NUR 3270 EXAM 5 - ADVANCED
CLINICAL NURSING QUESTIONS WITH
VERIFIED ANSWERS AND DETAILED
EXPLANATIONS
1. A 4-year-old child with Tetralogy of Fallot becomes acutely cyanotic and hyperpneic while
crying. Which nursing intervention is the highest priority?
A. Administer 100% oxygen via face mask
B. Prepare for immediate endotracheal intubation
C. Administer intramuscular morphine sulfate
D. Place the child in the knee-chest position
Answer: D
Conceptual Explanation: In a ‘Tet spell’ (hypercyanotic episode), placing the child in a
knee-chest position increases systemic vascular resistance, which reduces the right-to-left
shunt and improves pulmonary blood flow.
2. Which clinical manifestation should the nurse expect to find in a child diagnosed with
Hirschsprung disease during the neonatal period?
A. Currant jelly-like stools containing blood and mucus
B. Projectile vomiting after feedings
,C. Failure to pass meconium within the first 24 to 48 hours
D. Visible peristaltic waves across the upper abdomen
Answer: C
Conceptual Explanation: Hirschsprung disease is characterized by the absence of
ganglion cells in the colon, leading to a lack of peristalsis and failure to pass meconium
shortly after birth.
3. A nurse is caring for a child with Acute Glomerulonephritis. Which laboratory finding is
most consistent with this diagnosis?
A. Decreased serum creatinine
B. Low specific gravity of urine
C. High serum albumin levels
D. Elevated Antistreptolysin O (ASO) titer
Answer: D
Conceptual Explanation: Acute post-streptococcal glomerulonephritis often follows a
streptococcal infection; an elevated ASO titer confirms a recent infection.
4. A child is admitted with a suspected diagnosis of Wilms tumor. Which action should the
nurse strictly avoid during the physical assessment?
A. Measuring the abdominal circumference
B. Palpating the abdomen to determine tumor size
, C. Auscultating bowel sounds in all quadrants
D. Assessing the child’s blood pressure
Answer: B
Conceptual Explanation: Palpation of the abdomen in a patient with Wilms tumor
(nephroblastoma) is contraindicated because it may cause the tumor capsule to rupture
and spread cancer cells throughout the abdomen.
5. A 10-year-old child with Type 1 Diabetes Mellitus is found shaky, diaphoretic, and pale. The
child is awake but lethargic. What should the nurse do first?
A. Give a subcutaneous injection of glucagon
B. Administer 15 grams of rapid-acting carbohydrates
C. Check the blood glucose level immediately
D. Provide a high-protein snack like peanut butter
Answer: B
Conceptual Explanation: The child is symptomatic for hypoglycemia. The standard rule is
to treat with 15g of simple carbs immediately, then check BG. If the child is conscious and
able to swallow, oral treatment is preferred.
6. Which dietary instruction is essential for the parents of a child newly diagnosed with Celiac
Disease?
A. Increase intake of whole wheat bread for fiber
CLINICAL NURSING QUESTIONS WITH
VERIFIED ANSWERS AND DETAILED
EXPLANATIONS
1. A 4-year-old child with Tetralogy of Fallot becomes acutely cyanotic and hyperpneic while
crying. Which nursing intervention is the highest priority?
A. Administer 100% oxygen via face mask
B. Prepare for immediate endotracheal intubation
C. Administer intramuscular morphine sulfate
D. Place the child in the knee-chest position
Answer: D
Conceptual Explanation: In a ‘Tet spell’ (hypercyanotic episode), placing the child in a
knee-chest position increases systemic vascular resistance, which reduces the right-to-left
shunt and improves pulmonary blood flow.
2. Which clinical manifestation should the nurse expect to find in a child diagnosed with
Hirschsprung disease during the neonatal period?
A. Currant jelly-like stools containing blood and mucus
B. Projectile vomiting after feedings
,C. Failure to pass meconium within the first 24 to 48 hours
D. Visible peristaltic waves across the upper abdomen
Answer: C
Conceptual Explanation: Hirschsprung disease is characterized by the absence of
ganglion cells in the colon, leading to a lack of peristalsis and failure to pass meconium
shortly after birth.
3. A nurse is caring for a child with Acute Glomerulonephritis. Which laboratory finding is
most consistent with this diagnosis?
A. Decreased serum creatinine
B. Low specific gravity of urine
C. High serum albumin levels
D. Elevated Antistreptolysin O (ASO) titer
Answer: D
Conceptual Explanation: Acute post-streptococcal glomerulonephritis often follows a
streptococcal infection; an elevated ASO titer confirms a recent infection.
4. A child is admitted with a suspected diagnosis of Wilms tumor. Which action should the
nurse strictly avoid during the physical assessment?
A. Measuring the abdominal circumference
B. Palpating the abdomen to determine tumor size
, C. Auscultating bowel sounds in all quadrants
D. Assessing the child’s blood pressure
Answer: B
Conceptual Explanation: Palpation of the abdomen in a patient with Wilms tumor
(nephroblastoma) is contraindicated because it may cause the tumor capsule to rupture
and spread cancer cells throughout the abdomen.
5. A 10-year-old child with Type 1 Diabetes Mellitus is found shaky, diaphoretic, and pale. The
child is awake but lethargic. What should the nurse do first?
A. Give a subcutaneous injection of glucagon
B. Administer 15 grams of rapid-acting carbohydrates
C. Check the blood glucose level immediately
D. Provide a high-protein snack like peanut butter
Answer: B
Conceptual Explanation: The child is symptomatic for hypoglycemia. The standard rule is
to treat with 15g of simple carbs immediately, then check BG. If the child is conscious and
able to swallow, oral treatment is preferred.
6. Which dietary instruction is essential for the parents of a child newly diagnosed with Celiac
Disease?
A. Increase intake of whole wheat bread for fiber
