NSG434 Exam 4 Actual Exam Style V3 |
NSG 434 Nursing Care of Children | Grand
Canyon University
1. A 5-year-old child is brought to the emergency department with suspected septic shock.
Which of the following is the priority nursing intervention?
A. Obtaining a detailed medical history
B. Applying a cooling blanket for a high fever
C. Starting a broad-spectrum antibiotic within 4 hours
D. Administering a 20 mL/kg bolus of isotonic crystalloid
Answer: D
Rationale: In pediatric septic shock, rapid fluid resuscitation is the highest priority to
restore intravascular volume and improve tissue perfusion. The standard initial bolus is 20
mL/kg of normal saline or lactated Ringer’s. Delaying fluid resuscitation can lead to
irreversible organ damage and multisystem failure.
2. In a disaster scenario, using the JumpSTART triage system, a child who is not breathing but
has a palpable pulse should be categorized as:
A. Green (Minor)
B. Yellow (Delayed)
C. Black (Deceased)
,D. Red (Immediate)
Answer: D
Rationale: Under JumpSTART, if a child is apneic but has a pulse, the rescuer should
provide 5 rescue breaths. If breathing resumes, the child is tagged Red. This reflects the
pediatric physiological difference where respiratory arrest often precedes cardiac arrest,
unlike in adults.
3. A nurse is caring for a 10-year-old with full-thickness burns over 30% of the body. Which
clinical finding indicates effective fluid resuscitation?
A. Clear breath sounds on auscultation
B. Weight gain of 2 pounds in 24 hours
C. Blood pressure of 90/60 mmHg
D. Urinary output of 1 to 2 mL/kg/hr
Answer: D
Rationale: Urinary output is the most reliable indicator of organ perfusion during fluid
resuscitation in pediatric burn patients. For children weighing less than 30 kg, the goal is
typically 1-2 mL/kg/hr. Weight gain or blood pressure alone are less sensitive indicators of
adequate renal and systemic perfusion in the acute phase.
4. Which assessment finding is an early sign of increased intracranial pressure (ICP) in an
infant?
A. Bradycardia and hypertension
, B. Sunsetting eyes
C. Fixed and dilated pupils
D. High-pitched cry and irritability
Answer: D
Rationale: Early signs of increased ICP in infants are often behavioral and subtle, such as a
high-pitched cry, irritability, and poor feeding. Physical signs like sunsetting eyes or
bulging fontanelles follow as pressure increases. Late signs include Cushing’s triad, which
consists of bradycardia, hypertension, and irregular respirations.
5. A 12-year-old is admitted with Diabetic Ketoacidosis (DKA). Which laboratory result
requires the most immediate notification of the provider?
A. Blood glucose of 350 mg/dL
B. Bicarbonate level of 12 mEq/L
C. Potassium level of 2.8 mEq/L
D. Presence of ketones in the urine
Answer: C
Rationale: A potassium level of 2.8 mEq/L is critically low and poses a high risk for cardiac
arrhythmias, especially when starting insulin therapy. Insulin causes potassium to shift
from the extracellular fluid into the cells, further lowering serum levels. While glucose and
NSG 434 Nursing Care of Children | Grand
Canyon University
1. A 5-year-old child is brought to the emergency department with suspected septic shock.
Which of the following is the priority nursing intervention?
A. Obtaining a detailed medical history
B. Applying a cooling blanket for a high fever
C. Starting a broad-spectrum antibiotic within 4 hours
D. Administering a 20 mL/kg bolus of isotonic crystalloid
Answer: D
Rationale: In pediatric septic shock, rapid fluid resuscitation is the highest priority to
restore intravascular volume and improve tissue perfusion. The standard initial bolus is 20
mL/kg of normal saline or lactated Ringer’s. Delaying fluid resuscitation can lead to
irreversible organ damage and multisystem failure.
2. In a disaster scenario, using the JumpSTART triage system, a child who is not breathing but
has a palpable pulse should be categorized as:
A. Green (Minor)
B. Yellow (Delayed)
C. Black (Deceased)
,D. Red (Immediate)
Answer: D
Rationale: Under JumpSTART, if a child is apneic but has a pulse, the rescuer should
provide 5 rescue breaths. If breathing resumes, the child is tagged Red. This reflects the
pediatric physiological difference where respiratory arrest often precedes cardiac arrest,
unlike in adults.
3. A nurse is caring for a 10-year-old with full-thickness burns over 30% of the body. Which
clinical finding indicates effective fluid resuscitation?
A. Clear breath sounds on auscultation
B. Weight gain of 2 pounds in 24 hours
C. Blood pressure of 90/60 mmHg
D. Urinary output of 1 to 2 mL/kg/hr
Answer: D
Rationale: Urinary output is the most reliable indicator of organ perfusion during fluid
resuscitation in pediatric burn patients. For children weighing less than 30 kg, the goal is
typically 1-2 mL/kg/hr. Weight gain or blood pressure alone are less sensitive indicators of
adequate renal and systemic perfusion in the acute phase.
4. Which assessment finding is an early sign of increased intracranial pressure (ICP) in an
infant?
A. Bradycardia and hypertension
, B. Sunsetting eyes
C. Fixed and dilated pupils
D. High-pitched cry and irritability
Answer: D
Rationale: Early signs of increased ICP in infants are often behavioral and subtle, such as a
high-pitched cry, irritability, and poor feeding. Physical signs like sunsetting eyes or
bulging fontanelles follow as pressure increases. Late signs include Cushing’s triad, which
consists of bradycardia, hypertension, and irregular respirations.
5. A 12-year-old is admitted with Diabetic Ketoacidosis (DKA). Which laboratory result
requires the most immediate notification of the provider?
A. Blood glucose of 350 mg/dL
B. Bicarbonate level of 12 mEq/L
C. Potassium level of 2.8 mEq/L
D. Presence of ketones in the urine
Answer: C
Rationale: A potassium level of 2.8 mEq/L is critically low and poses a high risk for cardiac
arrhythmias, especially when starting insulin therapy. Insulin causes potassium to shift
from the extracellular fluid into the cells, further lowering serum levels. While glucose and
