QUESTIONS NEWEST VERSION COMPLETE 200
QUESTIONS AND CORRECT DETAILED ANSWERS |A+
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The pediatric nurse is reviewing anatomy and physiology
in order to have a better understanding of the pediatric
respiratory system. The nurse is aware that fluid in the
chest cavity can be normal. Which application of this
knowledge is correct?
1. Pleural fluid is abundant at birth and decreases over the
lifetime.
2. Only enough fluid is present to promote painless
movement.
3. Fluid will accumulate in the plural cavity from immobility.
4. Infections such as pneumonia cause fluid in the plural
cavity. - CORRECT ANSWERANS: 2
This is correct. There are two pleural membranes: one
around the lungs and one covering the inside of the
pleural cavity. The two pleural membranes are normally
separated by only enough fluid to lubricate the surfaces for
painless movement.
Fluid is not abundant in the plural cavity at birth; fluid is in
the lungs at birth. It is suctioned in order to promote
normal respirations. Normal fluid in the pleural cavity does
not decrease over the lifetime.
,Fluid can accumulate in the lungs as a result of immobility.
Pneumonia is an infection that causes fluid to build up in
the lungs.
The nurse in the newborn unit of a pediatric hospital is
providing care for a neonate born at 34 weeks' gestation.
The nurse is aware that the immediate risk to the neonate
is which condition?
1. A lack of a phospholipid in the alveoli
2. Inability to maintain body temperature
3. Delay in closure of cardiac foramen
4. A decrease in renal function - CORRECT ANSWERANS:
1
This is correct. The nurse's immediate concern is related
to respiratory function. A premature neonate is likely to
have a low level of surfactant, which is a phospholipid in
the alveoli that keeps alveoli pliable, preventing them from
collapsing completely at the end of each expiration.
phospholipid in the alveoli that keeps alveoli pliable,
preventing them from collapsing completely at the end of
each expiration. Neonates at any level of maturity can
have delays in the closure of cardiac foramen. The
immediate risk for a premature neonate is the ability to
provide adequate oxygenation. A decrease in renal
function in a premature neonate can be related to poor
oxygenation because of compromised respiratory function.
3. The nurse is providing care for an infant who is 2
months old. Which assessment finding will cause the
nurse to suspect an upper respiratory infection?
1. A raspy cry and occasional cough
,2. Adventitious lung sounds bilaterally
3. A stuffy nose and reddened eardrums
4. A fever, lethargy, and skin pallor - CORRECT
ANSWERANS: 3
The upper respiratory tract is a passageway that includes
the nasopharynx and oropharynx and is connected to the
ears by the eustachian tubes. Because of the stuffy nose
and reddened eardrums, the nurse suspects an upper
respiratory infection. The lungs are part of the lower
respiratory system due to the presence of the terminal
bronchioles, which end in sacs called alveoli. This finding
is indicative of a lower respiratory infection.
A raspy cry results from inflammation of the larynx;
however, an occasional cough is more indicative of
trachea irritation. The manifestations do not necessarily
indicate an upper respiratory infection because structures
of both the upper and lower respiratory tract are involved.
Fever, lethargy, and pallor can be seen in either an upper
or lower respiratory infection.
The nurse is providing care for a school-age patient who
received a head injury while playing sports. Which initial
assessment finding causes the nurse greatest concern?
1. Confusion and disorientation
2. Headache with periods of nausea
3. Immediate loss of consciousness
4. Changes in breathing and heart rates - CORRECT
ANSWERANS 4
Normal breathing is involuntary; the central nervous
system controls rate and volume of respiration.
, Adjustments are made in respiration rate, heart rate, and
cardiac output to maintain adequate gas exchange. The
finding will alert the nurse to either hypoxia in the brain or
injury to the part of the brain that controls respiratory
function. The scenario does not specify an increase or
decrease in the rates.
Confusion and disorientation are common manifestations
of a head injury. This finding does not cause the greatest
concern for the nurse.
Headache and periods of nausea are not uncommon after
a head injury. While initially this finding does not cause the
nurse greatest concern, frequent reassessment is
necessary to identify manifestations of increasing
intracranial pressure.
Immediate loss of consciousness at the time of a head
injury is not uncommon. However, the nurse will continue
to monitor for manifestations of increasing intracranial
pressure.
The pediatric nurse is preparing a teaching plan for new
mothers with small infants. Which is a key point for the
nurse to include in the teaching plan?
1. Infants are obligatory mouth breathers for the first
month.
2. All sinuses are formed and aerating within 2 months of
birth.
3. Infants are abdominal breathers until they are 12
months old.
4. Infant airways get blocked more easily than those in
older children. - CORRECT ANSWERANS 4