NSG 3600 Exam 3 exam with verified solutions
1. The nurse judges teaching as successful when the parent of a child with
myasthenia gravis states which of the following? Select all that apply.
1. "My child should play on the school's basketball team."
2. "My child should meditate every day."
3. "My child should be allowed to do what other kids do."
4. "My child should be watched carefully for signs of illness."
5. "My child should sleep in my room so that I can watch him better.": 3, 4.
1. Children with myasthenia gravis should not
play strenuous sports. The increased stress from being in a competitive sport tends
to negatively impact children, and they should learn strategies to decrease stress.
2. It is important that children with myasthenia gravis have activities they can par-
ticipate in without causing stress. Activities such as board games, horseback riding,
and hiking should be encouraged. Some children would benefit from meditation but
may take time to appreciate the results.
3. Children with myasthenia gravis can do many things other children do. They should
be advised not to play strenuous sports, and they should learn how to control stress.
4. Children are watched for signs of illness because of the exacerbation of signs of
myasthenia gravis.
5. It's not recommended that children sleep in the same bedroom as their parents
unless it can't be avoided.
TEST-TAKING HINT: The test taker must know the physiology of the illness and
consider that this is a chronic disease. The child is first a child, so he will have all
the growth and development issues children without a chronic disease have.
2. The parent of a newborn asks, "Will my baby spit out the formula if it is too
hot or too cold?" Which is the nurse's best response?
1. "Babies have a tendency to reject hot fluids but not cold fluids, which could
result in abdominal discomfort."
2. "Babies have a tendency to reject cold fluids but not hot fluids, which could
result in esophageal burns."
3. "Your baby would most likely spit out formula that was too hot, but your
baby could swallow some of it, which could result in a burn."
4. "Your baby is too young to be physically capable of spitting out fluids
,and will automatically swallow anything.": 1. Swallowing is a reflex in neonates;
infants younger than 6 weeks cannot voluntarily control swallowing.
2. Swallowing is a reflex in neonates; infants younger than 6 weeks cannot voluntarily
control swallowing.
3. The infant is not capable of selectively rejecting fluid because swallowing is a
reflex until 6 weeks.
4. Swallowing is a reflex in infants younger than 6 weeks.
,TEST-TAKING HINT: Swallowing is a reflex that is present until the age of 6 weeks.
The test taker should eliminate answers 1, 2,and 3 because they suggest that the
infant is capable of selectively rejecting fluids.
3. The mother of a newborn asks the nurse why the infant has to nurse so
frequently. Which is the best response?
1. Formula tends to be more calorically dense, and formula-fed babies require
fewer feedings than breastfed babies.
2. The newborn's stomach capacity is small, and peristalsis is slow.
3. The newborn's stomach capacity is small, and peristalsis is more rapid than
in older children.
4. Breastfed babies tend to take longer to complete a feeding than formula-fed
babies.: 1. The caloric content of breast milk and formula tends to be similar.
2. Peristalsis in infants is greater than in older
children.
3. The small-stomach capacity and rapid movement of fluid through the digestive
system account for the need for small, frequent feedings.
4. Breastfed babies and formula-fed babies do not necessarily have a difference in
feeding time.
TEST-TAKING HINT: The test taker should eliminate answers 1 and 4 because they
both form generalizations that are not supported by current literature.
4. A 4-month-old has had vomiting and diarrhea for 24 hours. The infant is
fussy, and the anterior fontanel is sunken. The nurse notes the infant does
not produce tears when crying. Which task will help confirm the diagnosis of
dehydration?
1. Urinalysis obtained by bagged specimen.
2. Urinalysis obtained by sterile catheterization.
3. Analysis of serum electrolytes.
4. Analysis of cerebrospinal fluid.: 1. The information obtained from a urinalysis
of an infant is not as helpful as serum electrolytes. The infant has limited ability to
concentrate urine, so the specific gravity is not usually affected.
2. The information obtained from a urinalysis of an infant is not as helpful as serum
electrolytes. The infant has limited ability to concentrate urine, so the specific gravity
is not usually affected. A urinalysis does not need to be obtained by catheterization.
3. The analysis of serum electrolytes offers the most information and assists with the
diagnosis of dehydration.
4. Although critical in diagnosing meningitis, a lumber puncture and analysis of
cerebrospinal fluid are not done to confirm dehydration.
TEST-TAKING HINT: Infants have limited ability to concentrate urine, so answers 1
and 2 can be eliminated immediately.
, 5. A 4-month-old is brought to the emergency department with severe dehy-
dration. The heart rate is 198, and her blood pressure is 68/38. The infant's
anterior fontanel is sunken. The nurse notes that the infant does not cry when
the intravenous lineis inserted. The child's parents state that she has not "held
anything down" in 18 hours. The nurse obtains a finger-stick blood sugar of
94. Which would the nurse expect to do immediately?
1. Administer a bolus of normal saline.
2. Administer a bolus of D10W.
3. Administer a bolus of normal saline with 5% dextrose added to the solution.
4. Offer the child an oral rehydrating solution such as Pedialyte.: 1. Dehydration
is corrected with the administration of an isotonic solution, such as normal saline or
lactated Ringer solution.
2. Solutions containing dextrose should never be administered in bolus form be-
cause they may result in cerebral edema.
3. Solutions containing dextrose should never be administered in bolus form be-
cause they may result in cerebral edema.
4. Severe dehydration is not usually corrected with oral solutions; children with
altered levels of consciousness should be kept NPO.
TEST-TAKING HINT: The test taker should immediately eliminate answers 2 and 3
because they both suggest administering glucose in bolus form, which is always
contraindicated in pediatric clients. Answer 4 should be eliminated because the
infant is severely dehydrated and not responding to painful stimulation, which is
suggested by the lack of a cry on intravenous insertion.
6. The nurse is caring for a 2-year-old child who was admitted to the pediatric
unit for moderate dehydration due to vomiting and diarrhea. The child is
restless with periods of irritability. The child is afebrile with a heart rate of 148
and a blood pressure of 90/42. Baseline laboratory tests reveal the following:
Na 152, Cl 119, and glucose 115. The parents state that the child has not
urinated in 12 hours. After establishing a saline lock, the nurse reviews the
physician's orders. Which order should the nurse question?
1. Administer a saline bolus of 10 mL/kg, which may be repeated if the child
does not urinate.
2. Recheck serum electrolytes in 12 hours.
3. After the saline bolus, begin maintenance fluids of D5 14 D NS with 10 mEq
KCl/L.
4. Give clear liquid diet as tolerated.: 1. Fluid boluses of normal saline are
administered according to the child's body weight. It is not unusual to have to repeat
the bolus multiple times in order to see an improvement in the child's condition.
2. It is important to monitor serum electrolytes frequently in the dehydrated child.
1. The nurse judges teaching as successful when the parent of a child with
myasthenia gravis states which of the following? Select all that apply.
1. "My child should play on the school's basketball team."
2. "My child should meditate every day."
3. "My child should be allowed to do what other kids do."
4. "My child should be watched carefully for signs of illness."
5. "My child should sleep in my room so that I can watch him better.": 3, 4.
1. Children with myasthenia gravis should not
play strenuous sports. The increased stress from being in a competitive sport tends
to negatively impact children, and they should learn strategies to decrease stress.
2. It is important that children with myasthenia gravis have activities they can par-
ticipate in without causing stress. Activities such as board games, horseback riding,
and hiking should be encouraged. Some children would benefit from meditation but
may take time to appreciate the results.
3. Children with myasthenia gravis can do many things other children do. They should
be advised not to play strenuous sports, and they should learn how to control stress.
4. Children are watched for signs of illness because of the exacerbation of signs of
myasthenia gravis.
5. It's not recommended that children sleep in the same bedroom as their parents
unless it can't be avoided.
TEST-TAKING HINT: The test taker must know the physiology of the illness and
consider that this is a chronic disease. The child is first a child, so he will have all
the growth and development issues children without a chronic disease have.
2. The parent of a newborn asks, "Will my baby spit out the formula if it is too
hot or too cold?" Which is the nurse's best response?
1. "Babies have a tendency to reject hot fluids but not cold fluids, which could
result in abdominal discomfort."
2. "Babies have a tendency to reject cold fluids but not hot fluids, which could
result in esophageal burns."
3. "Your baby would most likely spit out formula that was too hot, but your
baby could swallow some of it, which could result in a burn."
4. "Your baby is too young to be physically capable of spitting out fluids
,and will automatically swallow anything.": 1. Swallowing is a reflex in neonates;
infants younger than 6 weeks cannot voluntarily control swallowing.
2. Swallowing is a reflex in neonates; infants younger than 6 weeks cannot voluntarily
control swallowing.
3. The infant is not capable of selectively rejecting fluid because swallowing is a
reflex until 6 weeks.
4. Swallowing is a reflex in infants younger than 6 weeks.
,TEST-TAKING HINT: Swallowing is a reflex that is present until the age of 6 weeks.
The test taker should eliminate answers 1, 2,and 3 because they suggest that the
infant is capable of selectively rejecting fluids.
3. The mother of a newborn asks the nurse why the infant has to nurse so
frequently. Which is the best response?
1. Formula tends to be more calorically dense, and formula-fed babies require
fewer feedings than breastfed babies.
2. The newborn's stomach capacity is small, and peristalsis is slow.
3. The newborn's stomach capacity is small, and peristalsis is more rapid than
in older children.
4. Breastfed babies tend to take longer to complete a feeding than formula-fed
babies.: 1. The caloric content of breast milk and formula tends to be similar.
2. Peristalsis in infants is greater than in older
children.
3. The small-stomach capacity and rapid movement of fluid through the digestive
system account for the need for small, frequent feedings.
4. Breastfed babies and formula-fed babies do not necessarily have a difference in
feeding time.
TEST-TAKING HINT: The test taker should eliminate answers 1 and 4 because they
both form generalizations that are not supported by current literature.
4. A 4-month-old has had vomiting and diarrhea for 24 hours. The infant is
fussy, and the anterior fontanel is sunken. The nurse notes the infant does
not produce tears when crying. Which task will help confirm the diagnosis of
dehydration?
1. Urinalysis obtained by bagged specimen.
2. Urinalysis obtained by sterile catheterization.
3. Analysis of serum electrolytes.
4. Analysis of cerebrospinal fluid.: 1. The information obtained from a urinalysis
of an infant is not as helpful as serum electrolytes. The infant has limited ability to
concentrate urine, so the specific gravity is not usually affected.
2. The information obtained from a urinalysis of an infant is not as helpful as serum
electrolytes. The infant has limited ability to concentrate urine, so the specific gravity
is not usually affected. A urinalysis does not need to be obtained by catheterization.
3. The analysis of serum electrolytes offers the most information and assists with the
diagnosis of dehydration.
4. Although critical in diagnosing meningitis, a lumber puncture and analysis of
cerebrospinal fluid are not done to confirm dehydration.
TEST-TAKING HINT: Infants have limited ability to concentrate urine, so answers 1
and 2 can be eliminated immediately.
, 5. A 4-month-old is brought to the emergency department with severe dehy-
dration. The heart rate is 198, and her blood pressure is 68/38. The infant's
anterior fontanel is sunken. The nurse notes that the infant does not cry when
the intravenous lineis inserted. The child's parents state that she has not "held
anything down" in 18 hours. The nurse obtains a finger-stick blood sugar of
94. Which would the nurse expect to do immediately?
1. Administer a bolus of normal saline.
2. Administer a bolus of D10W.
3. Administer a bolus of normal saline with 5% dextrose added to the solution.
4. Offer the child an oral rehydrating solution such as Pedialyte.: 1. Dehydration
is corrected with the administration of an isotonic solution, such as normal saline or
lactated Ringer solution.
2. Solutions containing dextrose should never be administered in bolus form be-
cause they may result in cerebral edema.
3. Solutions containing dextrose should never be administered in bolus form be-
cause they may result in cerebral edema.
4. Severe dehydration is not usually corrected with oral solutions; children with
altered levels of consciousness should be kept NPO.
TEST-TAKING HINT: The test taker should immediately eliminate answers 2 and 3
because they both suggest administering glucose in bolus form, which is always
contraindicated in pediatric clients. Answer 4 should be eliminated because the
infant is severely dehydrated and not responding to painful stimulation, which is
suggested by the lack of a cry on intravenous insertion.
6. The nurse is caring for a 2-year-old child who was admitted to the pediatric
unit for moderate dehydration due to vomiting and diarrhea. The child is
restless with periods of irritability. The child is afebrile with a heart rate of 148
and a blood pressure of 90/42. Baseline laboratory tests reveal the following:
Na 152, Cl 119, and glucose 115. The parents state that the child has not
urinated in 12 hours. After establishing a saline lock, the nurse reviews the
physician's orders. Which order should the nurse question?
1. Administer a saline bolus of 10 mL/kg, which may be repeated if the child
does not urinate.
2. Recheck serum electrolytes in 12 hours.
3. After the saline bolus, begin maintenance fluids of D5 14 D NS with 10 mEq
KCl/L.
4. Give clear liquid diet as tolerated.: 1. Fluid boluses of normal saline are
administered according to the child's body weight. It is not unusual to have to repeat
the bolus multiple times in order to see an improvement in the child's condition.
2. It is important to monitor serum electrolytes frequently in the dehydrated child.
