NR 328 Exam #2 Practice Questions/ with
Definitive Solutions.
Terms in this set (139)
What factor predisposes an Answer: A
infant to fluid imbalances? Rationale: The infant’s kidneys are functionally immature at
a. Immature birth and are inefficient in excreting waste products of
metabolism. Infants have a relatively high body surface area
kidneyfunctioning
(BSA) compared with adults. This allows a higher loss of fluid
b. Decreased surface to the environment. A higher metabolic rate is present as a
area result of the higher BSA in relation to active metabolic
c. Lower metabolic rate tissue. The higher metabolic rate increases heat production,
d. Decreased which results in greater insensible water loss. Infants have a
dailyexchange of greater exchange of extracellular fluid, leaving them with a
extracellular fluid reduced fluid reserve in conditions of dehydration.
Answer: A
What is the required
Rationale: For the first 10 kg of body weight, a child requires
number of milliliters of fluid
100 mL/kg. For each additional kilogram of body weight, an
needed per day for a 14 kg
extra 50 mL is needed.
child? a. 1200
10 kg ´ 100 mL/kg/day = 1000 mL
b. 1100
4 kg ´ 50 mL/kg/day = 200 mL
c. 1300
1000 mL + 200 mL = 1200 ml/day
d. 1400
800 to 1000 mL is too little; 1400 mL is too much.
,An infant is brought to the Answer: A
emergency department with Rationale: These clinical manifestations indicate water
the following clinical depletion or dehydration. Edema and weight gain occur with
water excess or over-hydration. Sodium or potassium excess
manifestations: poor skin
would not cause these symptoms.
turgor, weight loss, lethargy,
tachycardia, and tachypnea.
This is suggestive of which
situation?
a. Water depletion
b. Water excess
c. Potassium excess
d. Sodium depletion
What explains Answer: A
physiologically the Rationale: With a major burn, capillary permeability
edema formation that increases, allowing plasma proteins, fluids, and electrolytes
occurs with burns? to be lost into the interstitial space, causing edema.
a. Increased Maximum edema in a small wound
capillarypermeability occurs about 8 to 12 hr after injury. In larger injuries, the
b. Decreased maximum edema may not occur until 18 to 24 hr later.
Vasodilation occurs, causing an increase in hydrostatic
capillarypermeability
pressure.
c. Vasoconstriction
d. Diminished
hydrostaticpressure within
capillaries
Answer: A
What is the most immediate Rationale: The immediate threat to life in children with
thermal injuries is airway compromise and profound shock.
threat to life in children with
Anemia is not of immediate concern. During the healing
thermal injuries? a. Shock phase, local infection or sepsis is the primary complication.
b. Anemia
c. Local infection
d. Systemic sepsis
,After the acute stage and Answer: A
during the healing process, Rationale: During the healing phase, local infection or sepsis
what is the primary is the primary complication. Respiratory problems, primarily
airway compromise, and shock are the primary
complication from burn
complications during the acute stage of burn injury. Renal
injury? a. Infection shutdown is not a complication of the burn injury but may
b. Shock be a result of the profound shock.
c. Renal shutdown
d. Asphyxia
What finding is the most Answer: A
reliable guide to the Rationale: Replacement fluid therapy is delivered to provide
adequacy of fluid a urinary output of 30 mL/hr in older children or 1 to 2
mL/kg of body weight/hr for children weighing less than 30
replacement for a small
kg (66 pounds). Thirst is the result of a complex set of
child with burns? interactions and is not a reliable indicator of hydration.
a. Urinary output of 1 to 2 Thirst occurs late in dehydration. A falling hematocrit would
mL/kg of body weight/hr b. be indicative of hemodilution. This may reflect fluid shifts
and may not accurately represent fluid replacement
Increased seepage from
therapy. Increased seepage from a burn wound would be
burn wound
indicative of increased output, not adequate hydration.
c. Falling hematocrit
d. Absence of thirst
What intervention is Answer: A
contraindicated in a Rationale: In any instance in which severe abdominal pain is
suspected case of observed and appendicitis is suspected, the nurse must be
aware of the danger of administering laxatives or enemas.
appendicitis?
Such measures stimulate bowel motility and increase the risk
a. Enemas of perforation. The abdomen is palpated after other
b. Palpating the assessments are made. Antibiotics should be administered,
abdomen and antipyretics are not contraindicated.
c. Administration
ofantibiotics
d. Administration
ofantipyretics for fever
, An infant had a gastrostomy Answer: A
tube placed for feedings Rationale: If bolus feedings are initiated through a
after a Nissen fundoplication gastrostomy after a Nissen fundoplication, the tube may
need to remain vented for several days or longer to avoid
and bolus feedings are
gastric distention from swallowed air. Edema surrounding
initiated. Between feedings the surgical site and a tight gastric wrap may prohibit the
while the tube is clamped, infant from expelling air through the esophagus, so burping
the infant becomes irritable, does not relieve the distention. Some infants benefit from
clamping of the tube for increasingly longer intervals until
and there is evidence of
they are able to tolerate continuous clamping between
cramping. What action
feedings. During this time, if the infant displays increasing
should the nurse irritability and evidence of cramping, some relief may be
implement? provided by venting the tube. The next feeding should not
a. Vent the be withheld, and calling the health care provider is not
necessary.
gastrostomytube.
b. Withhold the
nextfeeding.
c. Burp the infant.
d. Notify the health
careprovider.
The nurse should instruct Answer: A
parents to administer a daily Rationale: Proton pump inhibitors are most effective when
administered 30 minutes before breakfast so that the peak
proton pump
plasma concentrations occur with mealtime. If they are
inhibitor to their child with given twice a day, the second best time for administration is
gastroesophageal reflux at 30 minutes before the evening meal.
which time?
a. 30 minutes
beforebreakfast
b. Midmorning
c. Bedtime
d. With a meal
Definitive Solutions.
Terms in this set (139)
What factor predisposes an Answer: A
infant to fluid imbalances? Rationale: The infant’s kidneys are functionally immature at
a. Immature birth and are inefficient in excreting waste products of
metabolism. Infants have a relatively high body surface area
kidneyfunctioning
(BSA) compared with adults. This allows a higher loss of fluid
b. Decreased surface to the environment. A higher metabolic rate is present as a
area result of the higher BSA in relation to active metabolic
c. Lower metabolic rate tissue. The higher metabolic rate increases heat production,
d. Decreased which results in greater insensible water loss. Infants have a
dailyexchange of greater exchange of extracellular fluid, leaving them with a
extracellular fluid reduced fluid reserve in conditions of dehydration.
Answer: A
What is the required
Rationale: For the first 10 kg of body weight, a child requires
number of milliliters of fluid
100 mL/kg. For each additional kilogram of body weight, an
needed per day for a 14 kg
extra 50 mL is needed.
child? a. 1200
10 kg ´ 100 mL/kg/day = 1000 mL
b. 1100
4 kg ´ 50 mL/kg/day = 200 mL
c. 1300
1000 mL + 200 mL = 1200 ml/day
d. 1400
800 to 1000 mL is too little; 1400 mL is too much.
,An infant is brought to the Answer: A
emergency department with Rationale: These clinical manifestations indicate water
the following clinical depletion or dehydration. Edema and weight gain occur with
water excess or over-hydration. Sodium or potassium excess
manifestations: poor skin
would not cause these symptoms.
turgor, weight loss, lethargy,
tachycardia, and tachypnea.
This is suggestive of which
situation?
a. Water depletion
b. Water excess
c. Potassium excess
d. Sodium depletion
What explains Answer: A
physiologically the Rationale: With a major burn, capillary permeability
edema formation that increases, allowing plasma proteins, fluids, and electrolytes
occurs with burns? to be lost into the interstitial space, causing edema.
a. Increased Maximum edema in a small wound
capillarypermeability occurs about 8 to 12 hr after injury. In larger injuries, the
b. Decreased maximum edema may not occur until 18 to 24 hr later.
Vasodilation occurs, causing an increase in hydrostatic
capillarypermeability
pressure.
c. Vasoconstriction
d. Diminished
hydrostaticpressure within
capillaries
Answer: A
What is the most immediate Rationale: The immediate threat to life in children with
thermal injuries is airway compromise and profound shock.
threat to life in children with
Anemia is not of immediate concern. During the healing
thermal injuries? a. Shock phase, local infection or sepsis is the primary complication.
b. Anemia
c. Local infection
d. Systemic sepsis
,After the acute stage and Answer: A
during the healing process, Rationale: During the healing phase, local infection or sepsis
what is the primary is the primary complication. Respiratory problems, primarily
airway compromise, and shock are the primary
complication from burn
complications during the acute stage of burn injury. Renal
injury? a. Infection shutdown is not a complication of the burn injury but may
b. Shock be a result of the profound shock.
c. Renal shutdown
d. Asphyxia
What finding is the most Answer: A
reliable guide to the Rationale: Replacement fluid therapy is delivered to provide
adequacy of fluid a urinary output of 30 mL/hr in older children or 1 to 2
mL/kg of body weight/hr for children weighing less than 30
replacement for a small
kg (66 pounds). Thirst is the result of a complex set of
child with burns? interactions and is not a reliable indicator of hydration.
a. Urinary output of 1 to 2 Thirst occurs late in dehydration. A falling hematocrit would
mL/kg of body weight/hr b. be indicative of hemodilution. This may reflect fluid shifts
and may not accurately represent fluid replacement
Increased seepage from
therapy. Increased seepage from a burn wound would be
burn wound
indicative of increased output, not adequate hydration.
c. Falling hematocrit
d. Absence of thirst
What intervention is Answer: A
contraindicated in a Rationale: In any instance in which severe abdominal pain is
suspected case of observed and appendicitis is suspected, the nurse must be
aware of the danger of administering laxatives or enemas.
appendicitis?
Such measures stimulate bowel motility and increase the risk
a. Enemas of perforation. The abdomen is palpated after other
b. Palpating the assessments are made. Antibiotics should be administered,
abdomen and antipyretics are not contraindicated.
c. Administration
ofantibiotics
d. Administration
ofantipyretics for fever
, An infant had a gastrostomy Answer: A
tube placed for feedings Rationale: If bolus feedings are initiated through a
after a Nissen fundoplication gastrostomy after a Nissen fundoplication, the tube may
need to remain vented for several days or longer to avoid
and bolus feedings are
gastric distention from swallowed air. Edema surrounding
initiated. Between feedings the surgical site and a tight gastric wrap may prohibit the
while the tube is clamped, infant from expelling air through the esophagus, so burping
the infant becomes irritable, does not relieve the distention. Some infants benefit from
clamping of the tube for increasingly longer intervals until
and there is evidence of
they are able to tolerate continuous clamping between
cramping. What action
feedings. During this time, if the infant displays increasing
should the nurse irritability and evidence of cramping, some relief may be
implement? provided by venting the tube. The next feeding should not
a. Vent the be withheld, and calling the health care provider is not
necessary.
gastrostomytube.
b. Withhold the
nextfeeding.
c. Burp the infant.
d. Notify the health
careprovider.
The nurse should instruct Answer: A
parents to administer a daily Rationale: Proton pump inhibitors are most effective when
administered 30 minutes before breakfast so that the peak
proton pump
plasma concentrations occur with mealtime. If they are
inhibitor to their child with given twice a day, the second best time for administration is
gastroesophageal reflux at 30 minutes before the evening meal.
which time?
a. 30 minutes
beforebreakfast
b. Midmorning
c. Bedtime
d. With a meal
