ATI Respiratory Practice Questions with Rationales

1. A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply.) a. Symptoms are continuous throughout the day. R Symptoms are continuous throughout the day is incorrect. Continual asthma symptoms throughout the day are seen with severe persistent asthma. b. Daytime symptoms occur more than twice a week. R Daytime symptoms occur more than twice a week is correct. A child with mild persistent asthma will typically have daytime symptoms more than twice a week, but not daily. c. Nighttime symptoms occur approximately twice a month. R Nighttime symptoms occur approximately twice a month is incorrect. Nighttime symptoms occurring approximately twice a month are seen with intermittent asthma. d. Minor limitations occur with normal activity. R Minor limitations occur with normal activity is correct. A child with mild persistent asthma will have some minor limitations with normal daily activities. e. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value. R Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value is correct. A child with mild persistent asthma will have a PEF greater than or equal to 80% of the predicted value. 2. A nurse is planning care for a child with suspected epiglottitis. Which of the following is an appropriate action for the nurse to take? a. Obtain a throat culture R Obtaining a throat culture on a child with suspected epiglottitis could precipitate obstruction of the airway and should be avoided. b. Place client in an upright position R Placing the child in an upright position will assist in maintaining a patent airway and is an appropriate action for the nurse to take. c. Transfer for a throat x-ray R The airway of a child with suspected epiglottitis could become obstructed easily, therefore transferring for a throat x-ray is not an appropriate action for the nurse to take. d. Visualize the epiglottis with a tongue depressor R Visualizing the epiglottis with a tongue depressor on a child with suspected epiglottitis could precipitate obstruction of the airway and should be avoided. 3. A nurse is caring for a pre-school age child who has a epiglottitis with a barking cough. Which of the following is an appropriate nursing action? a. Encourage coughing. R Encouraging the client to cough is not an appropriate nursing and precipitates a complete obstruction. b. Attempt to obtain a throat culture. R Attempting to obtain a throat culture is not an appropriate nursing action and may precipitate a complete obstruction. c. Visualize the back of the throat. R Trying to visualize the back of the throat is not an appropriate nursing action and may precipitate a complete obstruction. d. Apply oxygen. R Applying high-flow oxygen on the client and keeping the client calm is an appropriate action by the nurse to improve oxygenation. 4. A nurse is reinforcing teaching to an assistive personnel to count respiration rate on a newborn. Which of the following statements indicate understanding of why the respiratory rate should be counted for a complete minute? a. “Newborns are abdominal breathers.” R Newborns are abdominal breathers. However, this has no impact on obtaining a respiratory rate. b. “Newborns do not expand their lungs fully with each respiration.” R The labor of breathing in a newborn will vary. However, this has no impact on obtaining a respiratory rate. c. “Activity will increase the respiration rate.” R Activity will increase the respiration rate. However, this has no impact on obtaining a respiratory rate. d. “The rate and rhythm are irregular in newborns.” R Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate. 5. A nurse is caring for a preterm newborn who is in an incubator. The nurse should make sure that the maximum oxygen concentration to deliver to this client is a. 30%. R This is a safe oxygen concentration to deliver to a preterm newborn, but not the maximum. Of course, the nurse should make sure the newborn receives the oxygen concentration the provider prescribes. b. 40%. R Oxygen concentrations higher than 40% can cause retinal damage and visual impairment. This is the maximum concentration to deliver. c. 50%. R This is an unsafe oxygen concentration to deliver to a preterm newborn. The nurse should make sure the newborn receives the oxygen concentration the provider prescribes. d. 60%. R This is an unsafe oxygen concentration to deliver to a preterm newborn. The nurse should make sure the newborn receives the oxygen concentration the provider prescribes. 6. A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings are associated with this diagnosis? (Select all that apply.) a. Coughing R Coughing is correct. Coughing is a finding associated with a tracheoesophageal fistula. b. Apnea R Apnea is correct. Apnea is a finding associated with a tracheoesophageal fistula. c. Sunken abdomen R Sunken abdomen is incorrect. Abdominal distension, not a sunken abdomen, is a finding associated with a tracheoesophageal fistula. d. Cyanosis R Cyanosis is correct. Cyanosis is a finding associated with a tracheoesophageal fistula. e. Frothy saliva R Frothy saliva is correct. Frothy saliva is a finding associated with a tracheoesophageal fistula. 7. A nurse is caring for a child with a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will the nurse prepare the child for to confirm the diagnosis? a. Sweat chloride test R Clients with cystic fibrosis have an increase of sodium and chloride in both saliva and sweat. Therefore, a sweat chloride test is a definitive diagnostic test to determine the diagnosis of cystic fibrosis. b. A sputum culture R A sputum culture will determine the organism infecting the lungs. However, it is not a diagnostic test to determine the diagnosis of cystic fibrosis. c. A stool fat content analysis R A stool fat content analysis will determine the amount of fat within a stool. However, it is not a diagnostic test to determine the diagnosis of cystic fibrosis. d. Pulmonary function test R Pulmonary function tests will determine the lung capability. However, it is not a diagnostic test to determine the diagnosis of cystic fibrosis. 8. A nurse is caring for a school-age child who has environmental allergies who is scheduled to begin desensitization therapy. Which of the following statements by the client indicates the teaching has been effective? a. "I'll receive my allergy shots daily for the first two weeks." R Allergen solutions are injected weekly during the first year of therapy. b. "At each visit, I'll receive an allergy shot with a little bit less of the allergen than I received the visit before." R Each allergy shot uses an increased amount of allergen so the client can build up an immunity to the allergen. c. "To reduce my symptoms I will need allergy shots for the rest of my life." R The recommended course of desensitization therapy is usually 5 years. d. "I'll need to remain in the clinic for 30 minutes after each shot." R After the allergy shot is administered, observation for a minimum of 30 minutes is required to monitor the client for any manifestations of an anaphylactic reaction to the injection. 9. A nurse is caring for a toddler who has laryngotracheobronchitis and is placed in a cool mist tent. Which of the following findings should the nurse expect as a result of the treatment? a. Decreased stridor R Laryngotracheobronchitis, or croup, is caused by infection of the upper airway (larynx, trachea, and bronchus) and is characterized by a barking cough. Edema and obstruction in the upper airways cause the cough and stridor. The cool mist tent humidifies the inspired air, which will reduces respiratory effort and stridor. b. Improved hydration R The treatment does not affect hydration. c. Barking cough R Edema and obstruction in the upper airways cause the characteristic cough, but this is a manifestation of the infection, not a result of the treatment. d. Temperature stabilization R Reducing the child's temperature may not occur as a result of the mist tent treatment. 10. A nurse is assessing a patient admitted for an asthma exacerbation. Which breath sounds does the nurse expect to assess? a. Rubs b. Rattles c. Wheezes R Asthma causes bronchoconstriction and narrowed passageways. Wheezes are produced as air passes through narrowed passageways. Rubs are the sound created by the friction of one surface rubbing over another. Pleural friction rub is caused by inflammation of the pleural space. Rattles is the term formerly used for crackles. Crackles are the sounds made when air passes through fluid or moisture. d. Crackles 11. While caring for a critically ill child, the nurse observes that respirations are gradually increasing in rate and depth, with periods of apnea. What pattern of respiration will the nurse document? a. Dyspnea b. Tachypnea c. Cheyne-Stokes respirations R Cheyne-Stokes respirations are a pattern of respirations that gradually increase in rate and depth, with periods of apnea. Dyspnea is defined as distress during breathing. Tachypnea is an increased respiratory rate. In seesaw respirations, the chest falls on inspiration and rises on expiration. d. Seesaw (paradoxic) respirations 12. A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching? a. "We will give our child pancreatic enzymes with snacks and meals." b. "We will restrict the amount of salt in our child's food." c. "I will limit my child's fluid intake." d. "I will prepare low-fat meals with limited protein for my child." 13. A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make? a. "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." b. "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me." c. "Your child did not seem upset, so I wouldn't worry about it if I were you." d. "Why does it bother you that your child has wet the bed?" 14. A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take? a. Obtain a throat culture. b. Place the child in an upright position. c. Transport the child to radiology for a throat x-ray. d. Visualize the epiglottis with a tongue depressor. 15. A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names? a. Chickenpox b. Whooping cough c. Mumps d. Fifth disease 16. A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following? a. "I will give my son the enzymes between meals." b. "The enzymes probably won't cause many adverse effects." c. "The enzymes help him digest fat." d. "I will put the enzyme crystals in his applesauce." 17. A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching? a. "My child will take the enzymes to improve her metabolism." b. "My child will take the enzymes following meals." c. "My child will take the enzymes to help digest the fat in foods." d. "My child will take the enzymes 2 hours before meals." 18. A nurse is reinforcing teaching to the parents of a child who has cystic fibrosis and has a prescription for pancrelipase (Pancrease) capsules. Which of the following should the nurse include in the teaching? a. Administer the medication with meals and snacks. R Pancrelipase is a digestive enzyme that must be administered with all snacks or meals in order for the food to be properly digested. b. Capsules must be taken whole. R The medication maybe taken whole or the capsules may be opened up and the contents sprinkled on soft food. c. This medication may be discontinued when symptoms diminish. R Pancreatic enzymes will be needed throughout the child's life. d. This medication may cause a diarrhea. R With sufficient replacement of the pancreatic enzyme, the client should experience a decrease in the number of stools. 19. A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn? a. 22/min R This rate is below the expected reference range for a newborn’s resting respiratory rate and indicates bradypnea. b. 48/min R The expected reference range for a newborn’s resting respiratory rate is 30 to 60/min. c. 100/min R This rate is above the expected reference range for a newborn’s resting respiratory rate and indicates tachypnea. d. 110/min R This rate is above the expected reference range for a newborn’s resting respiratory rate and indicates tachypnea. 20. A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? a. Remove the hood every hour for 10 min to facilitate bonding. R Supplemental oxygen must be provided if the hood is removed to minimize significant fluctuations in oxygenation. b. Insert an orogastric tube for decompression of the stomach. R Insertion of an orogastric tube is indicated with the use of continuous positive airway pressure therapy. c. Place the newborn in Trendelenburg position. R Trendelenburg position should be avoided because it increases intracranial pressure and reduces lung capacity. d. Maintain oxygen saturations between 93% to 95%. R Rates of retinopathy of prematurity and bronchopulmonary dysplasia in preterm newborns are reduced if oxygen saturations are maintained between 93% and 95%. 21. A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent indicates an understanding of the teaching? a. “I will make sure my child washes her hands before eating.” b. “I will restrict the amount of salt in my child’s meal.” Initiate droplet precautions c. “I will put my child in daycare to ensure that she socializes with other children.” d. “I will provide low fat meals for my child.” 22. A nurse is caring for a preschool age child who has croup. Which of the following findings should the nurse report to the provider? a. Barky cough b. Paroxysmal attacks of laryngeal spasm at night c. Hoarseness d. Drooling R That could mean there’s epiglottitis causing obstruction of the airway 23. A nurse is assisting with the care of a school age child who has respiratory failure due to pneumonia. Which of the following positons should the nurse encourage to allow maximal lung expansions? a. Prone b. Supine c. Side lying d. Upright R e.g., Orthopneic position, semi Fowler’s, high Fowler’s 24. A nurse is caring for a child who is to receive percussion, vibration, and postural drainage. Which of the following actions should the nurse take first? a. Administer albuterol by nebulizer R Opens the airway, and loosens the secretions (more effective to loosen it up) b. Percuss the upper posterior chest c. Perform vibration while the client exhales slowly through the nose d. Instruct the client to cough 25. A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take? a. Obtain a throat culture b. Prepare the child for a neck radiograph c. initiate airborne precaution (droplet) d. visualize the epiglottitis using a tongue depressor R It can stimulate spasm and cause airway obstruction 26. A nurse is assisting with the admission of a child who has pertussis. Which of the following actions should the nurse take? a. Initiate a protective environment b. Initiate airborne precautions c. d. Initiate contact precautions 27. A nurse is reinforcing teaching about preventing disease transmission with the parents of a child who has a streptococcal infection. Which of the following instructions should the nurse include? a. “I’ll continue to encourage him to drink lots of fluids.” b. “I'll take his temperature every 4 hours.” c. “I'll give him acetaminophen for the pain.” d. “I’ll discard his toothbrush and buy another.“ 28. A nurse is assisting with the admission of an infant who has Respiratory Syncytial Virus (RSV). Which of the following rooms should the nurse assign the infant? a. A semi-private room with an infant who has a croup b. A semi-private room with a toddler who has pneumonia c. A private room with contact/droplet precautions d. A private room with protective isolation 29. A nurse is caring for a toddler who has laryngotracheobronchitis (LTB). For which of the following findings should the nurse monitor to detect airway obstruction? a. Decreased stridor R Increased. Airway becomes more obstructed. b. Decreased restlessness R Increased c. R In order to deliver more blood pump more oxygen d. Decreased temperature R Increased 30. A nurse is reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following Increased heart rate statements should the nurse make? a. “Administer a bronchodilator to the child after chest percussion therapy .” b. “A pigeon-shaped chest might become evident as the disease progresses.” c. “Bradycardia is an early indicator of pneumothorax.” d. “Engage the child in daily aerobic exercise.” R Helps promote erection of the mucus. Endorphine will increase. 31. A nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which of the following meals best illustrates the most appropriate diet for a client with cystic fibrosis? a. A veggie salad and a caramel apple b. A strawberry jelly sandwich and pretzels c. A plate of nachos and cheese and a cupcake d. A piece of fried chicken and a loaded baked potato R Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. A piece of fried chicken and a loaded baked potato provides a high-calorie and highprotein meal that includes fat. 32. After receiving education on the correct use of emergency drug therapy for asthma, which statement by the adolescent indicates a correct understanding of the nurse's instructions? a. "All asthma drugs help everybody breathe better." b. "I must carry my emergency inhaler when activity is anticipated." c. "I must have my emergency inhaler with me at all times." d. "Preventive drugs can stop an attack. 33. A child recently diagnosed with asthma has a prescription to use an inhaled medication with a spacer. The nurse evaluates the child has correct understanding of the use of an inhaler with a spacer when the child states which of these? a. "I don't have to wait a minute between the two puffs if I use a spacer." b. "If the spacer makes a whistling sound, I am breathing in too fast." c. "I should rinse my mouth and then swallow the water to get all of the medicine." d. "I should shake the canister when I want to see whether it is empty." e. "I should hold my breath for at least ten seconds after inhaling the medication." 34. A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Choose the interventions that would be included in the plan of care. (Select all that apply.) a. Place the infant in a private room. b. Place the infant in a room near the nurses' station. R The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV. c. Ensure that the infant's head is in a flexed position. d. Wear a mask at all times when in contact with the infant. e. Place the child in a tent that delivers warm, humidified air. f. Position the infant side-lying, with the head lower than the chest. 35. A nurse prepares to administer a pancreatic enzyme powder to the child with cystic fibrosis (CF). Which of the following food items will the nurse mix with the medication? a. Tapioca b. Applesauce R Pancreatic enzyme powders are not to be mixed with hot foods or foods containing tapioca or other starches. Enzyme powder should be mixed with non-fat, non-protein foods such as applesauce. Pancreatic enzymes are inactivated by heat and are partially degraded by gastric acids. c. Hot oatmeal d. Mashed potatoes 36. A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is worsening? a. Warm, dry skin b. Increased wheezing c. Decreased wheezing R Decreased wheezing in a child who is not improving clinically may be interpreted incorrectly as a positive sign, when in fact it may signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child's condition is improving. Warm, dry skin indicates an improvement in the condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute. d. A pulse rate of 90 beats per minute 37. A mother of a child with cystic fibrosis asks the clinic nurse about the disease. The nurse tells the mother that it is: a. Transmitted as an autosomal dominant trait b. A chronic multisystem disorder affecting the exocrine glands R Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and the pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. c. A disease that causes the formation of multiple cysts in the lungs d. A disease that causes dilation of the passageways of many organs 38. A nurse is providing instructions to a mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the mother? a. "The immunization schedule will need to be altered." b. "The child should not receive any hepatitis vaccines." c. "The child will receive all of the immunizations except for the polio series." d. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination." R It is essential that children with cystic fibrosis be adequately protected from communicable diseases by immunization. It is recommended that in addition to the basic series of immunizations, children with cystic fibrosis also should receive yearly influenza vaccines. 39. A nurse checks the vital signs of an infant with a respiratory infection and notes that the respiratory rate is 50 breaths per minute. Which action is appropriate? a. Notify the registered nurse. b. Administer oxygen. c. Recheck the respiratory rate in 15 minutes. d. Document the findings. R The normal respiratory rate in an infant is 30 to 60 breaths per minute. The nurse would document the findings. 40. An 8-year-old boy is being treated with percussion treatments for cystic fibrosis. How would the nurse determine whether the treatment is effective? a. The child has a productive cough of thick sputum. R Percussion treatments are intended to produce sputum. Thick sputum is characteristic of cystic fibrosis. Being afebrile is not necessarily reflective of effectiveness of percussion treatments. Although a high sodium content in the skin is a sign associated with cystic fibrosis, percussion treatments will not help this characteristic. The percussion treatments will not help bowel movements. b. The child no longer has a fever. c. The child's skin is no longer high in sodium. d. The child's bowel movements are firmer 41. A nurse is developing goals for a school-age child with a knowledge deficit related to the use of inhalers and peak flowmeters. The nurse identifies which of the following as an appropriate goal for this child? a. Denies shortness of breath or difficulty breathing b. Has regular respirations at a rate of 18 to 22 breaths per minute c. Expresses feelings of mastery and competence with breathing devices R School-age children strive for mastery and competence to achieve the developmental task of industry and accomplishment. Options 1 and 2 do not relate to the knowledge deficit, which is the subject of the question. Option 4 is an intervention rather than a goal d. Provide an educational video and printed information 42. A nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse positions the infant: a. With the head at a 60-degree angle with the neck slightly flexed b. In a supine, side-lying position c. With the head and chest at a 30-degree angle, with the neck slightly extended R The nurse should position the infant with the head and the chest at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Options 1, 2, and 4 do not achieve these goals. d. Prone, with the head of the bed elevated 15 degrees 43. A nursing student is preparing a clinical conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The student prepares a handout for the group and lists which of the following on the handout? (Select all that apply.) a. b. c. R CF is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait and can affect both males and females. d. It is a disease that causes dilation of the passageways of all organs. e. It is a disease that affects males only. f. It is a disease that affects the lungs only. 44. A nurse is caring for a hospitalized infant with bronchiolitis. Diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which of the following would be the appropriate nursing action? a. Initiate strict enteric precautions. b. Wear a mask when caring for the child. c. Plan to move the infant to a room with another child with RSV. R RSV is a highly communicable disorder, but it is not transmitted via the airborne route. It is usually transferred by the hands, and meticulous handwashing is necessary to decrease the spread of organisms. The infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are not necessary; however, the nurse should wear a gown when the soiling of clothing may occur. d. Leave the infant in the present room, because RSV is not contagious. 45. A school nurse is evaluating a 7-year-old child who is having an asthma attack. The child is cyanotic and unable to speak, with decreased breath sounds and shallow respirations. Based on these physical findings, the nurse should first: a. Monitor the child with a pulse oximeter in her office. b. Prepare to ventilate the child. R The nurse should recognize these physical findings as signs and symptoms of impending respiratory collapse. Therefore, the nurse's top priority is to assess airway, breathing, and circulation, and prepare to ventilate the child if necessary. The nurse should then notify the emergency medical systems to transport the child to a local hospital. Because the child's condition requires immediate intervention, simply monitoring pulse oximetry would delay treatment. This child shouldn't be returned to class. When the child's condition allows, the nurse can notify the parents or guardian. c. Return the child to class. d. Contact the child's parent or guardian. 46. A 4-month-old infant is taken to the pediatrician by his parents because they're concerned about his frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the infant has failed to gain expected weight and recommends that the infant have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that: a. The baby will need to fast before the test. b. A sample of blood will be necessary. c. A low-sodium diet is necessary for 24 hours before the test. d. A low-intensity, painless electrical current is applied to the skin. R Because cystic fibrosis clients have elevated levels of sodium and chloride in their sweat, a sweat test is performed to confirm this disorder. The nurse should explain to the parents that after pilocarpine (a cholinergic medication that induces sweating) is applied to a gauze pad and placed on the arm, a low-intensity, painless electrical current is applied for several minutes. The arm is then washed off, and a filter paper is placed over the site with forceps to collect the sweat. Elevated levels of sodium and chloride are diagnostic of cystic fibrosis. No fasting is necessary before this test and no blood sample is required. A low-sodium diet isn't required before the test. It is transmitted as an autosomal recessive trait. It is a chronic multisystem disorder affecting the exocrine glands. It is a disease that causes mucus formation to be abnormally thick. 47. A 9-year-old child is admitted to the pediatric unit for treatment of cystic fibrosis. A nurse assessing the child's respiratory status should expect to identify: a. Production of thick, sticky mucus R Cystic fibrosis is associated with the production of thick, sticky mucus. Cystic fibrosis isn't associated with harsh, nonproductive coughing or with stridor or unilateral decrease in breath sounds. b. Harsh, nonproductive cough c. Stridor d. Unilateral decrease in breath sounds 48. At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase (Pancrease). At a follow-up visit, which finding in the infant suggests that the parents require more teaching about administering the pancreatic enzymes? a. Fatty stools R Pancreatic enzymes normally aid in food digestion in the intestine. In a child with cystic fibrosis, however, these natural enzymes cannot reach the intestine because mucus blocks the pancreatic duct. Without these enzymes, undigested fats and proteins produce fatty stools. If the parents were administering the pancreatic enzymes correctly, the child would have stools of normal consistency. Noncompliance doesn't cause liquid or bloody stools. b. Liquid stools c. Bloody stools d. Normal stools 49. A nurse is caring for a 10-year-old child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action should the nurse take? a. Tell the parents they should be glad their child has lived this long. b. Point out to the parents ways in which they might have done things differently. c. Counsel the parents on not having any more children because they could also have cystic fibrosis. d. Encourage the parents to allow their child to follow as normal a childhood as possible. R The nurse should encourage the parents to treat their child as much like a normal child as possible. The nurse should avoid being critical of how parents handle their child's condition. Children with cystic fibrosis can live productive lives well into adulthood, so telling the parents they're lucky their child has lived this long not only is rude, it's inappropriate. Although each child the couple has has a 25% chance of having cystic fibrosis, it isn't appropriate for the nurse to counsel the parents. If they express uncertainty about having more children, the nurse should refer them to their physician or a genetic counselor. 50. A nurse is caring for a 17-year-old girl with cystic fibrosis who has been admitted to the hospital to receive antibiotics and respiratory treatment for exacerbation of a lung infection. The girl has a number of questions about her future and the consequences of the disease. Which statement about the course of cystic fibrosis is true? a. The client is at risk for developing diabetes. R Clients with cystic fibrosis are at risk for developing diabetes mellitus because the pancreatic duct becomes obstructed as pancreatic tissues are destroyed. Clients with cystic fibrosis can expect to have normal sexual relationships, but fertility becomes difficult because thick secretions obstruct the cervix and block sperm entry. Males and females carry the gene for cystic fibrosis. Pulmonary disease commonly progresses as the client ages, requiring additional respiratory treatment — not less. R b. Pregnancy and child-bearing aren't affected. c. Only males carry the gene for the disease. d. By age 20, the client should be able to decrease the frequency of respiratory treatment. 51. The parents of a child with cystic fibrosis, an autosomal recessive disorder, are considering having a second child. Each parent is heterozygous for the cystic fibrosis trait. What is the chance that their second child will manifest the disorder? a. 0% b. 25% R To manifest, or express, an autosomal recessive disorder, a child must inherit the trait from both parents. A heterozygous person carries one normal gene and one affected gene and doesn't express the disorder. Therefore, a child of two heterozygous parents has a one-in-four (25%) chance of manifesting an autosomal recessive disorder. Also, outcomes of previous pregnancies don't influence the probability of subsequent offspring expressing the genetic disorder. c. 50% d. 100% 52. Which assessment should alert a nurse that a hospitalized 7-year-old child is at high risk for a severe asthma exacerbation? a. Oxygen saturation of 95% b. Mild work of breath c. Intercostal or substernal retractions d. A history of steroid-dependent asthma R The child's history of steroid-dependent asthma is a contributing factor to making him at high risk for a severe exacerbation. The nurse must treat the situation as a severe exacerbation regardless of the severity of the current episode. Decreased oxygen saturation, cyanosis, retractions, and increase (not mild) work of breathing are all assessments of an asthma exacerbation, not risk factors for it. These findings should be treated with oxygen, nebulized respiratory treatments, and steroids. However, if a significant history of high-risk factors is absent, the episode can be treated without hospitalization and followed up with the pediatrician. 53. When assessing a child with bronchiolitis, which finding does the nurse expect? a. Clubbed fingers b. Barrel chest c. Barking cough and stridor d. Productive cough R Bronchiolitis causes a productive cough. Clubbed fingers and a barrel chest are more likely in a client with chronic respiratory problems. A barking cough is associated with croup. 54. Parents of a child with cystic fibrosis ask the nurse why their child must receive supplemental pancreatic enzymes. Which response by the nurse is most appropriate? a. "Pancreatic enzymes promote absorption of nutrients and fat." R Pancreatic enzymes are given to a child with cystic fibrosis to aid fat and protein digestion. They don't promote rest or prevent mucus accumulation or meconium ileus. b. "Pancreatic enzymes promote adequate rest." c. "Pancreatic enzymes prevent intestinal mucus accumulation." d. "Pancreatic enzymes help prevent meconium ileus." 55. A nurse is preparing to teach a 13-year-old adolescent with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session? a. Adolescents are unable to follow detailed instructions. b. Adolescents are worried about appearing different from their peers. R Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this information will help the nurse construct an effective teaching plan. Adolescents are capable of following detailed instructions. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. Fine motor coordination is well developed by adolescence. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives to establish a sense of identity; identity isn't already well-developed. c. Adolescents' fine motor coordination isn't sufficiently developed to administer treatments. d. Adolescents have a well-developed sense of self-identity. 56. A 7-year-old boy is hospitalized with cystic fibrosis. To help him manage secretions and avoid respiratory distress, the nurse should: a. perform chest physiotherapy every 4 hours. R The nurse should perform chest physiotherapy because it aids in loosening secretions in the entire respiratory tract. Pancreatic enzymes aid in the absorption of necessary nutrients — not in managing secretions. Oxygen therapy doesn't aid in loosening secretions and can cause carbon dioxide retention and respiratory distress in children with cystic fibrosis. A high-calorie diet is appropriate but doesn't facilitate respiratory effort. b. give pancreatic enzymes as ordered. c. place the child in an oxygen tent and have oxygen administered continuously. d. serve a high-calorie diet. 57. A toddler is admitted to the facility for treatment of a severe respiratory infection. The child's recent history includes fatty stools and failure to gain weight steadily. The physician diagnoses cystic fibrosis. By the time of the child's discharge, the child's parents must be able to perform which task independently? a. Allergy-proofing the home b. Maintaining the child in an oxygen tent c. Maintaining the child on a fat-free diet d. Performing postural drainage R The child with cystic fibrosis is at risk for frequent respiratory infections secondary to increased viscosity of mucus gland secretions. To help prevent respiratory infections, caregivers must perform postural drainage several times daily to loosen and drain secretions. Because exocrine gland dysfunction, not an allergic response, causes bronchial obstruction in cystic fibrosis, allergyproofing the home isn't necessary. Oxygen therapy may be indicated, but only during acute disease episodes. Also, such therapy must be supervised closely; home oxygen therapy is inappropriate because chronic hypoxemia poses the risk of oxygen toxicity. If steatorrhea can't be controlled, the child should reduce, but not eliminate, dietary fat intake. 58. For a child who's admitted to the emergency department with an acute asthma attack, nursing assessment is most likely to reveal: a. apneic periods. b. expiratory wheezing. R Expiratory wheezing is common during an acute asthma attack and results from narrowing of the airway caused by edema. Acute asthma rarely causes apneic periods. Inspiratory stridor more commonly accompanies croup. The child may have some fine crackles but wheezing is much more common in an acute asthma attack. c. inspiratory stridor. d. fine crackles throughout. 59. A child is being discharged with proventil (Albuterol) nebulizer treatments. The nurse should instruct the parents to watch for: a. tachycardia. R Proventil is a beta-adrenergic blocker bronchodilator used to relieve bronchospasms associated with acute or chronic asthma or other obstructive airway diseases. Signs and symptoms of proventil toxicity that the nurse should instruct the parents to watch for include tachycardia, restlessness, nausea, vomiting, and dizziness. Unusually slow respirations, urine retention, and constipation aren't associated with proventil toxicity. b. bradypnea. c. urine retention. d. constipation. Wong 1. The nurse is teaching nursing students about normal physiologic changes in the respiratory system of toddlers. Which best describes why toddlers have fewer respiratory tract infections as they grow older? a. The amount of lymphoid tissue decreases. b. Repeated exposure to organisms causes increased immunity. R Children have increased immunity after exposure to a virus. The amount of lymphoid tissue increases as children grow older. Viral organisms are not less prevalent, but older children have the ability to resist invading organisms. Secondary infections after viral illnesses include Mycoplasma pneumoniae and group A -hemolytic streptococcal infections. c. Viral organisms are less prevalent in the population. d. Secondary infections rarely occur after viral illnesses. 2. A nurse is charting that a hospitalized child has labored breathing. Which describes labored breathing? a. Dyspnea R Dyspnea is labored breathing. Tachypnea is rapid breathing. Hypopnea is breathing that is too shallow. Orthopnea is difficulty breathing except in upright position. b. Tachypnea c. Hypopnea d. Orthopnea 3. The nurse is assessing a child with acute epiglottitis. Examining the child’s throat by using a tongue depressor might precipitate which symptom or condition? a. Inspiratory stridor b. Complete obstruction R If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place. Stridor is aggravated when a child with epiglottitis is supine. Sore throat and pain on swallowing are early signs of epiglottitis. Epiglottitis is caused by H. influenzae in the respiratory tract. c. Sore throat d. Respiratory tract infection 4. No Which type of croup is always considered a medical emergency? a. Laryngitis b. Epiglottitis R Epiglottitis is always a medical emergency needing antibiotics and airway support for treatment. Laryngitis is a common viral illness in older children and adolescents, with hoarseness and URI symptoms. Spasmodic croup is treated with humidity. LTB may progress to a medical emergency in some children. c. Spasmodic croup d. Laryngotracheobronchitis (LTB) 5. The nurse encourages the mother of a toddler with acute laryngotracheobronchitis (LTB) to stay at the bedside as much as possible. The nurse’s rationale for this action is described primarily in which statement? a. Mothers of hospitalized toddlers often experience guilt. b. The mother’s presence will reduce anxiety and ease child’s respiratory efforts. R The family’s presence will decrease the child’s distress. It is true that mothers of hospitalized toddlers often experience guilt but this is not the best answer. The main reason to keep parents at the child’s bedside is to ease anxiety and therefore respiratory effort. The child should have constant monitoring by cardiorespiratory monitor and noninvasive oxygen saturation monitoring, but the parent should not play this role in the hospital. c. Separation from mother is a major developmental threat at this age. d. The mother can provide constant observations of the child’s respiratory efforts. 6. A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. This is most suggestive of which diagnosis? a. Bronchitis R Bronchitis is characterized by these symptoms and occurs in children older than 6 years. Bronchiolitis is rare in children older than 2 years. Asthma is a chronic inflammation of the airways that may be exacerbated by a virus. Acute spasmodic laryngitis occurs in children between 3 months and 3 years. b. Bronchiolitis c. Viral-induced asthma d. Acute spasmodic laryngitis 7. Which frequency is recommended for childhood skin testing for tuberculosis (TB) using the Mantoux test? a. Every year for all children older than 2 years b. Every year for all children older than 10 years c. Every 2 years for all children starting at age 1 year d. Periodically for children who reside in high-prevalence regions R Children who reside in high-prevalence regions for TB should be tested every 2 to 3 years. Annual testing is not necessary. Testing is not necessary unless exposure is likely or an underlying medical risk factor is present. 8. Which consideration is the most important in managing tuberculosis (TB) in children? a. Skin testing annually b. Pharmacotherapy R Drug therapy for TB includes isoniazid, rifampin, and pyrazinamide daily for 2 months and two or three times a week for the remaining 4 months. Pharmacotherapy is the most important intervention for TB. c. Adequate nutrition Inability to speak d. Adequate hydration 9. The mother of a toddler yells to the nurse, “Help! He is choking to death on his food.” The nurse determines that lifesaving measures are necessary based on which symptom? a. Gagging b. Coughing c. Pulse over 100 beats/min d. R The inability to speak is indicative of a foreign-body airway obstruction of the larynx. Abdominal thrusts are needed for treatment of the choking child. Gagging indicates irritation at the back of the throat, not obstruction. Coughing does not indicate a complete airway obstruction. Tachycardia may be present for many reasons. 10. The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. Nursing actions should include: a. forcing fluids. b. monitoring pulse oximetry. R Monitoring cardiopulmonary status is an important evaluation tool in the care of the child with ARDS. Maintenance of vascular volume and hydration is important and should be done parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a highprotein diet is not helpful. c. instituting seizure precautions. d. encouraging a high-protein diet. 11. The nurse is caring for a child with carbon monoxide poisoning associated with smoke inhalation. Which is essential in this child’s care? a. Monitor pulse oximetry. b. Monitor arterial blood gases. R Arterial blood gases are the best way to monitor carbon monoxide poisoning. Pulse oximetry is contraindicated in the case of carbon monoxide poisoning because the PaO2 may be normal. The child should receive 100% oxygen as quickly as possible, not only if respiratory distress or other symptoms develop. c. Administer oxygen if respiratory distress develops. d. Administer oxygen if child’s lips become bright, cherry red. 12. A nurse is admitting an infant with asthma. The nurse understands that asthma in infants is usually triggered by: a. Medications. b. a viral infection. R Viral illnesses cause inflammation that causes increased airway reactivity in asthma. Medications such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics may aggravate asthma, but not frequently in infants. Exposure to cold air may exacerbate already existing asthma. Allergy is associated with asthma, but 20% to 40% of children with asthma have no evidence of allergic disease. c. exposure to cold air. d. allergy to dust or dust mites. 13. A nurse is conducting an in-service on asthma. Which statement is the most descriptive of bronchial asthma? a. There is heightened airway reactivity. R In bronchial asthma, spasm of the smooth muscle of the bronchi and bronchioles causes constriction, producing impaired respiratory function. In bronchial asthma, there is increased resistance in the airway. There are multiple causes of asthma, including allergens, irritants, exercise, cold air, infections, medications, medical conditions, and endocrine factors. Atopy or development of an immunoglobulin E (IgE)–mediated response is inherited but is not the only cause of asthma. b. There is decreased resistance in the airway. c. The single cause of asthma is an allergic hypersensitivity. d. It is inherited. 14. A child is admitted to the hospital with asthma. Which assessment findings support this diagnosis? a. Nonproductive cough, wheezing R Asthma presents with a nonproductive cough and wheezing. Pneumonia appears with an acute onset, fever, and general malaise. A productive cough and rales would be indicative of pneumonia. Stridor and substernal retractions are indicative of croup. b. Fever, general malaise c. Productive cough, rales d. Stridor, substernal retractions 15. It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently because which disease or assessment findings may develop? a. Cough b. Osteoporosis c. Slowed growth R The growth of children on long-term inhaled steroids should be assessed frequently to assess for systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence exists that inhaled steroids cause osteoporosis. Cushing syndrome is caused by long-term systemic steroids. d. Cushing syndrome 16. β-Adrenergic agonists and methylxanthines are often prescribed for a child with an asthma attack. Which describes their action? a. Liquefy secretions. b. Dilate the bronchioles. R β-Adrenergic agonists and methylxanthines work to dilate the bronchioles in acute exacerbations. These medications do not liquefy secretions or reduce infection. Corticosteroids and mast cell stabilizers reduce inflammation in the lungs. c. Reduce inflammation of the lungs. d. Reduce infection. 17. Parents of two school-age children with asthma ask the nurse, “What sports can our children participate in?” The nurse should recommend which sport? a. Soccer b. Running c. Swimming R Swimming is well tolerated in children with asthma because they are breathing air fully saturated with moisture and because of the type of breathing required in swimming. Exercise- induced bronchospasm is more common in sports that involve endurance, such as soccer. Prophylaxis with medications may be necessary. d. Basketball 18. Which drug is usually given first in the emergency treatment of an acute, severe asthma episode in a young child? a. Ephedrine b. Theophylline c. Aminophylline d. Short-acting β2 agonists R Short-acting β2 agonists are the first treatment in an acute asthma exacerbation. Ephedrine is not helpful in acute asthma exacerbations. Theophylline is unnecessary for treating asthma exacerbations. Aminophylline is not helpful for acute asthma exacerbation. 19. Parents of a child with cystic fibrosis ask the nurse about genetic implications of the disorder. Which statement, made by the nurse, expresses accurately the genetic implications? a. R CF is an autosomal recessive gene inherited from both parents and is inherited as an autosomal recessive, not autosomal dominant, trait. CF is found primarily in Caucasian populations. An autosomal recessive inheritance pattern means that there is a 25% chance a sibling will be infected but a 50% chance a sibling will be a carrier. b. It is inherited as an autosomal dominant trait. c. It is a genetic defect found primarily in non-Caucasian population groups. d. There is a 50% chance that siblings of an affected child also will be affected. If it is present in a child, both parents are carriers of this defective gene. 20. A nurse is teaching nursing students about clinical manifestations of cystic fibrosis (CF). Which is/are the earliest recognizable clinical manifestation(s) of CF? a. Meconium ileus R The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of children with CF. Clinical manifestations include abdominal distention, vomiting, failure to pass stools, and rapid development of dehydration. History of malabsorption is a later sign that manifests as failure to thrive. Foul-smelling stools are a later manifestation of CF. Recurrent respiratory tract infections are a later sign of CF. b. History of poor intestinal absorption c. Foul-smelling, frothy, greasy stools d. Recurrent pneumonia and lung infections 21. A child is being admitted to the hospital to be tested for cystic fibrosis (CF). Which tests should the nurse expect? a. Sweat chloride test, stool for fat, chest radiograph films R A sweat test result of greater than 60 mEq/L is diagnostic of CF, a high level of fecal fat is a gastrointestinal (GI) manifestation of CF, and a chest radiograph showing patchy atelectasis and obstructive emphysema indicates CF. Gastric contents contain hydrochloride normally; it is not diagnostic. Bronchoscopy and duodenal fluid are not diagnostic. Stool test for trypsin and intestinal biopsy are not helpful in diagnosing CF. b. Stool test for fat, gastric contents for hydrochloride, chest radiograph films c. Sweat chloride test, bronchoscopy, duodenal fluid analysis d. Sweat chloride test, stool for trypsin, biopsy of intestinal mucosa 22. Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this diagnosis? a. Bronchoscopy b. Serum calcium c. Urine creatinine d. Sweat chloride test R A sweat chloride test result greater than 60 mEq/L is diagnostic of CF. Bronchoscopy, although helpful for identifying bacterial infection in children with CF, is not diagnostic. Serum calcium is normal in children with CF. Urine creatinine is not diagnostic of CF. 23. A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this medication be administered? a. Before chest physiotherapy (CPT) R Bronchodilators should be given before CPT to open bronchi and make expectoration easier. Aerosolized bronchodilator medications are not helpful when used after CPT. Oxygen administration is necessary only in acute episodes with caution because of chronic carbon dioxide retention. b. After CPT c. Before receiving 100% oxygen d. After receiving 100% oxygen 24. A child with cystic fibrosis (CF) is receiving recombinant human deoxyribonuclease (DNase). Which is an adverse effect of this medication? a. Mucus thickens b. Voice alters R One of the only adverse effects of DNase is voice alterations and laryngitis. DNase decreases viscosity of mucus, is given in an aerosolized form, and is safe for children younger than 12 years. 2 agonists can cause tachycardia and jitteriness. c. Tachycardia d. Jitteriness 25. Pancreatic enzymes are administered to the child with cystic fibrosis (CF). Nursing considerations should include to: a. not administer pancreatic enzymes if child is receiving antibiotics. b. decrease dose of pancreatic enzymes if child is having frequent, bulky stools. c. administer pancreatic enzymes between meals if at all possible. d. pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal. R Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or swallowed whole. Pancreatic enzymes are not a contraindication for antibiotics. The dosage of enzymes should be increased if child is having frequent, bulky stools. Enzymes should be given just before meals and snacks. 26. In providing nourishment for a child with cystic fibrosis (CF), which factor should the nurse keep in mind? a. Diet should be high in carbohydrates and protein. R Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption. Enzyme supplementation helps digest foods; other modifications are not necessary. A well-balanced diet containing fruits and vegetables is important. Fats and proteins are a necessary part of a well-balanced diet. b. Diet should be high in easily digested carbohydrates and fats. c. Most fruits and vegetables are not well tolerated. d. Fats and proteins must be greatly curtailed. 27. Cardiopulmonary resuscitation (CPR) is begun on a toddler. Which pulse is usually palpated because it is the most central and accessible? a. Radial b. Carotid R In a toddler, the carotid pulse is palpated. The radial pulse is not considered a central pulse. The femoral pulse is not the most central and accessible. Brachial pulse is felt in infants younger than 1 year. c. Femorald. d. Brachial 28. Effective lone-rescuer CPR on a 5-year-old child should include a. two breaths to every 30 chest compressions. R Lone-rescuer CPR is two breaths to 30 compressions for all ages until signs of recovery occur. Reassessment of the child should take place after 20 cycles or 1 minute. b. two breaths to every 15 chest compressions. c. reassessment of child after 50 cycles of compression and ventilation. d. reassessment of child every 10 minutes that CPR continues. 29. The Heimlich maneuver is recommended for airway obstruction in children older than year(s). a. 1 R The Heimlich maneuver is recommended for airway obstruction in children older than 1 year. Younger than 1 year, back blows and chest thrusts are administered. The Heimlich maneuver can be used in children older than 1 year. b. 4 c. 8 d. 12 30. A nurse is caring for a child in acute respiratory failure. Which blood gas analysis indicates the child is still in respiratory acidosis? a. pH 7.50, CO2 48 b. pH 7.30, CO2 30 c. pH 7.32, CO2 50 R Respiratory failure is a process that involves pulmonary dysfunction generally resulting in impaired alveolar gas exchange, which can lead to hypoxemia or hypercapnia. Acidosis indicates the pH is less than 7.35 and the CO2 is greater than 45. If the pH is less than 7.35 but the CO2 is low, it is metabolic acidosis. Alkalosis is when the pH is greater than 7.45. If the pH is high and the CO2 is high, it is metabolic alkalosis. When the pH is high and the CO2 is low, it is respiratory alkalosis. d. pH 7.48, CO2 33 31. A nurse is teaching an adolescent how to use the peak expiratory flowmeter. The adolescent has understood the teaching if which statement is made? a. “I will record the average of the readings.” b. “I should be sitting comfortably when I perform the readings.” c. “I will record the readings at the same time every day.” R Instructions for use of a peak flowmeter include standing up straight before performing the reading, recording the highest of the three readings (not the average), measuring the peak expiratory flow rate (PEFR) close to the same time each day, and repeating the entire routine three times, waiting 30 seconds between each routine. d. “I will repeat the routine two times.” 32. A school-age child has been admitted with an acute asthma episode. The child is receiving oxygen by nasal prongs at 2 liters. How often should the nurse plan to monitor the child’s pulse oximetry status? a. Continuous R The child on supplemental oxygen requires intermittent or continuous oxygenation monitoring, depending on severity of respiratory compromise and initial oxygenation status. The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring. b. Every 30 minutes c. Every hour d. Every 2 hours 33. A nurse is interpreting the results of a tuberculin skin test (TST) on an adolescent who is HIV positive. Which induration size indicates a positive result for this child 48–72 hours after the test? a. 5 mm R Clinical evidence of a positive TST in children receiving immunosuppressive therapy, including immunosuppressive doses of steroids or who have immunosuppressive conditions, including HIV infection is an induration of 5 mm. Children younger than 4 years of age with: (a) other medical risk conditions, including Hodgkin disease, lymphoma, diabetes mellitus, chronic renal failure, or malnutrition; (b) born or whose parents were born in high-prevalence (TB) regions of the world; (c) frequently exposed to adults who are HIV infected, homeless, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized, or migrant farm workers; and (d) who travel to high-prevalence (TB) regions of the world are positive when the induration is 10 mm. Children 4 years of age or older without any risk factors are positive when the induration is 20 mm b. 10 mm c. 15 mm d. 20 mm 34. The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which intervention should be included in the child’s care? (Select all that apply.) a. Place in a mist tent. b. Administer antibiotics. c. Administer cough syrup. d. Encourage to drink 8 ounces of formula every 4 hours. e. Cluster care to encourage adequate rest. f. Place on noninvasive oxygen monitoring. R Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended. Mist tents are no longer used. Antibiotics do not treat illnesses with viral causes. Cough syrup suppresses clearing of respiratory secretions and is not indicated for young children. 35. The nurse enters a room and finds a 6-year-old child who is unconscious. After calling for help and before being able to use an automatic external defibrillator, which steps should the nurse take? Place in correct order. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d, e, f). a. Place on a hard surface. b. Administer 30 chest compressions with two breaths. c. Feel carotid pulse while maintaining head tilt with the other hand. d. Use the head tilt–chin lift maneuver and check for breathing. e. Place heel of one hand on lower half of sternum with other hand on top. f. Give two rescue breaths. R Answer: a, d, f, c, e, b 36. The nurse must do a heel stick on an ill neonate to obtain a blood sample. Which is recommended to facilitate this? a. Apply cool, moist compresses. b. Apply a tourniquet to ankle. c. Elevate foot for 5 minutes. d. Wrap foot in a warm washcloth. R Before the blood sample is taken, the heel is heated with warm moist compresses for 5 to 10 minutes to dilate the blood vessels in the area. Cooling causes vasoconstriction, making blood collection more difficult. A tourniquet is used to constrict superficial veins. It will have an insignificant effect on capillaries. Elevating the foot will decrease the blood in the foot available for collection. 37. The nurse has just collected blood by venipuncture in the antecubital fossa. Which should the nurse do next? a. Keep arm extended while applying a bandage to the site. b. Keep arm extended, and apply pressure to the site for a few minutes. R Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before bandage is applied. c. Apply a bandage to the site, and keep the arm flexed for 10 mi