NR 328 Exam 2 Practice Questions & Answers
A nurse is obtaining an infant's vital signs. The HR is 180 bpm, and the temperature is 40C (104F). The
father asks the nurse, "Why is my baby's heart beating so fast?" Which of the following is an appropriate
response by the nurse?
A. "This is within the expected range for your baby."
B. "The fever is causing an increase in your baby's heart rate."
C. "As your baby begins to fall asleep, the heart rate will decrease."
D. "Your baby's heart is beating fast in an attempt to cool down the body." - ANSWER:B. "The fever is
causing an increase in your baby's heart rate."
Rationale: The expected range for the temperature of an infant from birth to 1 year is 36.5° C (97.7° F) to
37.2° C (98.9° F). This infant has a fever. The infant's heart rate will increase as a result of the fever. The
expected range for heart rate in an infant 3 months to 2 years old is 80-150/min while awake and 70-
120/min while asleep. If the infant is active or has a fever, the heart rate may be as high as 220/min.
A nurse is caring for a child who is diagnosed with otitis media. Which of the following assessment
findings should the nurse expect?
A. Tugging on the affected ear lobe
B. Clear drainage from the affected ear
C. Pain when manipulating the affected ear lobe
D. Erythema and edema of the affected ear - ANSWER:A. Tugging on the affected ear lobe
Rationale: Otitis media is a middle ear infection. Expected findings include fever, purulent drainage (only
if the tympanic membrane is ruptured), and pain, demonstrated by the child tugging at the ear. Pain
when manipulating the ear lobe is the classic sign of otitis externa, swimmer's ear. Swimmer's ear is also
associated with erythema and edema of the affected ear. Clear drainage from the ear is more commonly
associated with CSF drainage.
A nurse is preparing to begin chest compressions for an infant. The nurse should perform compressions
using which of the following techniques?
A. Deliver compressions at 1/3 to 1/2 the depth of the chest.
,B. Deliver compressions with the heel of one hand only.
C. Deliver compressions just above the nipple line.
D. Deliver compressions at a depth of 1 1/2 to 2 inches. - ANSWER:A. Deliver compressions at 1/3 to 1/2
the depth of the chest.
A nurse is monitoring a child who has just had a tonsillectomy for signs of hemorrhage. Which of the
following findings is a sign of this postoperative complication?
A. Mouth breathing
B. Frequent swallowing
C. Reports of thirst
D. Reports of pain - ANSWER:B. Frequent swallowing
A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following
medications should the nurse administer first?
A. Fluticasone (Flovent)
B. Budesonide (Pulmicort)
C. Montelukast (Singulair)
D. Albuterol (Proventil) - ANSWER:D. Albuterol (Proventil)
A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following
medications should reduce the symptoms?
A. Cromolyn (Intal) via metered-dose inhaler
B. Oral montelukast (Singular)
C. Budesonide (Pulmicort) via dry-powder inhaler
D. Albuterol (Proventil) via jet nebulizer - ANSWER:D. Albuterol (Proventil) via jet nebulizer
A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a
reliable indicator of cyanosis?
A. Oral mucosa
B. Finger tips
,C. Ear lobes
D. Eye lids - ANSWER:A. Oral mucosa
Rationale: The nurse should assess the oral mucosa as an indicator of cyanosis because changes can be
seen easily in areas with less pigmentation.
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
B. A sputum culture
C. A stool fat content analysis
D. Pulmonary function test - ANSWER:A. Sweat chloride test
Rationale: 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.
A nurse is caring for a child who has cystic fibrosis (CF) and is being discharged after initial diagnosis and
treatment. The nurse should recognize that the parent understands the child's nutritional needs when
she states which of the following?
A. "I will make certain that pancreatic enzymes are taken with all of my child's snacks and meals."
B. "I will restrict the amount of salt in my child's food."
C. "I will limit my child's fluid intake."
D. "I will prepare low-fat meals for my child." - ANSWER:A. "I will make certain that pancreatic enzymes
are taken with all of my child's snacks and meals."
Rationale: CF interferes with the availability of pancreatic enzymes necessary for normal digestion and
absorption of nutrients. Therefore, pancreatic enzymes must be taken with all meals and snacks.
A nurse is preparing a 4 year old client for discharge following a bilateral myringotomy with
tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give
the parent which of the following instructions?
, A. Gently reinsert the tubes.
B. Take the child to the emergency department.
C. Call the health care clinic to report that the tubes have fallen out.
D. Reassure the mother that the tubes will not fall out. - ANSWER:C. Call the health care clinic to report
that the tubes have fallen out.
A nurse is teaching the mother of a 5 year old child with CF about pancreatic enzymes. The nurse
understands that further teaching is needed 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 a lot of side effects."
C. "The enzymes help him digest fat."
D. "I will put the enzyme crystals in his applesauce." - ANSWER:A. "I will give my son the enzymes
between meals."
A nurse is reinforcing discharge teaching with the parents of a preterm infant who has a prescription for
home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates
a need for further teaching?
A. "We will rotate the probe of the pulse oximeter every 24 hours."
B. "The probe of the pulse oximeter can be applied to a finger or a toe."
C. "The pulse oximeter may not be accurate during times of excessive movement."
D. "We will notify the doctor if the pulse oximeter consistently reads 100%." - ANSWER:A. "We will rotate
the probe of the pulse oximeter every 24 hours."
Rationale: Pulse oximeters are a noninvasive method of monitoring oxygen saturation (SaO2) of the
blood. It is obtained by the application of a probe around the hand, foot, finger, toes, or earlobe, which is
then connected to a machine that provides continuous oxygen saturation levels. The probe should be
rotated every 3 to 4 hr to prevent pressure necrosis from occurring. Excessive movement, as well as heat
and light, can interfere with the results. Due to the risk of oxygen toxicity, which is a particular concern
with preterm infants, the parents should be instructed to notify the provider for consistent SaO2
readings over 95%. This may be an indication the infant is receiving too much oxygen and the amount
should be decreased.
A nurse is caring for a toddler admitted with laryngotracheobronchitis who is placed in a cool mist tent.
As a result of this treatment, the nurse expects to observe...
A nurse is obtaining an infant's vital signs. The HR is 180 bpm, and the temperature is 40C (104F). The
father asks the nurse, "Why is my baby's heart beating so fast?" Which of the following is an appropriate
response by the nurse?
A. "This is within the expected range for your baby."
B. "The fever is causing an increase in your baby's heart rate."
C. "As your baby begins to fall asleep, the heart rate will decrease."
D. "Your baby's heart is beating fast in an attempt to cool down the body." - ANSWER:B. "The fever is
causing an increase in your baby's heart rate."
Rationale: The expected range for the temperature of an infant from birth to 1 year is 36.5° C (97.7° F) to
37.2° C (98.9° F). This infant has a fever. The infant's heart rate will increase as a result of the fever. The
expected range for heart rate in an infant 3 months to 2 years old is 80-150/min while awake and 70-
120/min while asleep. If the infant is active or has a fever, the heart rate may be as high as 220/min.
A nurse is caring for a child who is diagnosed with otitis media. Which of the following assessment
findings should the nurse expect?
A. Tugging on the affected ear lobe
B. Clear drainage from the affected ear
C. Pain when manipulating the affected ear lobe
D. Erythema and edema of the affected ear - ANSWER:A. Tugging on the affected ear lobe
Rationale: Otitis media is a middle ear infection. Expected findings include fever, purulent drainage (only
if the tympanic membrane is ruptured), and pain, demonstrated by the child tugging at the ear. Pain
when manipulating the ear lobe is the classic sign of otitis externa, swimmer's ear. Swimmer's ear is also
associated with erythema and edema of the affected ear. Clear drainage from the ear is more commonly
associated with CSF drainage.
A nurse is preparing to begin chest compressions for an infant. The nurse should perform compressions
using which of the following techniques?
A. Deliver compressions at 1/3 to 1/2 the depth of the chest.
,B. Deliver compressions with the heel of one hand only.
C. Deliver compressions just above the nipple line.
D. Deliver compressions at a depth of 1 1/2 to 2 inches. - ANSWER:A. Deliver compressions at 1/3 to 1/2
the depth of the chest.
A nurse is monitoring a child who has just had a tonsillectomy for signs of hemorrhage. Which of the
following findings is a sign of this postoperative complication?
A. Mouth breathing
B. Frequent swallowing
C. Reports of thirst
D. Reports of pain - ANSWER:B. Frequent swallowing
A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following
medications should the nurse administer first?
A. Fluticasone (Flovent)
B. Budesonide (Pulmicort)
C. Montelukast (Singulair)
D. Albuterol (Proventil) - ANSWER:D. Albuterol (Proventil)
A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following
medications should reduce the symptoms?
A. Cromolyn (Intal) via metered-dose inhaler
B. Oral montelukast (Singular)
C. Budesonide (Pulmicort) via dry-powder inhaler
D. Albuterol (Proventil) via jet nebulizer - ANSWER:D. Albuterol (Proventil) via jet nebulizer
A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a
reliable indicator of cyanosis?
A. Oral mucosa
B. Finger tips
,C. Ear lobes
D. Eye lids - ANSWER:A. Oral mucosa
Rationale: The nurse should assess the oral mucosa as an indicator of cyanosis because changes can be
seen easily in areas with less pigmentation.
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
B. A sputum culture
C. A stool fat content analysis
D. Pulmonary function test - ANSWER:A. Sweat chloride test
Rationale: 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.
A nurse is caring for a child who has cystic fibrosis (CF) and is being discharged after initial diagnosis and
treatment. The nurse should recognize that the parent understands the child's nutritional needs when
she states which of the following?
A. "I will make certain that pancreatic enzymes are taken with all of my child's snacks and meals."
B. "I will restrict the amount of salt in my child's food."
C. "I will limit my child's fluid intake."
D. "I will prepare low-fat meals for my child." - ANSWER:A. "I will make certain that pancreatic enzymes
are taken with all of my child's snacks and meals."
Rationale: CF interferes with the availability of pancreatic enzymes necessary for normal digestion and
absorption of nutrients. Therefore, pancreatic enzymes must be taken with all meals and snacks.
A nurse is preparing a 4 year old client for discharge following a bilateral myringotomy with
tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give
the parent which of the following instructions?
, A. Gently reinsert the tubes.
B. Take the child to the emergency department.
C. Call the health care clinic to report that the tubes have fallen out.
D. Reassure the mother that the tubes will not fall out. - ANSWER:C. Call the health care clinic to report
that the tubes have fallen out.
A nurse is teaching the mother of a 5 year old child with CF about pancreatic enzymes. The nurse
understands that further teaching is needed 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 a lot of side effects."
C. "The enzymes help him digest fat."
D. "I will put the enzyme crystals in his applesauce." - ANSWER:A. "I will give my son the enzymes
between meals."
A nurse is reinforcing discharge teaching with the parents of a preterm infant who has a prescription for
home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates
a need for further teaching?
A. "We will rotate the probe of the pulse oximeter every 24 hours."
B. "The probe of the pulse oximeter can be applied to a finger or a toe."
C. "The pulse oximeter may not be accurate during times of excessive movement."
D. "We will notify the doctor if the pulse oximeter consistently reads 100%." - ANSWER:A. "We will rotate
the probe of the pulse oximeter every 24 hours."
Rationale: Pulse oximeters are a noninvasive method of monitoring oxygen saturation (SaO2) of the
blood. It is obtained by the application of a probe around the hand, foot, finger, toes, or earlobe, which is
then connected to a machine that provides continuous oxygen saturation levels. The probe should be
rotated every 3 to 4 hr to prevent pressure necrosis from occurring. Excessive movement, as well as heat
and light, can interfere with the results. Due to the risk of oxygen toxicity, which is a particular concern
with preterm infants, the parents should be instructed to notify the provider for consistent SaO2
readings over 95%. This may be an indication the infant is receiving too much oxygen and the amount
should be decreased.
A nurse is caring for a toddler admitted with laryngotracheobronchitis who is placed in a cool mist tent.
As a result of this treatment, the nurse expects to observe...
