NURS 328 EXAM #2 PRACTICE QUESTIONS
WITH 100% CORRECT ANSWERS
A 10 month old is admitted after receiving a ventriculoperitoneal shunt. Which assessment
would indicate malfunction in this shunt? The infant...
a. cries but quiets when held
b. is irritable and vomiting
c. has an increased abdominal girth
d. has a fontanel that is full and soft
b. is irritable and vomiting
A newborn is being delivered with a known myelomeningocele. The nurse attending the
delivery will perform the following activities. Select all that apply.
a. Sterile saline and gauze dressings
b. Latex free environment
c. NGT to straight drainage
d. Lay the child prone
e. Establish IV access
f. Rectal temperature
a, b, d, and e
A 4 month old infant has a tonic clonic seizure. It is important during this time for the
nurse to do which of the following interventions. Select all that apply.
a. Time and observe the infant's reactions
b. Place an oral airway during the infant's seizure
c. Administer anticonvulsants as ordered
d. Restrain the infant
e. Ensure a bag and mask is at bedside
a, c, and e
A 3 year child ,admitted to the pediatric floor for seizure control, has a generalized tonic-
clonic seizure. The initial action the nurse should perform is:
a. Place child on his side and assess the child.
b. Take off the child's clothes and administer oxygen.
c. Hold the child down and try to communicate with the patient.
d. Call the MD.
a. Place child on his side and assess the child.
,A nurse is expecting a delivery of a baby with myelomeningocele. The nurse is aware that
this defect in comparison to a meningocele is that this infant will have:
a. An open sac over the lumbar area
b. Lower extremity paralysis
c. Infections of the spinal fluid
d. Meningitis
b. Lower extremity paralysis
A 5 month old infant with RSV bronchiolitis is in respiratory distress. The baby has
copious secretions, increased work of breathing, cyanosis, and a respiratory rate of 78.
What is the most appropriate initial nursing intervention?
a. Attempt to calm the infant by placing him in his mother's lap and offering him a bottle.
b. Alert the physician to the situation and ask for an order for a stat chest x-ray.
c. Suction secretions, provide 100% oxygen via mask, and anticipate respiratory failure.
d. Bring the emergency equipment to the room and begin bag-valve-mask ventilation
c. Suction secretions, provide 100% oxygen via mask, and anticipate respiratory failure.
no oral feeds rr over 60
When caring for a child following a tonsillectomy, what should the nurse do?
a. Watch for continuous swallowing.
b. Encourage gargling to reduce discomfort.
c. Position the child on the back for sleeping.
d. Apply warm compresses to the throat.
a. Watch for continuous swallowing.
A 4-year old girl is brought to the ED. She has "froglike" croaking sounds on inspiration,
is agitated, and is drooling. She insists on sitting upright. what should the nurse do?
a. Examine her oral pharynx and report to the physician
b. Make her lie down and rest quietly
c. Auscultate her lungs, and make preparations for placement in a mist tent.
d. Notify the physician immediately and be prepared to assist with a tracheostomy or
intubation
d. Notify the physician immediately and be prepared to assist with a tracheostomy or intubation
Apnea of infancy has been diagnosed in an infant who will soon be discharged with home
monitoring. Which information should the nurse include when teaching the parents about
the infant's care?
,a. Cardiopulmonary resuscitation
b. Importance of adequate fluids
c. Reassurance that the infant cannot be electrocuted during monitoring
d. Advice that the infant not be left with other caretakers, such as babysitters
a. Cardiopulmonary resuscitation
The mother of a 20-month old boy tells the nurse that he has a barking cough at night. His
temperature is 37 degrees C (98.6 F). The nurse suspects croup. What should she
recommend?
a. Control fever with acetaminophen and call if cough gets worse tonight
b. Try a cool-mist vaporizor at night and watch for signs of difficulty breathing
c. Try over-the-counter medicine and come to the clinic tomorrow if no improvement
d. Admit to the hospital and observe for impending epiglottitis
b. Try a cool-mist vaporizor at night and watch for signs of difficulty breathing
A 4-year-old boy needs to use a metered-dose inhaler to treat asthma. He cannot coordinate
the breathing to use it effectively. The nurse should suggest that he use a :
a. spacer
b. nebulizer
c. peak expiratory flowmeter
d. trial of chest physiotherapy
a. spacer
A 7 month old infant is brought into the ER for injuries stemming from a bookcase falling
on her immediately prior to arrival to the hospital. The parents reported the child was
pulling herself up using the bookcase when it toppled over. Which clinical findings would
lead the nurse to suspect child maltreatment? Select all that apply?
a. Crying
b. Hugging the mother tightly.
c. Spiral Fracture of the leg
d. A yellow color bruise on the buttock
c and d
Which order should the nurse question when caring for a 5-year-old child after surgery for
Hirschsprung's disease?
a. Monitor rectal temperature every 4 hours and report an elevation greater than 38.5° C.
b. Assess stools after surgery.
c. Keep the child NPO until bowel sounds return.
d. Maintain IV fluids at ordered rate.
, a. Monitor rectal temperature every 4 hours and report an elevation greater than 38.5° C.
The nurse assesses the neonate immediately after birth. The presence of what symptom
would cause a tracheoesophageal fistula to be suspected?
a. Jaundice
b. Oligohydramnios
c. Absence of sucking
d. Excessive amount of frothy saliva in the mouth
d. Excessive amount of frothy saliva in the mouth
What is the most important information to be included in the discharge planning for an
infant with gastroesophageal reflux?
a. Teach parents to position the infant on the left side.
b. Reinforce the parents' knowledge of the infant's developmental needs.
c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR).
d. Have the parents keep an accurate record of intake and output.
c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR).
What factor indicates that a child has a recently ruptured appendix?
a. Abdominal pain shifts from the left to the right side.
b. Vomiting and diarrhea become more intense.
c. Elevated temperature decreases to normal.
d. Abdominal pain is relieved.
d. Abdominal pain is relieved.
A 5-year-old girl has been sent to the school nurse for urinary incontinence three times in
the past 2 days. The nurse should recommend to her parent that the first action is to have
her daughter evaluated for is:
a. school phobia.
b. emotional causes.
c. possible urinary tract infection.
d. possible structural defects of urinary tract.
c. possible urinary tract infection.
A young child is diagnosed with vesicoureteral reflux (VUR). The nurse should know that
this is usually associated with:
a. incontinence.
b. urinary obstruction.
WITH 100% CORRECT ANSWERS
A 10 month old is admitted after receiving a ventriculoperitoneal shunt. Which assessment
would indicate malfunction in this shunt? The infant...
a. cries but quiets when held
b. is irritable and vomiting
c. has an increased abdominal girth
d. has a fontanel that is full and soft
b. is irritable and vomiting
A newborn is being delivered with a known myelomeningocele. The nurse attending the
delivery will perform the following activities. Select all that apply.
a. Sterile saline and gauze dressings
b. Latex free environment
c. NGT to straight drainage
d. Lay the child prone
e. Establish IV access
f. Rectal temperature
a, b, d, and e
A 4 month old infant has a tonic clonic seizure. It is important during this time for the
nurse to do which of the following interventions. Select all that apply.
a. Time and observe the infant's reactions
b. Place an oral airway during the infant's seizure
c. Administer anticonvulsants as ordered
d. Restrain the infant
e. Ensure a bag and mask is at bedside
a, c, and e
A 3 year child ,admitted to the pediatric floor for seizure control, has a generalized tonic-
clonic seizure. The initial action the nurse should perform is:
a. Place child on his side and assess the child.
b. Take off the child's clothes and administer oxygen.
c. Hold the child down and try to communicate with the patient.
d. Call the MD.
a. Place child on his side and assess the child.
,A nurse is expecting a delivery of a baby with myelomeningocele. The nurse is aware that
this defect in comparison to a meningocele is that this infant will have:
a. An open sac over the lumbar area
b. Lower extremity paralysis
c. Infections of the spinal fluid
d. Meningitis
b. Lower extremity paralysis
A 5 month old infant with RSV bronchiolitis is in respiratory distress. The baby has
copious secretions, increased work of breathing, cyanosis, and a respiratory rate of 78.
What is the most appropriate initial nursing intervention?
a. Attempt to calm the infant by placing him in his mother's lap and offering him a bottle.
b. Alert the physician to the situation and ask for an order for a stat chest x-ray.
c. Suction secretions, provide 100% oxygen via mask, and anticipate respiratory failure.
d. Bring the emergency equipment to the room and begin bag-valve-mask ventilation
c. Suction secretions, provide 100% oxygen via mask, and anticipate respiratory failure.
no oral feeds rr over 60
When caring for a child following a tonsillectomy, what should the nurse do?
a. Watch for continuous swallowing.
b. Encourage gargling to reduce discomfort.
c. Position the child on the back for sleeping.
d. Apply warm compresses to the throat.
a. Watch for continuous swallowing.
A 4-year old girl is brought to the ED. She has "froglike" croaking sounds on inspiration,
is agitated, and is drooling. She insists on sitting upright. what should the nurse do?
a. Examine her oral pharynx and report to the physician
b. Make her lie down and rest quietly
c. Auscultate her lungs, and make preparations for placement in a mist tent.
d. Notify the physician immediately and be prepared to assist with a tracheostomy or
intubation
d. Notify the physician immediately and be prepared to assist with a tracheostomy or intubation
Apnea of infancy has been diagnosed in an infant who will soon be discharged with home
monitoring. Which information should the nurse include when teaching the parents about
the infant's care?
,a. Cardiopulmonary resuscitation
b. Importance of adequate fluids
c. Reassurance that the infant cannot be electrocuted during monitoring
d. Advice that the infant not be left with other caretakers, such as babysitters
a. Cardiopulmonary resuscitation
The mother of a 20-month old boy tells the nurse that he has a barking cough at night. His
temperature is 37 degrees C (98.6 F). The nurse suspects croup. What should she
recommend?
a. Control fever with acetaminophen and call if cough gets worse tonight
b. Try a cool-mist vaporizor at night and watch for signs of difficulty breathing
c. Try over-the-counter medicine and come to the clinic tomorrow if no improvement
d. Admit to the hospital and observe for impending epiglottitis
b. Try a cool-mist vaporizor at night and watch for signs of difficulty breathing
A 4-year-old boy needs to use a metered-dose inhaler to treat asthma. He cannot coordinate
the breathing to use it effectively. The nurse should suggest that he use a :
a. spacer
b. nebulizer
c. peak expiratory flowmeter
d. trial of chest physiotherapy
a. spacer
A 7 month old infant is brought into the ER for injuries stemming from a bookcase falling
on her immediately prior to arrival to the hospital. The parents reported the child was
pulling herself up using the bookcase when it toppled over. Which clinical findings would
lead the nurse to suspect child maltreatment? Select all that apply?
a. Crying
b. Hugging the mother tightly.
c. Spiral Fracture of the leg
d. A yellow color bruise on the buttock
c and d
Which order should the nurse question when caring for a 5-year-old child after surgery for
Hirschsprung's disease?
a. Monitor rectal temperature every 4 hours and report an elevation greater than 38.5° C.
b. Assess stools after surgery.
c. Keep the child NPO until bowel sounds return.
d. Maintain IV fluids at ordered rate.
, a. Monitor rectal temperature every 4 hours and report an elevation greater than 38.5° C.
The nurse assesses the neonate immediately after birth. The presence of what symptom
would cause a tracheoesophageal fistula to be suspected?
a. Jaundice
b. Oligohydramnios
c. Absence of sucking
d. Excessive amount of frothy saliva in the mouth
d. Excessive amount of frothy saliva in the mouth
What is the most important information to be included in the discharge planning for an
infant with gastroesophageal reflux?
a. Teach parents to position the infant on the left side.
b. Reinforce the parents' knowledge of the infant's developmental needs.
c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR).
d. Have the parents keep an accurate record of intake and output.
c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR).
What factor indicates that a child has a recently ruptured appendix?
a. Abdominal pain shifts from the left to the right side.
b. Vomiting and diarrhea become more intense.
c. Elevated temperature decreases to normal.
d. Abdominal pain is relieved.
d. Abdominal pain is relieved.
A 5-year-old girl has been sent to the school nurse for urinary incontinence three times in
the past 2 days. The nurse should recommend to her parent that the first action is to have
her daughter evaluated for is:
a. school phobia.
b. emotional causes.
c. possible urinary tract infection.
d. possible structural defects of urinary tract.
c. possible urinary tract infection.
A young child is diagnosed with vesicoureteral reflux (VUR). The nurse should know that
this is usually associated with:
a. incontinence.
b. urinary obstruction.
