NR 328 Exam #2 Practice Questions |NR 328 CHAMBERLAIN UNIVERSITY-
ILLINOIS
Terms in this set (139)
What factor predisposes an infant to fluid imbalances? Answer: A
a.Immature kidney functioning Rationale: The infant’s kidneys are functionally immature at birth and are inefficient
b.Decreased surface area in excreting waste products of metabolism. Infants have a relatively high body
c. Lower metabolic rate surface area (BSA) compared with adults. This allows a higher loss of fluid to the
d.Decreased daily exchange of extracellular fluid environment. A higher metabolic rate is present as a result of the higher BSA in
relation to active metabolic tissue. The higher metabolic rate increases heat
production, which results in greater insensible water loss. Infants have a greater
exchange of extracellular fluid, leaving them with a reduced fluid reserve in
conditions of dehydration.
What is the required number of milliliters of fluid Answer: A
needed per day for a 14 kg child? Rationale: For the first 10 kg of body weight, a child requires 100 mL/kg. For each
a.1200 additional kilogram of body weight, an extra 50 mL is needed.
b.1100 10 kg ´ 100 mL/kg/day = 1000 mL
c. 1300 4 kg ´ 50 mL/kg/day = 200 mL
d.1400 1000 mL + 200 mL = 1200 ml/day
800 to 1000 mL is too little; 1400 mL is too much.
An infant is brought to the emergency department with Answer: A
the following clinical manifestations: poor skin turgor, Rationale: These clinical manifestations indicate water depletion or dehydration.
weight loss, lethargy, tachycardia, and tachypnea. This Edema and weight gain occur with water excess or over-hydration. Sodium or
is suggestive of which situation? potassium excess would not cause these symptoms.
a. Water depletion
b.Water excess
c. Potassium excess
d.Sodium depletion
,What explains physiologically the edema formation Answer: A
that occurs with burns? Rationale: With a major burn, capillary permeability increases, allowing plasma
a.Increased capillary permeability proteins, fluids, and electrolytes to be lost into the interstitial space, causing
b.Decreased capillary permeability edema. Maximum edema in a small wound occurs about 8 to 12 hr after injury. In
c.Vasoconstriction larger injuries, the maximum edema may not occur until 18 to 24 hr later.
d.Diminished hydrostatic pressure within capillaries Vasodilation occurs, causing an increase in hydrostatic pressure.
What is the most immediate threat to life in children Answer: A
with thermal injuries? Rationale: The immediate threat to life in children with thermal injuries is airway
a.Shock compromise and profound shock. Anemia is not of immediate concern. During the
b.Anemia healing phase, local infection or sepsis is the primary complication.
c. Local infection
d.Systemic sepsis
After the acute stage and during the healing process, Answer: A
what is the primary complication from burn injury? Rationale: During the healing phase, local infection or sepsis is the primary
a.Infection complication. Respiratory problems, primarily airway compromise, and shock are
b. Shock the primary complications during the acute stage of burn injury. Renal shutdown is
c. Renal shutdown not a complication of the burn injury but may be a result of the profound shock.
d.Asphyxia
What finding is the most reliable guide to the adequacy Answer: A
of fluid replacement for a small child with burns? Rationale: Replacement fluid therapy is delivered to provide a urinary output of
a.Urinary output of 1 to 2 mL/kg of body weight/hr 30 mL/hr in older children or 1 to 2 mL/kg of body weight/hr for children weighing
b.Increased seepage from burn wound less than 30 kg (66 pounds). Thirst is the result of a complex set of interactions and
c. Falling hematocrit is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling
d.Absence of thirst hematocrit would be indicative of hemodilution. This may reflect fluid shifts and
may not accurately represent fluid replacement therapy. Increased seepage
from a burn wound would be indicative of increased output, not adequate
hydration.
What intervention is contraindicated in a suspected Answer: A
case of appendicitis? Rationale: In any instance in which severe abdominal pain is observed and
a.Enemas appendicitis is suspected, the nurse must be aware of the danger of administering
b.Palpating the abdomen laxatives or enemas. Such measures stimulate bowel motility and increase the risk
c.Administration of antibiotics of perforation. The abdomen is palpated after other assessments are made.
d.Administration of antipyretics for fever Antibiotics should be administered, and antipyretics are not contraindicated.
An infant had a gastrostomy tube placed for feedings Answer: A
after a Nissen fundoplication and bolus feedings are Rationale: If bolus feedings are initiated through a gastrostomy after a
Nissen initiated. Between feedings while the tube is clamped, fundoplication, the tube may need to remain vented for several
days or longer to the infant becomes irritable, and there is evidence of avoid gastric distention from swallowed air. Edema
surrounding the surgical site cramping. What action should the nurse implement? and a tight gastric wrap may prohibit the
infant from expelling air through the
a. Vent the gastrostomy tube. esophagus, so burping does not relieve the
distention. Some infants benefit from
b.Withhold the next feeding. clamping of the tube for increasingly longer intervals until they are able to tolerate
c. Burp the infant. continuous clamping between feedings. During this time, if the infant displays
d.Notify the health care provider. increasing irritability and evidence of cramping, some relief may be provided by
venting the tube. The next feeding should not be withheld, and calling the
health care provider is not necessary.
, The nurse should instruct parents to administer a daily Answer: A
proton pump inhibitor to their child with Rationale: Proton pump inhibitors are most effective when administered 30
gastroesophageal reflux at which time? minutes before breakfast so that the peak plasma concentrations occur with
a.30 minutes before breakfast mealtime. If they are given twice a day, the second best time for administration is 30
b. Midmorning minutes before the evening meal.
c. Bedtime
d.With a meal
The nurse is assisting a child with celiac disease to Answer: A
select foods from a menu. What foods should the nurse Rationale: Treatment of celiac disease consists primarily of dietary management.
suggest? Although a gluten-free diet is prescribed, it is difficult to remove every source of
a.Corn on the cob with butter this protein. Some patients are able to tolerate restricted amounts of gluten.
b.Hamburger on a bun Because gluten occurs mainly in the grains of wheat and rye but also in smaller
c. Spaghetti with meat sauce quantities in barley and oats, these foods are eliminated. Corn, rice, and millet are
d.Peanut butter and crackers substitute grain foods. Corn on the cob with butter would be gluten free.
An infant is born with a gastroschisis. Care Answer: A
preoperatively should include which priority Rationale: Initial management of a gastroschisis involves covering the exposed
intervention? bowel with a transparent plastic bowel bag or loose, moist dressings. The infant
a.Covering the defect with a sterile bowel bag cannot be placed prone, and feedings will be withheld until surgery is performed.
b.Monitoring serum laboratory electrolytes Electrolyte laboratory values will be monitored but not before covering the defect
c. Sterile water feedings with a sterile bowel bag.
d. Prone position
A 3-day-old infant presents with abdominal distention, Answer: A
is vomiting, and has not passed any meconium stools. Rationale: The clinical manifestations of Hirschsprung disease in a 3-day-old
What disease should the nurse suspect? infant include abdominal distention, vomiting, and failure to pass meconium stools.
a.Hirschsprung disease Pyloric stenosis would present with vomiting but not distention or failure to pass
b. Intussusception meconium stools. Intussusception presents with abdominal cramping and celiac
c. Celiac disease disease presents with malabsorption.
d. Pyloric stenosis
The parents of a newborn with an umbilical hernia ask Answer: A
about treatment options. The nurse’s response should Rationale: The umbilical hernia usually resolves by ages 3 to 5 years of age
be based on which knowledge? without intervention. Umbilical hernias rarely become problematic. Incarceration,
a. The defect usually resolves spontaneously by 3 to 5 where the hernia
is constricted and cannot be reduced manually, is rare. Umbilical years of age. hernias are not associated with a high mortality rate.
Taping the abdomen flat does
b.Surgery is recommended as soon as possible. not help heal the hernia; it can cause skin irritation.
c.Aggressive treatment is necessary to reduce its
high mortality.
d.Taping the abdomen to flatten the protrusion
is sometimes helpful.
A child with pyloric stenosis is having excessive Answer: A
vomiting. The nurse should assess for what potential Rationale: Infants with excessive vomiting are prone to metabolic alkalosis from
complication? the loss of hydrogen ions. Potassium and chloride ions are lost with vomiting.
a.Metabolic alkalosis Metabolic alkalosis, not acidosis, is likely.
b. Metabolic acidosis
c. Hyperchloremia
d. Hyperkalemia
ILLINOIS
Terms in this set (139)
What factor predisposes an infant to fluid imbalances? Answer: A
a.Immature kidney functioning Rationale: The infant’s kidneys are functionally immature at birth and are inefficient
b.Decreased surface area in excreting waste products of metabolism. Infants have a relatively high body
c. Lower metabolic rate surface area (BSA) compared with adults. This allows a higher loss of fluid to the
d.Decreased daily exchange of extracellular fluid environment. A higher metabolic rate is present as a result of the higher BSA in
relation to active metabolic tissue. The higher metabolic rate increases heat
production, which results in greater insensible water loss. Infants have a greater
exchange of extracellular fluid, leaving them with a reduced fluid reserve in
conditions of dehydration.
What is the required number of milliliters of fluid Answer: A
needed per day for a 14 kg child? Rationale: For the first 10 kg of body weight, a child requires 100 mL/kg. For each
a.1200 additional kilogram of body weight, an extra 50 mL is needed.
b.1100 10 kg ´ 100 mL/kg/day = 1000 mL
c. 1300 4 kg ´ 50 mL/kg/day = 200 mL
d.1400 1000 mL + 200 mL = 1200 ml/day
800 to 1000 mL is too little; 1400 mL is too much.
An infant is brought to the emergency department with Answer: A
the following clinical manifestations: poor skin turgor, Rationale: These clinical manifestations indicate water depletion or dehydration.
weight loss, lethargy, tachycardia, and tachypnea. This Edema and weight gain occur with water excess or over-hydration. Sodium or
is suggestive of which situation? potassium excess would not cause these symptoms.
a. Water depletion
b.Water excess
c. Potassium excess
d.Sodium depletion
,What explains physiologically the edema formation Answer: A
that occurs with burns? Rationale: With a major burn, capillary permeability increases, allowing plasma
a.Increased capillary permeability proteins, fluids, and electrolytes to be lost into the interstitial space, causing
b.Decreased capillary permeability edema. Maximum edema in a small wound occurs about 8 to 12 hr after injury. In
c.Vasoconstriction larger injuries, the maximum edema may not occur until 18 to 24 hr later.
d.Diminished hydrostatic pressure within capillaries Vasodilation occurs, causing an increase in hydrostatic pressure.
What is the most immediate threat to life in children Answer: A
with thermal injuries? Rationale: The immediate threat to life in children with thermal injuries is airway
a.Shock compromise and profound shock. Anemia is not of immediate concern. During the
b.Anemia healing phase, local infection or sepsis is the primary complication.
c. Local infection
d.Systemic sepsis
After the acute stage and during the healing process, Answer: A
what is the primary complication from burn injury? Rationale: During the healing phase, local infection or sepsis is the primary
a.Infection complication. Respiratory problems, primarily airway compromise, and shock are
b. Shock the primary complications during the acute stage of burn injury. Renal shutdown is
c. Renal shutdown not a complication of the burn injury but may be a result of the profound shock.
d.Asphyxia
What finding is the most reliable guide to the adequacy Answer: A
of fluid replacement for a small child with burns? Rationale: Replacement fluid therapy is delivered to provide a urinary output of
a.Urinary output of 1 to 2 mL/kg of body weight/hr 30 mL/hr in older children or 1 to 2 mL/kg of body weight/hr for children weighing
b.Increased seepage from burn wound less than 30 kg (66 pounds). Thirst is the result of a complex set of interactions and
c. Falling hematocrit is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling
d.Absence of thirst hematocrit would be indicative of hemodilution. This may reflect fluid shifts and
may not accurately represent fluid replacement therapy. Increased seepage
from a burn wound would be indicative of increased output, not adequate
hydration.
What intervention is contraindicated in a suspected Answer: A
case of appendicitis? Rationale: In any instance in which severe abdominal pain is observed and
a.Enemas appendicitis is suspected, the nurse must be aware of the danger of administering
b.Palpating the abdomen laxatives or enemas. Such measures stimulate bowel motility and increase the risk
c.Administration of antibiotics of perforation. The abdomen is palpated after other assessments are made.
d.Administration of antipyretics for fever Antibiotics should be administered, and antipyretics are not contraindicated.
An infant had a gastrostomy tube placed for feedings Answer: A
after a Nissen fundoplication and bolus feedings are Rationale: If bolus feedings are initiated through a gastrostomy after a
Nissen initiated. Between feedings while the tube is clamped, fundoplication, the tube may need to remain vented for several
days or longer to the infant becomes irritable, and there is evidence of avoid gastric distention from swallowed air. Edema
surrounding the surgical site cramping. What action should the nurse implement? and a tight gastric wrap may prohibit the
infant from expelling air through the
a. Vent the gastrostomy tube. esophagus, so burping does not relieve the
distention. Some infants benefit from
b.Withhold the next feeding. clamping of the tube for increasingly longer intervals until they are able to tolerate
c. Burp the infant. continuous clamping between feedings. During this time, if the infant displays
d.Notify the health care provider. increasing irritability and evidence of cramping, some relief may be provided by
venting the tube. The next feeding should not be withheld, and calling the
health care provider is not necessary.
, The nurse should instruct parents to administer a daily Answer: A
proton pump inhibitor to their child with Rationale: Proton pump inhibitors are most effective when administered 30
gastroesophageal reflux at which time? minutes before breakfast so that the peak plasma concentrations occur with
a.30 minutes before breakfast mealtime. If they are given twice a day, the second best time for administration is 30
b. Midmorning minutes before the evening meal.
c. Bedtime
d.With a meal
The nurse is assisting a child with celiac disease to Answer: A
select foods from a menu. What foods should the nurse Rationale: Treatment of celiac disease consists primarily of dietary management.
suggest? Although a gluten-free diet is prescribed, it is difficult to remove every source of
a.Corn on the cob with butter this protein. Some patients are able to tolerate restricted amounts of gluten.
b.Hamburger on a bun Because gluten occurs mainly in the grains of wheat and rye but also in smaller
c. Spaghetti with meat sauce quantities in barley and oats, these foods are eliminated. Corn, rice, and millet are
d.Peanut butter and crackers substitute grain foods. Corn on the cob with butter would be gluten free.
An infant is born with a gastroschisis. Care Answer: A
preoperatively should include which priority Rationale: Initial management of a gastroschisis involves covering the exposed
intervention? bowel with a transparent plastic bowel bag or loose, moist dressings. The infant
a.Covering the defect with a sterile bowel bag cannot be placed prone, and feedings will be withheld until surgery is performed.
b.Monitoring serum laboratory electrolytes Electrolyte laboratory values will be monitored but not before covering the defect
c. Sterile water feedings with a sterile bowel bag.
d. Prone position
A 3-day-old infant presents with abdominal distention, Answer: A
is vomiting, and has not passed any meconium stools. Rationale: The clinical manifestations of Hirschsprung disease in a 3-day-old
What disease should the nurse suspect? infant include abdominal distention, vomiting, and failure to pass meconium stools.
a.Hirschsprung disease Pyloric stenosis would present with vomiting but not distention or failure to pass
b. Intussusception meconium stools. Intussusception presents with abdominal cramping and celiac
c. Celiac disease disease presents with malabsorption.
d. Pyloric stenosis
The parents of a newborn with an umbilical hernia ask Answer: A
about treatment options. The nurse’s response should Rationale: The umbilical hernia usually resolves by ages 3 to 5 years of age
be based on which knowledge? without intervention. Umbilical hernias rarely become problematic. Incarceration,
a. The defect usually resolves spontaneously by 3 to 5 where the hernia
is constricted and cannot be reduced manually, is rare. Umbilical years of age. hernias are not associated with a high mortality rate.
Taping the abdomen flat does
b.Surgery is recommended as soon as possible. not help heal the hernia; it can cause skin irritation.
c.Aggressive treatment is necessary to reduce its
high mortality.
d.Taping the abdomen to flatten the protrusion
is sometimes helpful.
A child with pyloric stenosis is having excessive Answer: A
vomiting. The nurse should assess for what potential Rationale: Infants with excessive vomiting are prone to metabolic alkalosis from
complication? the loss of hydrogen ions. Potassium and chloride ions are lost with vomiting.
a.Metabolic alkalosis Metabolic alkalosis, not acidosis, is likely.
b. Metabolic acidosis
c. Hyperchloremia
d. Hyperkalemia
