Ricci Chapter 40 UPDATED ACTUAL
Exam Questions and CORRECT Answers
1. The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurse
anticipates which test as most helpful in determining the extent of the child's hypoxia?
A. Pulmonary function test
B. Pulse oximetry
C. Peak expiratory flow
D. Chest radiograph - CORRECT ANSWER - Answer: B
Rationale: Pulse oximetry is a useful tool for determining the extent of hypoxia. It can be used by
the nurse for continuous or intermittent monitoring. Pulmonary function testing measures
respiratory flow and lung volumes and is indicated for asthma, cystic fibrosis, and chronic lung
disease. Peak expiratory flow testing is used to monitor the adequacy of asthma control. Chest
radiographs can show hyperinflation, atelectasis, pneumonia, foreign bodies, pleural effusion,
and abnormal heart or lung size.
2. The nurse is discussing discharge instructions with the parents of a 6-year-old who had a
tonsillectomy. What is the most important thing to stress?
A. Administer analgesics.
B. Encourage the child to drink liquids.
C. Inspect the throat for bleeding.
D. Apply an ice collar. - CORRECT ANSWER - Answer: C
Rationale: Inspecting the throat for bleeding is the most important discharge information to give
the parents. Hemorrhage is unusual postoperatively but may occur any time from the immediate
postoperative period to as late as 10 days after surgery. The nurse should inspect the throat for
bleeding. Mucus tinged with blood may be expected, but fresh blood in the secretions indicates
bleeding. Administering analgesics, encouraging fluids and applying an ice color are important
but not as important as assessing for bleeding.
, 3. A nurse is administering 100% oxygen to a child with a pneumothorax based on the
understanding that this treatment is used primarily for which reason?
A. Improve gas exchange
B. Bypass the obstruction
C. Hasten air reabsorption
D. Prevent hypoxemia - CORRECT ANSWER - Answer: C
Rationale: Administration of 100% oxygen is used to treat pneumothorax primarily because it
hastens the reabsorption of air. Generally this is used only for a few hours. Although the oxygen
also improves gas exchange and prevents hypoxemia, these are not the reasons for its use in this
situation. There is no obstruction with a pneumothorax.
4. Bacterial pneumonia is suspected in a 4-year-old boy with fever, headache, and chest pain.
Which assessment finding would most likely indicate the need for this child to be hospitalized?
A. Fever
B. Oxygen saturation level of 96%
C. Tachypnea with retractions
D. Pale skin color - CORRECT ANSWER - Answer: C
Rationale: Pneumonia is usually a self-limiting disease. Children with bacterial pneumonia can
be successfully managed at home if the work of breathing is not severe and oxygen saturation is
within normal limits. Hospitalization would most likely be required for the child with tachypnea,
significant retractions, poor oral intake, or lethargy for the administration of supplemental
oxygen, intravenous hydration, and antibiotics. Fever, although common in children with
pneumonia, would not necessitate hospitalization. An oxygen saturation level of 96% would be
within normal limits. Pallor (pale skin color) occurs as a result of peripheral vasoconstriction in
an effort to conserve oxygen for vital functions; this finding also would not necessitate
hospitalization.
Exam Questions and CORRECT Answers
1. The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurse
anticipates which test as most helpful in determining the extent of the child's hypoxia?
A. Pulmonary function test
B. Pulse oximetry
C. Peak expiratory flow
D. Chest radiograph - CORRECT ANSWER - Answer: B
Rationale: Pulse oximetry is a useful tool for determining the extent of hypoxia. It can be used by
the nurse for continuous or intermittent monitoring. Pulmonary function testing measures
respiratory flow and lung volumes and is indicated for asthma, cystic fibrosis, and chronic lung
disease. Peak expiratory flow testing is used to monitor the adequacy of asthma control. Chest
radiographs can show hyperinflation, atelectasis, pneumonia, foreign bodies, pleural effusion,
and abnormal heart or lung size.
2. The nurse is discussing discharge instructions with the parents of a 6-year-old who had a
tonsillectomy. What is the most important thing to stress?
A. Administer analgesics.
B. Encourage the child to drink liquids.
C. Inspect the throat for bleeding.
D. Apply an ice collar. - CORRECT ANSWER - Answer: C
Rationale: Inspecting the throat for bleeding is the most important discharge information to give
the parents. Hemorrhage is unusual postoperatively but may occur any time from the immediate
postoperative period to as late as 10 days after surgery. The nurse should inspect the throat for
bleeding. Mucus tinged with blood may be expected, but fresh blood in the secretions indicates
bleeding. Administering analgesics, encouraging fluids and applying an ice color are important
but not as important as assessing for bleeding.
, 3. A nurse is administering 100% oxygen to a child with a pneumothorax based on the
understanding that this treatment is used primarily for which reason?
A. Improve gas exchange
B. Bypass the obstruction
C. Hasten air reabsorption
D. Prevent hypoxemia - CORRECT ANSWER - Answer: C
Rationale: Administration of 100% oxygen is used to treat pneumothorax primarily because it
hastens the reabsorption of air. Generally this is used only for a few hours. Although the oxygen
also improves gas exchange and prevents hypoxemia, these are not the reasons for its use in this
situation. There is no obstruction with a pneumothorax.
4. Bacterial pneumonia is suspected in a 4-year-old boy with fever, headache, and chest pain.
Which assessment finding would most likely indicate the need for this child to be hospitalized?
A. Fever
B. Oxygen saturation level of 96%
C. Tachypnea with retractions
D. Pale skin color - CORRECT ANSWER - Answer: C
Rationale: Pneumonia is usually a self-limiting disease. Children with bacterial pneumonia can
be successfully managed at home if the work of breathing is not severe and oxygen saturation is
within normal limits. Hospitalization would most likely be required for the child with tachypnea,
significant retractions, poor oral intake, or lethargy for the administration of supplemental
oxygen, intravenous hydration, and antibiotics. Fever, although common in children with
pneumonia, would not necessitate hospitalization. An oxygen saturation level of 96% would be
within normal limits. Pallor (pale skin color) occurs as a result of peripheral vasoconstriction in
an effort to conserve oxygen for vital functions; this finding also would not necessitate
hospitalization.
