Ch47: Respiratory FXN

Question 135809Id: 135809

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Type: MCSADifficulty Level:

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Question Stem

A toddler has had recurrent respiratory infections. The mother of the child expresses concern that her infant seems to be at increased risk for complications from respiratory infections in comparison with her older children. The best response from the nurse would be:

Stimulus

Answer

Choice 1 "You are incorrect in your assessment."

Rationale 1 The mother is correct in her statement.

Answer 1 false

Choice 2 "The younger child’s airways are smaller and more easily occluded."

Rationale 2Airways are smaller in the younger child and are more easily occluded when mucus is produced.

Answer 2 true

Choice 3"Air passages are more likely to become blocked with mucus because younger children make more mucus than older children."

Rationale 3Blockage of air passages with mucus is not related to the age of the child but more to the etiology of mucus production and the continuation of the causative agent.

Answer 3 false

Choice 4 "Toddlers do not breathe as deeply as do older children."

Rationale 4 Depth of breathing is not age-dependent.

Answer 4 false

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Learning Outcome 1:47.1 Describe unique characteristics of the pediatric respiratory system anatomy and physiology and apply that information to the care of children with respiratory conditions.

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Which nursing diagnosis would be most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)?

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Answer

Choice 1 Activity intolerance

Rationale 1Activity intolerance is a problem because of the imbalance between oxygen supply and demand.

Answer 1 true

Choice 2 Tissue perfusion, ineffective (peripheral)

Rationale 2Tissue perfusion (peripheral) is not affected by this respiratory disease process.

Answer 2 false

Choice 3 Pain, acute

Rationale 3 Pain is not usually associated with acute bronchiolitis.

Answer 3 false

Choice 4 Decreased cardiac output

Rationale 4 Cardiac output is not compromised during an acute phase of bronchiolitis.

Answer 4 false

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Learning Outcome 1:47.5 Distinguish between conditions of the lower respiratory tract that cause illness in children.

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A two-year-old male child arrived in the emergency department with complaints of sore throat, difficulty swallowing, and suspected diagnosis of acute epiglottitis. Which of the following interventions should not be included in the child's immediate care and assessment?

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Answer

Choice 1 Throat culture

Rationale 1Throat cultures should never be done when a diagnosis of epiglottis is suspected. Manipulation of the throat can stimulate the gag reflex in an already inflamed airway and can cause complete occlusion of the airway.

Answer 1 true

Choice 2 Medical history

Rationale 2 Medical history should be obtained, which assists in diagnosis.

Answer 2 false

Choice 3 Vital signs

Rationale 3 Vital signs should always be taken when assessment is done.

Answer 3 false

Choice 4 Assessment of breath sounds

Rationale 4 Assessment of breath sounds is essential for diagnosis.

Answer 4 false

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Learning Outcome 1:47.6 Create a nursing care plan for a child with a common acute respiratory condition.

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The family rushes a four-month-old infant to the hospital after finding the infant not breathing. The child is diagnosed as a victim of sudden infant death syndrome. Supportive care for this family would include:

Stimulus

Answer

Choice 1Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints.

Rationale 1 Parents will want any personal items available.

Answer 1 false

Choice 2 Allowing parents to hold, touch, and rock the dead infant.

Rationale 2The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby.

Answer 2 true

Choice 3 Advising parents that an autopsy is not necessary.

Rationale 3The death of an infant without a known medical condition is an indication for an autopsy.

Answer 3 false

Choice 4 Interviewing parents to determine the cause of the SIDS incident.

Rationale 4 The parents need to know that SIDS is not their fault.

Answer 4 false

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The nurse is teaching a group of mothers of infants about the benefits of immunization. The nurse will explain that the life-threatening disease epiglottitis can be prevented by immunization against:

Stimulus

Answer

Choice 1 Hepatitis B.

Rationale 1Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis.

Answer 1 false

Choice 2 Polio.


Answer 2 false

Choice 3 Measles, mumps, and rubella (MMR).


Answer 3 false

Choice 4 Haemophilus influenzae type B (HIB).

Rationale 4The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis.

Answer 4 true

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Learning Outcome 1:47.2 Contrast the different respiratory conditions and injuries that can cause respiratory distress in infants and children.

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A child is on rifampin (Rimactane) for treatment of tuberculosis. The parents call the clinic and report that the child's urine is orange. The nurse should advise the parents to:

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Answer

Choice 1 Encourage the child to drink cranberry juice.

Rationale 1Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options.

Answer 1 false

Choice 2 Expect orange-colored urine while the child is on rifampin.

Rationale 2Rifampin can color the urine orange, so the parents and child should be taught that this is an expected side effect.

Answer 2 true

Choice 3 Bring the child to the clinic for a urinalysis.


Answer 3 false

Choice 4 Bring the child to the clinic for a radiograph of the kidneys.


Answer 4 false

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The nurse is evaluating the parent's understanding of teaching related to environmental control for their child's asthma management. Which statement by the parents indicates that they understand the teaching?

Stimulus

Answer

Choice 1 "We're glad the dog can continue to sleep in our child's room."

Rationale 1 When possible, pets and plants should not be kept in the home.

Answer 1 false

Choice 2 "We'll keep the plants in our child's room dusted."

Rationale 2 When possible, pets and plants should not be kept in the home.

Answer 2 false

Choice 3"We'll be sure to use the fireplace often to keep the house warm in the winter."

Rationale 3 Smoke from fireplaces should be eliminated.

Answer 3 false

Choice 4 "We will replace the carpet in our child's bedroom with tile."

Rationale 4Control of dust in the child's bedroom is an important aspect of environmental control for asthma management.

Answer 4 true

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Learning Outcome 1: 47.7 Develop a school-based nursing care plan for a child with asthma.

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A newborn who is 24 hours old is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse what symptoms made the physician suspect cystic fibrosis. The nurse would reply that the clinical manifestation of cystic fibrosis that is seen first is:

Stimulus

Answer

Choice 1 Rectal prolapse.

Rationale 1 Rectal prolapse is a complication of the large, bulky fatty stools.

Answer 1 false

Choice 2 Constipation.

Rationale 2 Constipation is not a symptom of cystic fibrosis.

Answer 2 false

Choice 3 Steatorrheic stools.

Rationale 3Steatorrhea and rectal prolapse might be signs of cystic fibrosis seen in an older infant or child.

Answer 3 false

Choice 4 Meconium ileus.

Rationale 4Newborns with cystic fibrosis might present in the first 48 hours with meconium ileus.

Answer 4 true

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The nurse is teaching the parents of a patient who is newly diagnosed with cystic fibrosis how to administer the pancreatic enzymes. The nurse will advise the parents to administer the enzymes:

Stimulus

Answer

Choice 1 qid (four times daily).

Rationale 1A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

Answer 1 false

Choice 2 bid (twice daily).


Answer 2 false

Choice 3 With meals and snacks.

Rationale 3 Pancreatic enzymes are administered with meals and large snacks.

Answer 3 true

Choice 4 Every six hours around the clock.


Answer 4 false

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A mother of a three-year-old tells the nurse that her child often puts small toys in his mouth and she is concerned about choking. She asks the nurse what she should do if the child chokes. In addition to recommending the mother take a CPR course, the best response by the nurse would be to:

Stimulus

Answer

Choice 1 Show the mother how to do cardiac compressions and rescue breathing.

Rationale 1Cardiac compressions and rescue breathing is not the first thing that the mother needs to know.

Answer 1 false

Choice 2 Recommend the mother perform back blows and chest thrusts.

Rationale 2 This is the treatment for a choking infant, not a child.

Answer 2 false

Choice 3 Teach the mother how to perform abdominal thrusts.

Rationale 3 Giving abdominal thrusts is the correct intervention for a choking child.

Answer 3 true

Choice 4 Tell the mother to do nothing until the child loses consciousness.

Rationale 4The mother should respond to the choking child before the child loses consciousness.

Answer 4

Choice 5

Rationale 5

Answer 5

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A premature infant develops acute respiratory distress syndrome (ARDS). How will the nurse position the baby?

Standard Text Select all that apply.

Stimulus

Answer

Choice 1 Upright

Rationale 1 An infant cannot be placed in an upright position.

Answer 1 false

Choice 2 Semi-Fowler’s position

Rationale 2The semi-Fowler’s position elevates the head of bed. This allows better movement of the diaphragm.

Answer 2 true

Choice 3 Prone position

Rationale 3 Prone positioning will not promote respirations.

Answer 3 false

Choice 4 With his head hyperextended

Rationale 4The head should not be hyperextended as that position does not open the airway in an infant.

Answer 4 false

Choice 5 With his head in a sniffing position

Rationale 5A sniffing position straightens and shortens the airway and is the position that is best.

Answer 5 true

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After a routine vaginal delivery, the infant transitions with the mother in the recovery room without difficulty. Prior to being discharged from the recovery room, it is noted that the infant’s respiratory rate is 102 and the lungs are clear to auscultation. Based on these findings, an appropriate transfer for this infant would be to:

Stimulus

Answer

Choice 1 The newborn nursery for the first bath.

Rationale 1The infant is tachypneic. Bathing will only add to the respiratory distress and should be avoided.

Answer 1 false

Choice 2 The NICU and placed under an over-bed warmer for observation.

Rationale 2This infant needs to remain under constant observation due to the respiratory rate.

Answer 2 true

Choice 3 To the mother’s room to promote bonding with the parents.

Rationale 3 The infant needs to be monitored.

Answer 3 false

Choice 4 The newborn nursery for its first feeding.

Rationale 4With a respiratory rate this high, aspiration is likely so feeding should be avoided.

Answer 4 false

Choice 5

Rationale 5

Answer 5

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Learning Outcome 1:47.4 Assess the child’s respiratory status and analyze the need for oxygen supplementation.

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A two-month-old infant is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent life-threatening event). The physician is to see the infant to write medical orders. The nurse completes the nursing history and performs an assessment and finds no abnormal findings. While waiting on the physician, which activity can the nurse perform independently?

Stimulus

Answer

Choice 1 Place the child on an apnea monitor.

Rationale 1 This is appropriate monitoring of the infant.

Answer 1 true

Choice 2 Place the child on nasal cannula oxygen.

Rationale 2Oxygen is a dependent order except under emergency situations. There is no evidence the child needs oxygen.

Answer 2 false

Choice 3 Draw blood for arterial blood gases.

Rationale 3 Lab tests are not an independent action.

Answer 3 false

Choice 4 Place the child on contact isolation.

Rationale 4There is no indication of a respiratory infection. At this time, contact isolation is not indicated.

Answer 4 false

Choice 5

Rationale 5

Answer 5

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Learning Outcome 1:47.4 Assess the child’s respiratory status and analyze the need for oxygen supplementation.

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An infant was born at 34 weeks’ gestation and is being treated in the NICU for apnea of prematurity. The infant is in an isolette with an apnea monitor and intravenous fluids. The apnea monitor sounds, and the nurse checks the infant to find the infant is not breathing. The initial intervention by the nurse would be to:

Stimulus

Answer

Choice 1 Administer oxygen.

Rationale 1 If the infant is not breathing, oxygen will not help.

Answer 1 false

Choice 2 Perform back blows and chest thrusts.

Rationale 2 This is intervention for choking, not apnea.

Answer 2 false

Choice 3 Call a code.

Rationale 3A code is not the initial response. If the nurse is unable to restart breathing, then a code should be initiated.

Answer 3 false

Choice 4 Stroke the infant’s back.

Rationale 4Tactile stimulation is often sufficient to restart the infant’s respirations. Apnea of prematurity is due to immaturity of the respiratory center.

Answer 4 true

Choice 5

Rationale 5

Answer 5

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A child is being discharged from the hospital following treatment of asthma. Discharge medications include cromolyn sodium (a mast cell stabilizer). Nursing instructions to the parents about this medication would include explaining:

Standard Text Select all that apply.

Stimulus

Answer

Choice 1 The medication works to prevent exacerbations.

Rationale 1This statement is true. Cromolyn Sodium is used to inhibit an asthmatic response to allergens.

Answer 1 true

Choice 2The medication should be administered at the first symptom of an asthmatic attack.

Rationale 2This is incorrect. This medication does not improve the child’s condition during an asthmatic attack.

Answer 2 false

Choice 3 The medication should be taken on a daily basis.

Rationale 3 This is a preventative medication so doses should not be missed.

Answer 3 true

Choice 4 Avoid taking the medication if the child has symptoms of a cold.

Rationale 4 The medication should be taken daily.

Answer 4 false

Choice 5 The medication desensitizes the child against specific allergens.

Rationale 5 This medication does not desensitize the child against allergens.

Answer 5 false

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The nurse stops at the scene of an accident and finds a child conscious but with a sucking wound of the chest. The immediate action by the nurse would be to:

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Answer

Choice 1 Place the child in trendelenburg.

Rationale 1 This would not be the appropriate response to a sucking chest wound.

Answer 1 false

Choice 2 Begin rescue breathing.

Rationale 2 The child is conscious. Rescue breathing is not appropriate at this time.

Answer 2 false

Choice 3 Begin cardiac resuscitation.

Rationale 3 There is no need for cardiac resuscitation at this time.

Answer 3 false

Choice 4 Cover the wound with an air occlusive dressing.

Rationale 4 This prevents more air from entering the chest and is appropriate.

Answer 4 true

Choice 5

Rationale 5

Answer 5

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Learning Outcome 1: 47.8 Develop a home nursing care plan for the child with cystic fibrosis.

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Ch47: Respiratory FXN