NR328 Exam 2 Kahoot!
Question & Rationales
NR328 Exam 2 Kahoot!
https://create.kahoot.it/share/nr-328-peds-exam-2-kahoot/b53c6b5d-a05a-4c6b-b367-
066c3cc5ca4c
1. 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
Rationale: C. 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. Observe
for infection later—especially skin graphs.
2. 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.
Rationale B: 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. Do not forget that
sunlight and bath water can burn an infant—parents should be educated to apply sunscreen to
infants and to turn the hot water heater to it’s lowest setting.
, 3. 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.
Rationale: A. 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. Oral rehydration solution is the most appropriate to give a
child who is ill with acute gastroenteritis.
4. Nurse is assessing an infant with severe dehydration. What assessment findings are
associated? SATA
a. The skin is elastic.
b. There are decreased tears.
c. The capillary refill is 5 seconds.
d. The fontanels are sunken.
Rationale: B, C & D. The 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. Remember assessment
findings that are the opposite of above as well as urine specific gravity and urine output of 1-2
mL/kg/hr are signs that the dehydration is normalizing. Also—blood gas with vomiting?
Diarrhea?
Question & Rationales
NR328 Exam 2 Kahoot!
https://create.kahoot.it/share/nr-328-peds-exam-2-kahoot/b53c6b5d-a05a-4c6b-b367-
066c3cc5ca4c
1. 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
Rationale: C. 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. Observe
for infection later—especially skin graphs.
2. 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.
Rationale B: 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. Do not forget that
sunlight and bath water can burn an infant—parents should be educated to apply sunscreen to
infants and to turn the hot water heater to it’s lowest setting.
, 3. 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.
Rationale: A. 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. Oral rehydration solution is the most appropriate to give a
child who is ill with acute gastroenteritis.
4. Nurse is assessing an infant with severe dehydration. What assessment findings are
associated? SATA
a. The skin is elastic.
b. There are decreased tears.
c. The capillary refill is 5 seconds.
d. The fontanels are sunken.
Rationale: B, C & D. The 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. Remember assessment
findings that are the opposite of above as well as urine specific gravity and urine output of 1-2
mL/kg/hr are signs that the dehydration is normalizing. Also—blood gas with vomiting?
Diarrhea?
