NSG 3600 Exam 2 Actual Exam V3 | NSG 3600 Nursing Practice –
Children’s Health (NSG3600 Exam 2)
1. A 10-month-old infant is admitted with respiratory syncytial virus (RSV) bronchiolitis.
Which finding should the nurse prioritize as a sign of impending respiratory failure?
A. Intermittent non-productive cough
B. Nasal flaring and grunting
C. Oxygen saturation of 92% on room air
D. Heart rate of 140 beats per minute
Answer: B
Rationale: Nasal flaring and expiratory grunting are significant signs of increased work of
breathing and indicate that the infant is struggling to maintain airway patency. This finding
suggests potential deterioration toward respiratory failure. The nurse must immediately
assess the child’s airway and prepare for possible escalation of respiratory support.
2. A 6-year-old child is admitted for acute glomerulonephritis. Which assessment finding is
most important for the nurse to report to the healthcare provider?
A. Tea-colored urine
B. Periorbital edema
C. Blood pressure of 148/96 mmHg
D. Mild lethargy
Answer: C
Rationale: Hypertension is a major complication of acute glomerulonephritis and can lead
to hypertensive encephalopathy or seizures. While tea-colored urine and edema are
expected findings of the disease, a significantly elevated blood pressure requires
immediate intervention. The nurse should continue to monitor the patient for neurological
changes while notifying the provider.
3. The nurse is providing discharge instructions to the parents of a toddler diagnosed with
Celiac disease. Which food choice indicates that the parents understand the dietary
restrictions?
A. Whole wheat crackers with cheese
B. Oatmeal cookies with raisins
C. Barley soup with vegetables
D. Rice cakes with peanut butter
,Answer: D
Rationale: Celiac disease requires a strict gluten-free diet, which means avoiding wheat,
barley, rye, and often oats. Rice and corn are safe alternatives for children with this
condition. The nurse must emphasize label reading to the family to prevent accidental
ingestion of hidden gluten.
4. A child is receiving intravenous (IV) fluids for severe dehydration. Which of the following is
the most reliable indicator that the fluid resuscitation is effective?
A. Urine output of 1-2 mL/kg/hr
B. Improved skin turgor
C. Moist mucous membranes
D. A decrease in heart rate
Answer: A
Rationale: In pediatric patients, urine output is the most objective and reliable measure of
organ perfusion and adequate fluid volume. For infants and children, a goal of 1 to 2
mL/kg/hour is typically used to confirm effective resuscitation. While skin turgor and
mucous membranes improve, they are more subjective findings.
5. A 4-year-old is suspected of having epiglottitis. Which action by the nurse is the priority?
A. Obtain a throat culture to identify the pathogen
B. Examine the throat using a tongue depressor
C. Place the child in a supine position
D. Keep the child calm and prepare for intubation
Answer: D
Rationale: Epiglottitis is a medical emergency that can lead to sudden total airway
obstruction. Attempting to visualize the throat or upsetting the child can trigger a
laryngospasm. The nurse must maintain a calm environment, avoid invasive procedures,
and have emergency airway equipment at the bedside.
6. The nurse is caring for an infant following a cleft lip repair. What is the priority nursing
intervention to protect the surgical site?
A. Position the infant on their abdomen
B. Apply elbow restraints (Logan bow)
C. Use a standard nipple for feeding
D. Perform oral suctioning every 2 hours
Answer: B
, Rationale: Preventing the infant from touching or rubbing the suture line is critical for
successful healing after a cleft lip repair. Elbow restraints (often called ‘no-no’s’) are used
to keep the infant from reaching their face. The infant should also be positioned on their
back or side, never the abdomen, to avoid friction on the surgical site.
7. A 12-year-old child with Type 1 Diabetes Mellitus presents with deep, rapid respirations
and a fruity breath odor. What is the nurse’s first action?
A. Administer 15 grams of simple carbohydrates
B. Initiate an intravenous infusion of Normal Saline
C. Give a subcutaneous injection of glucagon
D. Check the child’s blood glucose level
Answer: D
Rationale: The child is exhibiting signs of Diabetic Ketoacidosis (DKA), including Kussmaul
respirations and acetone breath. The first step in management is to confirm the blood
glucose level to guide treatment. Once confirmed, rapid fluid resuscitation and insulin
therapy will be initiated.
8. Which clinical manifestation would the nurse expect to find in a child with Tetralogy of
Fallot?
A. Bounding pulses in the upper extremities
B. Machinery-like heart murmur
C. Hypotension in the lower extremities
D. Clubbing of the fingers and toes
Answer: D
Rationale: Tetralogy of Fallot involves chronic cyanosis due to decreased pulmonary blood
flow. Over time, this chronic hypoxia leads to compensatory polycythemia and clubbing of
the nail beds. The other options describe findings related to Patent Ductus Arteriosus or
Coarctation of the Aorta.
9. A 2-year-old is admitted with suspected intussusception. Which assessment finding is
considered a hallmark sign of this condition?
A. Currant jelly-like stools
B. Projectile vomiting after feedings
C. Ribbon-like, foul-smelling stools
D. Painless abdominal distention
Answer: A
Children’s Health (NSG3600 Exam 2)
1. A 10-month-old infant is admitted with respiratory syncytial virus (RSV) bronchiolitis.
Which finding should the nurse prioritize as a sign of impending respiratory failure?
A. Intermittent non-productive cough
B. Nasal flaring and grunting
C. Oxygen saturation of 92% on room air
D. Heart rate of 140 beats per minute
Answer: B
Rationale: Nasal flaring and expiratory grunting are significant signs of increased work of
breathing and indicate that the infant is struggling to maintain airway patency. This finding
suggests potential deterioration toward respiratory failure. The nurse must immediately
assess the child’s airway and prepare for possible escalation of respiratory support.
2. A 6-year-old child is admitted for acute glomerulonephritis. Which assessment finding is
most important for the nurse to report to the healthcare provider?
A. Tea-colored urine
B. Periorbital edema
C. Blood pressure of 148/96 mmHg
D. Mild lethargy
Answer: C
Rationale: Hypertension is a major complication of acute glomerulonephritis and can lead
to hypertensive encephalopathy or seizures. While tea-colored urine and edema are
expected findings of the disease, a significantly elevated blood pressure requires
immediate intervention. The nurse should continue to monitor the patient for neurological
changes while notifying the provider.
3. The nurse is providing discharge instructions to the parents of a toddler diagnosed with
Celiac disease. Which food choice indicates that the parents understand the dietary
restrictions?
A. Whole wheat crackers with cheese
B. Oatmeal cookies with raisins
C. Barley soup with vegetables
D. Rice cakes with peanut butter
,Answer: D
Rationale: Celiac disease requires a strict gluten-free diet, which means avoiding wheat,
barley, rye, and often oats. Rice and corn are safe alternatives for children with this
condition. The nurse must emphasize label reading to the family to prevent accidental
ingestion of hidden gluten.
4. A child is receiving intravenous (IV) fluids for severe dehydration. Which of the following is
the most reliable indicator that the fluid resuscitation is effective?
A. Urine output of 1-2 mL/kg/hr
B. Improved skin turgor
C. Moist mucous membranes
D. A decrease in heart rate
Answer: A
Rationale: In pediatric patients, urine output is the most objective and reliable measure of
organ perfusion and adequate fluid volume. For infants and children, a goal of 1 to 2
mL/kg/hour is typically used to confirm effective resuscitation. While skin turgor and
mucous membranes improve, they are more subjective findings.
5. A 4-year-old is suspected of having epiglottitis. Which action by the nurse is the priority?
A. Obtain a throat culture to identify the pathogen
B. Examine the throat using a tongue depressor
C. Place the child in a supine position
D. Keep the child calm and prepare for intubation
Answer: D
Rationale: Epiglottitis is a medical emergency that can lead to sudden total airway
obstruction. Attempting to visualize the throat or upsetting the child can trigger a
laryngospasm. The nurse must maintain a calm environment, avoid invasive procedures,
and have emergency airway equipment at the bedside.
6. The nurse is caring for an infant following a cleft lip repair. What is the priority nursing
intervention to protect the surgical site?
A. Position the infant on their abdomen
B. Apply elbow restraints (Logan bow)
C. Use a standard nipple for feeding
D. Perform oral suctioning every 2 hours
Answer: B
, Rationale: Preventing the infant from touching or rubbing the suture line is critical for
successful healing after a cleft lip repair. Elbow restraints (often called ‘no-no’s’) are used
to keep the infant from reaching their face. The infant should also be positioned on their
back or side, never the abdomen, to avoid friction on the surgical site.
7. A 12-year-old child with Type 1 Diabetes Mellitus presents with deep, rapid respirations
and a fruity breath odor. What is the nurse’s first action?
A. Administer 15 grams of simple carbohydrates
B. Initiate an intravenous infusion of Normal Saline
C. Give a subcutaneous injection of glucagon
D. Check the child’s blood glucose level
Answer: D
Rationale: The child is exhibiting signs of Diabetic Ketoacidosis (DKA), including Kussmaul
respirations and acetone breath. The first step in management is to confirm the blood
glucose level to guide treatment. Once confirmed, rapid fluid resuscitation and insulin
therapy will be initiated.
8. Which clinical manifestation would the nurse expect to find in a child with Tetralogy of
Fallot?
A. Bounding pulses in the upper extremities
B. Machinery-like heart murmur
C. Hypotension in the lower extremities
D. Clubbing of the fingers and toes
Answer: D
Rationale: Tetralogy of Fallot involves chronic cyanosis due to decreased pulmonary blood
flow. Over time, this chronic hypoxia leads to compensatory polycythemia and clubbing of
the nail beds. The other options describe findings related to Patent Ductus Arteriosus or
Coarctation of the Aorta.
9. A 2-year-old is admitted with suspected intussusception. Which assessment finding is
considered a hallmark sign of this condition?
A. Currant jelly-like stools
B. Projectile vomiting after feedings
C. Ribbon-like, foul-smelling stools
D. Painless abdominal distention
Answer: A
