NR328/NR 328 Exam 2 V1 | Pediatric Nursing Q&A
with Rationale | Chamberlain University
1. A 4-year-old child is admitted to the pediatric unit with a diagnosis of acute epiglottitis.
Which nursing action should the nurse prioritize first?
A. Obtain a throat culture to identify the causative organism.
B. Assess the child’s airway patency and respiratory status.
C. Administer the prescribed intravenous antibiotics.
D. Place the child in a supine position to facilitate rest.
Correct Answer: B
Explanation: Airway management is the primary priority in acute epiglottitis due to the
risk of sudden total airway obstruction. The nurse must avoid invasive procedures like
throat cultures which could trigger a laryngospasm. Continuous monitoring of respiratory
status ensures early detection of worsening distress.
2. The nurse is caring for an infant with Tetralogy of Fallot who begins to have a
hypercyanotic ‘Tet’ spell. Which action should the nurse take immediately?
A. Place the infant in the knee-chest position.
B. Administer 100% oxygen via a non-rebreather mask.
C. Prepare to administer a dose of intravenous morphine.
D. Call the rapid response team for immediate intubation.
,Correct Answer: A
Explanation: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves oxygenation. This is the first-line non-
pharmacological intervention used to resolve the acute hypoxia of a Tet spell. After
positioning, the nurse would then proceed with oxygen and potential medication
administration.
3. A school-age child with cystic fibrosis is being educated on the use of pancreatic enzymes.
Which instruction is most accurate for the nurse to provide?
A. Take the enzymes only when consuming high-fat meals.
B. Take the enzymes twice daily regardless of oral intake.
C. Crush the enteric-coated beads if the child has trouble swallowing.
D. Administer the enzymes within 30 minutes of eating snacks or meals.
Correct Answer: D
Explanation: Pancreatic enzymes are required with every meal and snack to ensure
proper absorption of fats and proteins in patients with cystic fibrosis. The timing is critical
because the enzymes must be present in the duodenum when food arrives. Crushing the
beads is contraindicated as it destroys the enteric coating meant to protect the enzymes
from stomach acid.
, 4. The nurse is assessing a 2-year-old child for possible intussusception. Which clinical
manifestation is most characteristic of this condition?
A. Ribbon-like, foul-smelling stools.
B. Projectile vomiting after every feeding.
C. Currant jelly-like stools containing blood and mucus.
D. Pain that is relieved by eating a small meal.
Correct Answer: C
Explanation: Currant jelly stools occur when the intestinal mucosa becomes inflamed and
bleeds due to the telescoping effect of the bowel. This classic sign, along with sudden
abdominal pain and a sausage-shaped mass, is indicative of intussusception. Immediate
diagnosis and treatment via air or saline enema are necessary to prevent bowel necrosis.
5. A 10-year-old child is hospitalized with a vaso-occlusive sickle cell crisis. What is the priority
nursing intervention?
A. Encouraging a high-protein, low-calorie diet.
B. Providing intravenous hydration and pain management.
C. Administering oral iron supplements twice daily.
D. Applying cold compresses to the painful joints.
Correct Answer: B
with Rationale | Chamberlain University
1. A 4-year-old child is admitted to the pediatric unit with a diagnosis of acute epiglottitis.
Which nursing action should the nurse prioritize first?
A. Obtain a throat culture to identify the causative organism.
B. Assess the child’s airway patency and respiratory status.
C. Administer the prescribed intravenous antibiotics.
D. Place the child in a supine position to facilitate rest.
Correct Answer: B
Explanation: Airway management is the primary priority in acute epiglottitis due to the
risk of sudden total airway obstruction. The nurse must avoid invasive procedures like
throat cultures which could trigger a laryngospasm. Continuous monitoring of respiratory
status ensures early detection of worsening distress.
2. The nurse is caring for an infant with Tetralogy of Fallot who begins to have a
hypercyanotic ‘Tet’ spell. Which action should the nurse take immediately?
A. Place the infant in the knee-chest position.
B. Administer 100% oxygen via a non-rebreather mask.
C. Prepare to administer a dose of intravenous morphine.
D. Call the rapid response team for immediate intubation.
,Correct Answer: A
Explanation: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt and improves oxygenation. This is the first-line non-
pharmacological intervention used to resolve the acute hypoxia of a Tet spell. After
positioning, the nurse would then proceed with oxygen and potential medication
administration.
3. A school-age child with cystic fibrosis is being educated on the use of pancreatic enzymes.
Which instruction is most accurate for the nurse to provide?
A. Take the enzymes only when consuming high-fat meals.
B. Take the enzymes twice daily regardless of oral intake.
C. Crush the enteric-coated beads if the child has trouble swallowing.
D. Administer the enzymes within 30 minutes of eating snacks or meals.
Correct Answer: D
Explanation: Pancreatic enzymes are required with every meal and snack to ensure
proper absorption of fats and proteins in patients with cystic fibrosis. The timing is critical
because the enzymes must be present in the duodenum when food arrives. Crushing the
beads is contraindicated as it destroys the enteric coating meant to protect the enzymes
from stomach acid.
, 4. The nurse is assessing a 2-year-old child for possible intussusception. Which clinical
manifestation is most characteristic of this condition?
A. Ribbon-like, foul-smelling stools.
B. Projectile vomiting after every feeding.
C. Currant jelly-like stools containing blood and mucus.
D. Pain that is relieved by eating a small meal.
Correct Answer: C
Explanation: Currant jelly stools occur when the intestinal mucosa becomes inflamed and
bleeds due to the telescoping effect of the bowel. This classic sign, along with sudden
abdominal pain and a sausage-shaped mass, is indicative of intussusception. Immediate
diagnosis and treatment via air or saline enema are necessary to prevent bowel necrosis.
5. A 10-year-old child is hospitalized with a vaso-occlusive sickle cell crisis. What is the priority
nursing intervention?
A. Encouraging a high-protein, low-calorie diet.
B. Providing intravenous hydration and pain management.
C. Administering oral iron supplements twice daily.
D. Applying cold compresses to the painful joints.
Correct Answer: B
