NR 328 Exam #2 Practice Questions

What factor predisposes an infant to fluid imbalances? a. Immature kidney functioning b. Decreased surface area c. Lower metabolic rate d. Decreased daily exchange of extracellular fluid Answer: A Rationale: The infant’s kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the 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 needed per day for a 14 kg child? a. 1200 b. 1100 c. 1300 d. 1400 Answer: A Rationale: For the first 10 kg of body weight, a child requires 100 mL/kg. For each additional kilogram of body weight, an extra 50 mL is needed. 10 kg ´ 100 mL/kg/day = 1000 mL 4 kg ´ 50 mL/kg/day = 200 mL 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 the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation? a. Water depletion b. Water excess c. Potassium excess d. Sodium depletion Answer: A Rationale: These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or over-hydration. Sodium or potassium excess would not cause these symptoms. What explains physiologically the edema formation that occurs with burns? a. Increased capillary permeability b. Decreased capillary permeability c. Vasoconstriction d. Diminished hydrostatic pressure within capillaries Answer: A Rationale: With a major burn, capillary permeability increases, allowing plasma proteins, fluids, and electrolytes to be lost into the interstitial space, causing edema. Maximum edema in a small wound occurs about 8 to 12 hr after injury. In larger injuries, the maximum edema may not occur until 18 to 24 hr later. Vasodilation occurs, causing an increase in hydrostatic pressure. What is the most immediate threat to life in children with thermal injuries? a. Shock b. Anemia c. Local infection d. Systemic sepsis Answer: A Rationale: The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis is the primary complication. After the acute stage and during the healing process, what is the primary complication from burn injury? a. Infection b. Shock c. Renal shutdown d. Asphyxia Answer: A Rationale: During the healing phase, local infection or sepsis is the primary complication. Respiratory problems, primarily airway compromise, and shock are the primary complications during the acute stage of burn injury. Renal shutdown is not a complication of the burn injury but may be a result of the profound shock. What finding is the most reliable guide to the adequacy of fluid replacement for a small child with burns? a. Urinary output of 1 to 2 mL/kg of body weight/hr b. Increased seepage from burn wound c. Falling hematocrit d. Absence of thirst Answer: A Rationale: Replacement fluid therapy is delivered to provide a urinary output of 30 mL/hr in older children or 1 to 2 mL/kg of body weight/hr for children weighing less than 30 kg (66 pounds). Thirst is the result of a complex set of interactions and is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling 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 case of appendicitis? a. Enemas b. Palpating the abdomen c. Administration of antibiotics d. Administration of antipyretics for fever Answer: A Rationale: In any instance in which severe abdominal pain is observed and appendicitis is suspected, the nurse must be aware of the danger of administering laxatives or enemas. Such measures stimulate bowel motility and increase the risk of perforation. The abdomen is palpated after other assessments are made. Antibiotics should be administered, and antipyretics are not contraindicated. An infant had a gastrostomy tube placed for feedings after a Nissen fundoplication and bolus feedings are initiated. Between feedings while the tube is clamped, the infant becomes irritable, and there is evidence of cramping. What action should the nurse implement? a. Vent the gastrostomy tube. b. Withhold the next feeding. c. Burp the infant. d. Notify the health care provider. Answer: A Rationale: If bolus feedings are initiated through a gastrostomy after a Nissen fundoplication, the tube may need to remain vented for several days or longer to avoid gastric distention from swallowed air. Edema surrounding the surgical site and a tight gastric wrap may prohibit the infant from expelling air through the esophagus, so burping does not relieve the distention. Some infants benefit from clamping of the tube for increasingly longer intervals until they are able to tolerate continuous clamping between feedings. During this time, if the infant displays 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 proton pump inhibitor to their child with gastroesophageal reflux at which time? a. 30 minutes before breakfast b. Midmorning c. Bedtime d. With a meal Answer: A Rationale: Proton pump inhibitors are most effective when administered 30 minutes before breakfast so that the peak plasma concentrations occur with mealtime. If they are given twice a day, the second best time for administration is 30 minutes before the evening meal. The nurse is assisting a child with celiac disease to select foods from a menu. What foods should the nurse suggest? a. Corn on the cob with butter b. Hamburger on a bun c. Spaghetti with meat sauce d. Peanut butter and crackers Answer: A Rationale: Treatment of celiac disease consists primarily of dietary management. Although a gluten-free diet is prescribed, it is difficult to remove every source of this protein. Some patients are able to tolerate restricted amounts of gluten. Because gluten occurs mainly in the grains of wheat and rye but also in smaller quantities in barley and oats, these foods are eliminated. Corn, rice, and millet are substitute grain foods. Corn on the cob with butter would be gluten free. An infant is born with a gastroschisis. Care preoperatively should include which priority intervention? a. Covering the defect with a sterile bowel bag b. Monitoring serum laboratory electrolytes c. Sterile water feedings d. Prone position Answer: A Rationale: Initial management of a gastroschisis involves covering the exposed bowel with a transparent plastic bowel bag or loose, moist dressings. The infant cannot be placed prone, and feedings will be withheld until surgery is performed. Electrolyte laboratory values will be monitored but not before covering the defect with a sterile bowel bag. A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed any meconium stools. What disease should the nurse suspect? a. Hirschsprung disease b. Intussusception c. Celiac disease d. Pyloric stenosis Answer: A Rationale: The clinical manifestations of Hirschsprung disease in a 3-day-old infant include abdominal distention, vomiting, and failure to pass meconium stools. Pyloric stenosis would present with vomiting but not distention or failure to pass meconium stools. Intussusception presents with abdominal cramping and celiac disease presents with malabsorption. The parents of a newborn with an umbilical hernia ask about treatment options. The nurse’s response should be based on which knowledge? a. The defect usually resolves spontaneously by 3 to 5 years of age. b. Surgery is recommended as soon as possible. c. Aggressive treatment is necessary to reduce its high mortality. d. Taping the abdomen to flatten the protrusion is sometimes helpful. Answer: A Rationale: The umbilical hernia usually resolves by ages 3 to 5 years of age without intervention. Umbilical hernias rarely become problematic. Incarceration, where the hernia is constricted and cannot be reduced manually, is rare. Umbilical hernias are not associated with a high mortality rate. Taping the abdomen flat does not help heal the hernia; it can cause skin irritation. A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication? a. Metabolic alkalosis b. Metabolic acidosis c. Hyperchloremia d. Hyperkalemia Answer: A Rationale: Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Potassium and chloride ions are lost with vomiting. Metabolic alkalosis, not acidosis, is likely. When caring for a child with probable appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation? a. Sudden relief from pain b. Anorexia c. Bradycardia d. Decreased abdominal distention Answer: A Rationale: Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Anorexia is already a clinical manifestation of appendicitis. Tachycardia, not bradycardia, is a manifestation of peritonitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen). A child is admitted with acute glomerulonephritis. What should the nurse expect the urinalysis during this acute phase to show? a. Hematuria and proteinuria b. Bacteriuria and hematuria c. Bacteriuria and increased specific gravity d. Proteinuria and decreased specific gravity Answer: A Rationale: Urinalysis during the acute phase characteristically shows hematuria, proteinuria, and increased specific gravity. Proteinuria generally parallels the hematuria but is not usually the massive proteinuria seen in nephrotic syndrome. Gross discoloration of urine reflects its red blood cell and hemoglobin content. Microscopic examination of the sediment shows many red blood cells, leukocytes, epithelial cells, and granular and red blood cell casts. Bacteria are not seen, and urine culture results are negative. The nurse is teaching the parents of preschoolers about preventing urinary tract infections (UTIs). What strategies should the nurse instruct the parents to use to prevent UTIs? (Select all that apply). a. "Ensure that your children evacuate their bowels regularly." b. "Encourage your children to drink 6 to 8 glasses of water each day." c. "Give cranberry juice to your children on a regular basis." d. "Put a diaper on your child overnight." e. "Do not allow your children to urinate in public toilets." Answers: A, B A 6-year-old child with Nephrotic Syndrome is being transferred out of the intensive care unit. Which child, in light of this diagnosis, is the most appropriate roommate for this child? a. 5-year-old child with a fractured femur b. 6-year-old child with pneumonia c. 4-year-old child with gastroenteritis d. 7-year-old child who has undergone surgery for a ruptured appendix Answer: A Rationale: The 5-year-old orthopedic patient is the best choice of roommate. This child does not have an illness of viral or bacterial origin. A child with pneumonia or gastroenteritis has an illness of viral or bacterial origin and should not be placed in the same room as a child with Nephrotic Syndrome. A child who has had surgery for a ruptured appendix may have an illness of viral or bacterial origin and should not be placed in the same room as a child with Nephrotic Syndrome. What is the best method of assessing dehydration in a toddler? a. Accurate measurements of fluid intake and output b. Assessing the fontanels c. Weighing the child daily at different times d. Checking the intravenous infusion site for signs of infiltration Answer: A Rationale: The priority nursing intervention for assessing dehydration in a child is recording of accurate measurements of fluid intake and output, including oral and parenteral intake and losses from urine, stools, vomiting, fistulas, nasogastric suction, sweat, and wound drainage. Assessing fontanels for bulging is an indicator of dehydration in infants, not toddlers. Weighing the child at the same time each day is more helpful than weighing the child at varying times. Monitoring the intravenous infusion site does not provide the nurse with assessment data that will reveal dehydration. Nurse is caring for a 3-yo who is the victim of a house fire. Child has burns to the face & head. What is priority? a. Nutritional b. Cardiac c. Respiratory d. Neurologic Answer: C Rationale: The primary emphasis during the emergent phase is the treatment of burn shock and the management of pulmonary status since respiratory obstruction poses the biggest threat to the patient’s life. Monitoring vital signs, output, fluid infusion, and respiratory parameters are ongoing activities in the hours immediately after injury. Following assessment of the patient’s airway, the nurse can assess the patient’s nutritional, cardiac, and neurologic statuses. Baby sustained minor oral burns from drinking hot milk that had been warmed in a microwave for 3 mins. Teaching needs? a. Warm the milk in the microwave only for 1 minute. b. Never use a microwave for warming milk. c. Provide only chilled milk to the baby to avoid oral burns. d. Warm the milk in the microwave for 30 seconds only. Answer: B Rationale: Parents should be advised that they should never thaw or rewarm expressed milk in a microwave because it can cause uneven warming of milk and result in oral burns. They should be advised to thaw the frozen milk by either placing it in lukewarm water. A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solution (ORS). The child's mother calls the clinic nurse because the child is also occasionally vomiting. What should the nurse recommend? a. Continuing to give ORS frequently in small amounts. b. Alternating ORS and carbonated drinks. c. Bringing the child to the hospital for intravenous fluids. d. Institute NPO status for the child for 8 hrs & resume ORS if no vomiting. Answer: A Rationale: Vomiting is not a contraindication to the use of oral rehydration solution (ORS) unless it is severe. The mother should continue to give the ORS in small amounts and at frequent intervals. For a school-age child with mild dehydration, rehydration can be safely done at home with the use of oral solutions. Carbonated drinks should not be used; they may have a high carbohydrate content and contain caffeine, which is a diuretic and could exacerbate fluid loss and dehydration. Nothing-by-mouth (NPO) status is not indicated. Administration of small, frequent amounts of ORS is recommended. Nurse is assessing an infant with severe dehydration. What assessment findings are associated? SATA a. The skin has decreased turgor. b. There are decreased tears. c. The capillary refill is 5 seconds. d. The fontanels are sunken. Answers: B, C, D Rationale: he infant with severe dehydration has poor peripheral circulation and delayed capillary refill due to reduced blood volume. The capillary refill is delayed to more than 4 seconds. The skin appears acrocyanotic or mottled with tenting. The child has hyperpnea, or deep and rapid respiration, as a result of poor oxygenation. Physical examination of the eyes reveals sunken eyes with absence of tears. The fontanels will be sunken. What is the best method of assessing dehydration in a toddler? a. Assessing the fontanels b. Weighing the child daily at different times c. Checking the intravenous infusion site for signs of infiltration d. Accurate measurements of fluid intake and output Answer: D Rationale: The priority nursing intervention for assessing dehydration in a child is recording of accurate measurements of fluid intake and output, including oral and parenteral intake and losses from urine, stools, vomiting, fistulas, nasogastric suction, sweat, and wound drainage. Assessing fontanels for bulging is an indicator of dehydration in infants, not toddlers. Weighing the child at the same time each day is more helpful than weighing the child at varying times. Monitoring the intravenous infusion site does not provide the nurse with assessment data that will reveal dehydration. The nurse is teaching the parents of preschoolers about preventing urinary tract infections (UTIs). What strategies should the nurse instruct the parents to use to prevent UTIs? Select all that apply. a. "Give cranberry juice to your children on a regular basis." b. "Do not allow your children to urinate in public toilets." c. "Encourage your children to drink 6 to 8 glasses of water each day." d. "Ensure that your children evacuate their bowels regularly." Answer: C, D Rationale: Drinking adequate amounts of water promotes flushing of the normal bladder and lowers the concentration of pathogens in the bladder. It also helps enhance the antibacterial properties of the renal medulla. Constipation can cause bladder obstruction and increase the risk of UTI. Thus, the parents must ensure that the children clear their bowels regularly. Much has been reported about the use of cranberry products for prevention of UTI. Initially it was thought to alter the urine acidity, but studies have not shown that ingestion results in a lower pH; but instead it appeared to decrease the adherence of certain bacteria to the bladder wall. Recent review of the literature showed that cranberry products did not significantly reduce the occurrence of symptomatic UTI overall or in any of the subgroups, including children. Because the benefit is small, cranberry juice cannot currently be recommended for prevention of UTIs. Other cranberry preparations need to be quantified using standardized methods to ensure the potency before being evaluated in clinical studies or recommended for use. If the child is outside the home and has a desire to void, the child should be allowed to use the public toilets, because holding urine in the bladder for a long time can increase the risk of UTI. Nephrotic syndrome is a clinical state that includes hypoalbuminemia, hyperlipidemia, and what? a. Creatine and edema b. Proteinuria and edema c. Uric acid and edema d. Blood urea nitrogen and proteinuria Answer: B Rationale: Nephrotic syndrome is a clinical state that includes massive proteinuria, hypoalbuminemia, hyperlipidemia, and edema. True or False: A daily weight is not indicated in a child with Nephrotic Syndrome. Answer: False Rationale: A daily weight taken at the same time every day, with the child wearing the same clothing, is the most accurate way to determine fluid gains and losses. The parent of a child hospitalized with acute glomerulonephritis (AGN) asks the nurse why blood pressure readings are being taken so often. What is the most appropriate response by the nurse, drawing on knowledge of AGN? a. Acute hypertension must be anticipated and identified. b. Hypotension leading to sudden shock can develop at any time. c. Blood pressure fluctuations are a common side effect of antibiotic therapy. d. Blood pressure fluctuations are a sign that the condition has become chronic. Answer: A Rationale: Vital signs, in particular the blood pressure, provide information about the severity of acute glomerular nephritis (AGN) and early signs of complications. Acute hypertension is anticipated and requires frequent monitoring for early intervention. Blood pressure does not commonly fluctuate with antibiotic therapy. Blood pressure fluctuations are not indicative of chronic disease. Most children with AGN fully recover. Hypertension, not hypotension, is more likely with AGN. After reviewing the laboratory reports of a patient with acute glomerulonephritis, the nurse ensures that the patient is on a low-potassium diet. What is the reason for this intervention? a. The patient has oliguria. b. The patient has proteinuria. c. The patient has hypertension. d. The patient has chronic inflammation. Answer: A Rationale: The patient with acute glomerulonephritis with oliguria will be at risk for hyperkalemia, an increase in serum potassium level. Therefore, the nurse ensures that the patient has low-potassium diet. The patient with acute glomerulonephritis may have proteinuria, but will be on a protein-restricted diet instead of a low-potassium diet. The patient with hypertension will be prescribed a sodium-restricted diet, because sodium increases blood pressure. The patient with chronic inflammation may be on a low-sugar and a fat-free diet. What are some clinical manifestations of gastroesophageal reflux in infants? Select all that apply. a. Spitting up b. Failure to thrive c. Chronic cough d. Excessive crying and arching of the back Answers: A, B, D Rationale: Clinical manifestations of gastroesophageal reflux in infants include spitting up, excessive crying and arching of the back, and failure to thrive. Heartburn and chronic cough are symptoms of gastroesophageal reflux in children, not infants. What should the nurse teach the parents about caring for the infant with gastroesophageal reflux (GER)? a. Place the infant supine after feeding. b. Feed the infant just before bedtime. c. Place the infant on the side to sleep. d. Avoid vigorous play after feedings. Answer: D Rationale: Parents should avoid vigorous play with the infant after feedings to prevent regurgitation. The head of the bed may be raised to 30 degrees after feedings to prevent discomfort and regurgitation. Parents must avoid feeding the infant just before bedtime to avoid GER. The infant must not be positioned on the side to sleep. The Task Force on Sudden Infant Death Syndrome recommends that the infant be placed in the supine position when sleeping. As the infant ages foods to avoid are: citrus, fatty foods, peppermint. What care must the nurse take when obtaining abdominal measurements for a child with Hirschsprung disease? a. Obtain abdominal circumference just above the umbilicus. b. Mark the point of measurement on the abdomen with a pen. c. Obtain and document the measurement once a day. d. Remove the tape after each measurement is recorded. Answer: B Rationale: Distention of the abdomen is a serious sign in the child with Hirschsprung disease. The nurse must obtain the abdominal circumference with a paper tape measure. The abdomen must be marked with a pen at the point of measurement to maintain reliability of later measurements. Abdominal circumference is usually taken at the level of the umbilicus or the widest part of the abdomen. This measurement must be obtained with the vital sign measurements and is recorded in a serial order so that any change is evident. When frequent measurements are needed, the tape is left in place beneath the child to reduce the stress each time it is removed. Remember to teach the parents of the child that has surgery with a colostomy that the colostomy is usually reversible.