RNSG 1538 ACTUAL FINALS ANSWERS AND
QUESTIONS SET A+
✔✔A nurse is assessing an infant. Which of the following findings are clinical
manifestations of acute otitis media?
A) Decreased pain in the supine position
B) Rolling head side to side
C) Loss of appetite
D) Increased sensitivity to sound
E) Crying - ✔✔B) Rolling head side to side
C) Loss of appetite
E) Crying
✔✔UTI patient teaching to prevent recurrence - ✔✔Know at risk people:
-debilitated people
-older people
-immune compromised
-conditions that cause urinary stasis
Health promotion activities:
-empty regularly and completely
-evacuate bowel regularly
-wipe from front to back after going
-drink 15ml/lb/day
-drinking cranberry juice/tab may reduce attachment of pathogens to bladder epithelium
-seek treatment asap
For hospital acquired UTI:
-RN must follow aseptic technique
-wash hands before/after procedure or contact with pt
-wear gloves
-routine/thorough perineal hygiene especially when a bed pan is used
,✔✔What Evidence-based practice should the nurse implement for antibiotic treatment in
children who have UTIs? - ✔✔-7 to 14 day course of antibiotics is often prescribed,
though 2 TO 5 DAY COURSE may be as effective.
✔✔A female patient has been experiencing recurrent urinary tract infections. What
health education should the nurse provide to this patient?
A) Bathe daily and keep the perineal region clean.
B) Avoid voiding immediately after sexual intercourse.
C) Drink liberal amounts of fluids.
D) Void at least every 6 to 8 hours. - ✔✔C) Drink liberal amounts of fluids.
✔✔HPV vaccine - ✔✔Human Papilloma Virus (HPV2, HPV4)
-Three doses should be given over a 6 month
-interval for females at 11 to 12 years of age (minimum age is 9 years).
-The second dose should be administered 2 months after the first dose, and the third
dose should be administered 6 months after the first dose.
-HPV4 may be given to males starting at age 9 years of age.
-young women aged b/w 9 and 26 should consider getting GARDASIL 9, vaccine
against HPV
✔✔Principles/purpose of immunizations - ✔✔-activation
-active immunity
-immunity lasting years to a lifetime
✔✔immunity - ✔✔is the ability to destroy and remove a specific antigen from the body.
The acquisition of immunity can be active or passive
✔✔passive immunity - ✔✔is produced when the immunoglobulins of one person are
transferred to another. This immunity lasts only weeks or months.
-can be obtained by injection of exogenous immunoglobulins.
-also can be transferred from mothers to infants via colostrum or placenta
✔✔active immunity - ✔✔acquired when a person's own immune system generates the
immune response. Active immunity lasts for many years or for a lifetime.
✔✔Principles of Immunization - ✔✔The immune system has the ability to recognize
materials present in the body as "self" or "nonself." Foreign materials (nonself) are
called antigens. When an antigen is recognized by the immune system, the immune
system responds by producing antibodies (immunoglobulins) or directing special cells to
destroy and remove the antigen.
✔✔A 15-month-old girl is having her first health visit at a clinic. The mother has no
immunization record but says the child was immunized 3 months ago at the local health
department. Which of the following is the best action for the nurse to take?
A) Ask the mother to bring the records to the next health maintenance visit.
,B) Start the catch-up schedule since there are no immunization records.
C) Keep the child at the facility while the mother returns home for the records.
D) Call the local health department and verify the child's immunization status. - ✔✔D)
Call the local health department and verify the child's immunization status.
✔✔The mother of a 15-month-old child is questioning the nurse about the need for the
hepatitis B vaccination. Which of the following comments provides the most compelling
reason for the vaccine?
A) "The most common side effect is injection site soreness."
B) "This is a recombinant or genetically engineered vaccine."
C) "Immunizations are needed to protect the general population."
D) "This protects your child from infection that can cause liver disease." - ✔✔D) "This
protects your child from infection that can cause liver disease.
✔✔After teaching the mother about follow-up immunizations for her daughter, who
received the varicella vaccine at age 14 months, the nurse determines that the teaching
was successful when the mother states that a follow-up dose should be given
at which time?
A) When the child is 20 to 36 months of age
B) When the child is 4 to 6 years of age
C) When the child is 11 to 12 years of age
D) When the child is 13 to 15 years of age - ✔✔B) When the child is 4 to 6 years of age.
✔✔Hepatitis B vaccine - ✔✔-1st dose is given at BIRTH
-2nd dose is given at 1-2 months.
-3rd dose is given at 6-18 months.
*same for children and adolescents age 7-18 yrs
✔✔patent ductus arteriosus (PDA) - ✔✔an abnormal opening between the pulmonary
artery and the aorta caused by failure of the fetal ductus arteriosus to close after birth.
This results in increased pulmonary blood flow.
-can cause left sided heart failure
-ACYANOTIC
-LEFT to RIGHT shunt
✔✔What are the clinical manifestations of PDA? - ✔✔-murmur (machine hum)
-wide pulse pressure
-bounding pulses
-asymptomatic (possible)
-heart failure
-tachycardia
-low diastolic BP
-tachypnea
-rales upon auscultation
, ✔✔When assessing a neonate. Which heart defect at 30 weeks has signs and
symptoms of BOUNDING PULSES, TACHYPNEA, TACHYCARDIA, and
CRACKLES/THRILLS? - ✔✔PATENT DUCTUS ARTERIOSUS
✔✔The nurse is caring for an infant with suspected patent ductus arteriosus. Which of
the following assessment findings would the nurse identify as helping to confirm this
suspicion?
A) Thrill at the base of the heart
B) Harsh, continuous, machine-like murmur under the left clavicle
C) Faint pulses
D) Systolic murmur best heard along the left sternal border - ✔✔B) Harsh, continuous,
machine-like murmur under the left clavicle at the first and second intercostal spaces.
✔✔A newborn is diagnosed with patent ductus arteriosus. The nurse anticipates that
the physician will most likely order which medication?
A) Alprostadil
B) Heparin
C) Indomethacin
D) Spironolactone - ✔✔C) Indomethacin
✔✔Indomethacin (Indocin) - ✔✔-NSAID.
-Inhibit prostaglandin synthesis resulting in decreased inflammatory responses.
-Uses: provide rapid, symptomatic relief of inflammation and pain and to close PDA.
-Precautions/Interactions: hypersensitivity to aspirin or other NSAIDs, may increase the
risk of MI and stroke.
✔✔congenital heart defects teachings - ✔✔-give medications, if ordered, exactly as
perscribed
-weigh the child at least once a week or as ordered, same time of day w/same amount
of clothes
-allow the child to engage in activity as directed. Provide time for the child to rest
frequently to avoid overexertion
-notify physician or NP if child has increased episodes of respiratory distress, cyanosis,
or difficulty breathing; fever; increased edema of the hands, feet, or face; decreased
urinary output; weight loss or difficulty eating or drinking; increased fatigue; decreased
LOA; vomiting or diarrhea
✔✔A 2-day old neonate is 30 min post-op of a surgical correction for CHD. Which
finding would you report to the physician? - ✔✔-pulse rate of 90
✔✔The nurse is caring for a 2-month-old infant who has been diagnosed with acute
heart failure. The nurse is providing teaching about nutrition. Which of the following
statements by the mother indicates a need for further teaching?
A) "The baby may need as much as 150 calories/kg/day."
B) "Small, frequent feedings are best if tolerated."
QUESTIONS SET A+
✔✔A nurse is assessing an infant. Which of the following findings are clinical
manifestations of acute otitis media?
A) Decreased pain in the supine position
B) Rolling head side to side
C) Loss of appetite
D) Increased sensitivity to sound
E) Crying - ✔✔B) Rolling head side to side
C) Loss of appetite
E) Crying
✔✔UTI patient teaching to prevent recurrence - ✔✔Know at risk people:
-debilitated people
-older people
-immune compromised
-conditions that cause urinary stasis
Health promotion activities:
-empty regularly and completely
-evacuate bowel regularly
-wipe from front to back after going
-drink 15ml/lb/day
-drinking cranberry juice/tab may reduce attachment of pathogens to bladder epithelium
-seek treatment asap
For hospital acquired UTI:
-RN must follow aseptic technique
-wash hands before/after procedure or contact with pt
-wear gloves
-routine/thorough perineal hygiene especially when a bed pan is used
,✔✔What Evidence-based practice should the nurse implement for antibiotic treatment in
children who have UTIs? - ✔✔-7 to 14 day course of antibiotics is often prescribed,
though 2 TO 5 DAY COURSE may be as effective.
✔✔A female patient has been experiencing recurrent urinary tract infections. What
health education should the nurse provide to this patient?
A) Bathe daily and keep the perineal region clean.
B) Avoid voiding immediately after sexual intercourse.
C) Drink liberal amounts of fluids.
D) Void at least every 6 to 8 hours. - ✔✔C) Drink liberal amounts of fluids.
✔✔HPV vaccine - ✔✔Human Papilloma Virus (HPV2, HPV4)
-Three doses should be given over a 6 month
-interval for females at 11 to 12 years of age (minimum age is 9 years).
-The second dose should be administered 2 months after the first dose, and the third
dose should be administered 6 months after the first dose.
-HPV4 may be given to males starting at age 9 years of age.
-young women aged b/w 9 and 26 should consider getting GARDASIL 9, vaccine
against HPV
✔✔Principles/purpose of immunizations - ✔✔-activation
-active immunity
-immunity lasting years to a lifetime
✔✔immunity - ✔✔is the ability to destroy and remove a specific antigen from the body.
The acquisition of immunity can be active or passive
✔✔passive immunity - ✔✔is produced when the immunoglobulins of one person are
transferred to another. This immunity lasts only weeks or months.
-can be obtained by injection of exogenous immunoglobulins.
-also can be transferred from mothers to infants via colostrum or placenta
✔✔active immunity - ✔✔acquired when a person's own immune system generates the
immune response. Active immunity lasts for many years or for a lifetime.
✔✔Principles of Immunization - ✔✔The immune system has the ability to recognize
materials present in the body as "self" or "nonself." Foreign materials (nonself) are
called antigens. When an antigen is recognized by the immune system, the immune
system responds by producing antibodies (immunoglobulins) or directing special cells to
destroy and remove the antigen.
✔✔A 15-month-old girl is having her first health visit at a clinic. The mother has no
immunization record but says the child was immunized 3 months ago at the local health
department. Which of the following is the best action for the nurse to take?
A) Ask the mother to bring the records to the next health maintenance visit.
,B) Start the catch-up schedule since there are no immunization records.
C) Keep the child at the facility while the mother returns home for the records.
D) Call the local health department and verify the child's immunization status. - ✔✔D)
Call the local health department and verify the child's immunization status.
✔✔The mother of a 15-month-old child is questioning the nurse about the need for the
hepatitis B vaccination. Which of the following comments provides the most compelling
reason for the vaccine?
A) "The most common side effect is injection site soreness."
B) "This is a recombinant or genetically engineered vaccine."
C) "Immunizations are needed to protect the general population."
D) "This protects your child from infection that can cause liver disease." - ✔✔D) "This
protects your child from infection that can cause liver disease.
✔✔After teaching the mother about follow-up immunizations for her daughter, who
received the varicella vaccine at age 14 months, the nurse determines that the teaching
was successful when the mother states that a follow-up dose should be given
at which time?
A) When the child is 20 to 36 months of age
B) When the child is 4 to 6 years of age
C) When the child is 11 to 12 years of age
D) When the child is 13 to 15 years of age - ✔✔B) When the child is 4 to 6 years of age.
✔✔Hepatitis B vaccine - ✔✔-1st dose is given at BIRTH
-2nd dose is given at 1-2 months.
-3rd dose is given at 6-18 months.
*same for children and adolescents age 7-18 yrs
✔✔patent ductus arteriosus (PDA) - ✔✔an abnormal opening between the pulmonary
artery and the aorta caused by failure of the fetal ductus arteriosus to close after birth.
This results in increased pulmonary blood flow.
-can cause left sided heart failure
-ACYANOTIC
-LEFT to RIGHT shunt
✔✔What are the clinical manifestations of PDA? - ✔✔-murmur (machine hum)
-wide pulse pressure
-bounding pulses
-asymptomatic (possible)
-heart failure
-tachycardia
-low diastolic BP
-tachypnea
-rales upon auscultation
, ✔✔When assessing a neonate. Which heart defect at 30 weeks has signs and
symptoms of BOUNDING PULSES, TACHYPNEA, TACHYCARDIA, and
CRACKLES/THRILLS? - ✔✔PATENT DUCTUS ARTERIOSUS
✔✔The nurse is caring for an infant with suspected patent ductus arteriosus. Which of
the following assessment findings would the nurse identify as helping to confirm this
suspicion?
A) Thrill at the base of the heart
B) Harsh, continuous, machine-like murmur under the left clavicle
C) Faint pulses
D) Systolic murmur best heard along the left sternal border - ✔✔B) Harsh, continuous,
machine-like murmur under the left clavicle at the first and second intercostal spaces.
✔✔A newborn is diagnosed with patent ductus arteriosus. The nurse anticipates that
the physician will most likely order which medication?
A) Alprostadil
B) Heparin
C) Indomethacin
D) Spironolactone - ✔✔C) Indomethacin
✔✔Indomethacin (Indocin) - ✔✔-NSAID.
-Inhibit prostaglandin synthesis resulting in decreased inflammatory responses.
-Uses: provide rapid, symptomatic relief of inflammation and pain and to close PDA.
-Precautions/Interactions: hypersensitivity to aspirin or other NSAIDs, may increase the
risk of MI and stroke.
✔✔congenital heart defects teachings - ✔✔-give medications, if ordered, exactly as
perscribed
-weigh the child at least once a week or as ordered, same time of day w/same amount
of clothes
-allow the child to engage in activity as directed. Provide time for the child to rest
frequently to avoid overexertion
-notify physician or NP if child has increased episodes of respiratory distress, cyanosis,
or difficulty breathing; fever; increased edema of the hands, feet, or face; decreased
urinary output; weight loss or difficulty eating or drinking; increased fatigue; decreased
LOA; vomiting or diarrhea
✔✔A 2-day old neonate is 30 min post-op of a surgical correction for CHD. Which
finding would you report to the physician? - ✔✔-pulse rate of 90
✔✔The nurse is caring for a 2-month-old infant who has been diagnosed with acute
heart failure. The nurse is providing teaching about nutrition. Which of the following
statements by the mother indicates a need for further teaching?
A) "The baby may need as much as 150 calories/kg/day."
B) "Small, frequent feedings are best if tolerated."
