adequate hydration.
Correct Answer: D
Explanation: Pain management is critical in a vaso-occlusive crisis due to tissue ischemia
caused by sickled cells. Hydration is equally important to reduce blood viscosity and help
move the sickled cells through the vasculature. While infection prevention is important, it
is not the primary focus during an acute crisis.
