MEDICAL SURGICAL NURSING END SEMSTER EXAM SET 2025

Nurse Ann is assessing a 3 month old infant during a pediatric clinic visit. The nurse believes the infant is demonstrating early manifestations of respiratory distress. Which clinical manifestations should the nurse document? Select all that applies. 1. Bradypneia 2. Acrocyanosis 3. Intercostal retractions 4. Nasal Congestions 5. Tachypneia a. 1 and 2 b. 3 and 4 c. 4 and 5 d. 3 and 5 - -C. 4 and 5 When caring for a child with acute bronchitis which nursing interventions should be included in the plan of care? Select all that applies. 1. Encourage fluid intake 2. Administer oxygen 3. Suction the nose 4. Administer Antibiotics 5. Follow contact precautions 6. Encourage activity a. 1,2,3,4,6 b. 1,2,3,5 c. 2,3,4,5 d. 1,2,3,4,5,6 - -D. 1,2,3,4,5,6 The nurse is assisting in the development of a plan of care for a child with asthma. In planning care, many goals would be appropriate for this child and or family caregiver. Which two goals would be the highest priority for this child or family? 1. The child will maintain a clear airway. 2. The child will have adequate fluid intake. 3. The child and the family will connect with families living with the same diagnosis. 4. The child and the family will improve knowledge and understanding of varied pharmacologic options. 5. The child will maintain adequate pain control. Medical Medical a. 1,2 b. 3,4 c. 1,5 d. 2,4 e. 4,5 - -A. 1 and 2 A 1 year old with tetralogy of Fallot turns blue during temper tantrum. What will the nurse do first? a. Place the child in the knee chest position b. Assess for irregular heart rate c. Listen for an increased respiratory rate d. Explain to the child the need to calm down - -A. Place the child in the knee chest position The nurse is caring for a child with rheumatic fever who has polyarthritis. which lab result would the nurse most anticipate with this child's diagnosis and symptoms. a. increase clotting time b. decreased white blood cell count c. increased erythrocyte sedimentation rate (ESR) d. decreased leukocyte - -C. Increased erythrocyte sedimentation rate The parents of a 10 year old boy bring the child to the clinic for an evaluation. Which statement by the parents would alert the nurse the possibility of rheumatic fever? a. He had a pretty bad sore throat 10 days ago b. His fever has been running around 100F (38.7C) the past 2 days. c. We noticed a white, thick coating on his tongue yesterday. d. He's been tired the last several; days. - -A. He had a pretty bad sore throat 10 days ago. Nurse Gina sees a 10 year old child in an ambulatory setting because of rheumatic fever. Which of the following would the nurse expect t find revealed by the health history? a. knee pain, abdominal rash, subcutaneous nodules b. an elevated temperature, back pain, loss hair c. fatigue, slow pulse, frequent urination d. loss of weight, abdominal pain, chest pain - -A. knee pain, abdominal rash, subcutaneous nodules Nurse Boyet is caring for a 7 year old child with reports of generalized joint pain and pharyngitis. During assessment, the nurse notes a cardiac murmur. Which action by the nurse is priority? Medical Medical a. Administer penicillin b. Assess skin for rash c. Swab throat culture d. Evaluate C-reactive protein - -C. Swab throat culture After teaching a class about the hemodynamic characteristics of congenital heart disease, the instructor determines that the teaching has been successful when the class identifies which defect as an example of a disorder involvinh increased pulmonary flow? a. Tetralogy of Fallot b. Atrial septal defect c. Hypoplastic left heart syndrome d. Transposition of the great vessels - -b. Atrial septal defect Nurse Joshua is assessing children in an ambulatory clinic. Which child would be most likely to have iron deficiency anemia? a. A 3 month old infant who is totally breastfed. b. A 15 year old adolescent who has heavy menstrual periods c. An 8 year old child who carries lunch to school d. A 7 month old infant who has started table food - -b. A 15 year old adolescent who has heavy menstrual periods Nurse Bubbles is caring for a 10 year old boy with hemophilia. He asks the nurse for suggestions about appropriate physical activities. Which activity would the nurse most likely recommend? a. Basketball b. Volleyball c. Wrestling d. Soccer - -a. Basketball The nurse is admitting to an examination room a child with diagnosis of probable acute lymphoblastic leukemia (ALL). What will confirm the diagnosis? a. Complete blood count b. Lethargy, bruising and pallor c. History of leukemia in twin d. Bone marrow aspiration - -d. Bone marrow aspiration A 5 year old child is at the pediatric clinic for a well child visit. Which symptom alerts the healthcare provider that this child might have acute lymphoblastic leukemia (ALL). a. joint pain and swelling b. anorexia and weight loss c. abdominal pain, nausea, vomiting Medical Medical d. lethargy, bruises, and lymphadenopathy - -d. lethargy, bruises, and lymphadenopathy The parents of a 6 week old boy come to the clinic for evaluation because the infant has been vomiting. The parents report that the vomiting has been increasing in frequency and forcefulness over last week. The mother says "sometimes, it seems like it just bursts out of his mouth". A diagnosis of hypertonic pyloric stenosis is suspected. When performing the physical examination, what would be the nurse most likely find? a. Sausage shape mass in the upper mid abdomen b. Hard, moveable, olive shaped mass in the right upper quadrant c. Tenderness over the McBurney point in the lower quadrant d. Abdominal pain in the epigastric or umbilical cord - -b. Hard, moveable, olive shaped mass in the right upper quadrant The nurse is caring for a child admitted with pyloric stenosis. Which clinical manifestation would likely have been noted in the child with this diagnosis? a. Explosive diarrhea b. Projectile vomiting c. Severe abdominal pain d. Frequent urination - -b. Projectile vomiting A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? a. Gastroenteritis b. Ulcerative colitis c. Hirschsprung disease d. Short bowel syndrome - -c. Hirschsprung disease The nurse is providing preoperative teaching for the parents of an 8 month old child with Hirschsprung disease who will have two stage surgery as treatment. Which statement by the parents demonstrates the need for further teaching? a. Our child will have a nasogastric tube for the first day after the surgery to receive nutrition b. Our child will have colostomy from the first surgery and a second surgery to repair the bowel c. We will be able to resume breastfeeding about one day after the surgery d. After the surgery, we will slowly reintroduce easy to digest foods. - -a. Our child will have a nasogastric tube for the first day after the surgery to receive nutrition When caring for a child who has a diagnosis of acute glomerulonephritis, which nursing interventions would most likely be included in the child's plan of care? Select all that apply? Medical Medical 1. The nurse encourages ambulation several times a day 2. The nurse promotes increased fluid intake 3. The nurse administers diuretics 4. The nurse administers antihypertensive 5. The nurse weighs the child every day using the same scale. 6. The nurse dipsticks the child urine to test for protein. a. 1,2,3,4 b. 3,4,5,6 c. 1,2,5,6 d. 1,2,34,5,6, - - The parents of a school aged client diagnosed with acute glomerulonephritis are asking when their child can increase activity. Which instruction is most accurate? a. when fatigue has diminished d. when the client is afebrile c. when gross hematuria has subsided d. after antibiotics are fully completed - -c. when gross hematuria has subsided The mother of a 4 year old client with nephrotic syndrome asks the nurse what can be done about the child's edema. Which action would the nurse suggests? a. Provide a regular diet low salt and without fluid restrictions b. Provide a regular diet low in salt, high in potassium and with fluid restrictions. c. Provide a diet low in protein and salt and without fluid restrictions. d. Provide diet that is high in protein and potassium, low