ENPC FINAL EXAM QUESTIONS AND ANSWERS
VERIFIED 100% CORRECT
Cardiopulmonary resuscitation (CPR) is in progress on an 8-year-old boy who is in
shock. Which is the priority nursing intervention?
a) Using a large bore catheter for peripheral venous access
b) Inserting an indwelling urinary catheter to measure urine output
c) Attaining central venous access via the femoral route
d) Drawing a blood sample for arterial blood gas analysis - ANSWER- Attaining
central venous access via the femoral route Correct Explanation:
Attaining central venous access is the priority intervention for a child in shock who
is receiving respiratory support. Gaining access via the femoral route will not
interfere with CPR efforts. Peripheral venous access may be unattainable in
children who have significant vascular compromise. Blood samples and urinary
catheter placement can wait until fluid is administered.
A 13-year-old boy has had a near-drowning experience. The nurse notices he has
labored breathing and a cough. Which of the following is the priority intervention?
a) Provide sedation as ordered.
b) Check his capillary refill time.
c) Administer 100% oxygen by mask.
d) Have the child sit up straight in a chair. - ANSWER- Administer 100% oxygen
by mask. Explanation:
Management of the near-drowning victim focuses on assessing his airway,
breathing, and circulation (ABCs) and correcting hypoxemia. Administering
oxygen is the primary intervention to assist breathing. It is best to let the child
assume the most comfortable position for him. Checking capillary refill time helps
determine ineffective tissue perfusion. Providing sedation is an intervention for
pain that will be assessed after effective breathing is established.
An 8-year-old girl with tachycardia is alert, breathing comfortably, and exhibiting
signs of adequate tissue perfusion. Which nursing intervention would be most
appropriate for this child?
,a) Administering epinephrine as ordered
b) Oxygenating and ventilating the child
c) Applying ice to the child's face
d) Initiating cardiac compressions - ANSWER- Applying ice to the child's face
Explanation:
The child is exhibiting compensated supraventricular tachycardia (SVT). Vagal
maneuvers such as ice to the face or blowing through a straw that is obstructed are
priority interventions for compensated SVT. Oxygenating and ventilating the child
as ordered are interventions for bradycardia. Epinephrine is given for bradycardia.
Initiating cardiac compressions is the priority intervention for collapsed (pulseless)
rhythms.
Which of the following nursing diagnoses would be appropriate for teaching
interventions for a single mother who leaves her toddler unattended in the bathtub?
a) Risk for Falls
b) Risk for Imbalanced Body Temperature
c) Noncompliance
d) Risk for Suffocation - ANSWER- Risk for Suffocation Correct Explanation:
Death from drowning occurs from suffocation. Nearly half of all drowning victims
are children under the age of 5. Most drowning deaths in young children occur
because of inadequate supervision of a bathtub or pool.
The nurse has performed an across-the-room assessment of an 8-year-old child and
has classified her as emergent. Which of the following signs and symptoms has the
nurse seen?
a) The child is guarding one hand.
b) The child is asleep on the mother's lap.
c) The child is scratching a rash.
d) There is a blue color to the lips. - ANSWER- There is a blue color to the lips.
Correct Explanation:
Blue lips is a sign of cyanosis. The child is in respiratory distress and should be
cared for on an emergency basis. An injured hand and a rash are not emergencies.
The sleeping child could have a fever that may be the result of an underlying
pathology; however, this cannot be determined from across the room.
The nurse is caring for a 10-month-old infant with signs of respiratory distress.
,Which is the best way to maintain this child's airway?
a) Inserting a small towel under shoulders
b) Using the head tilt chin lift technique
c) Employing the jaw-thrust maneuver
d) Placing the hand under the neck - ANSWER- Inserting a small towel under
shoulders Explanation:
Inserting a small, folded towel under shoulders best positions the infant's airway in
the "sniff" position as is recommended by the American Heart Association (AHA)
Basic Cardiac Life Support (BCLS) guidelines. The hand should never be placed
under the neck to open the airway. The head tilt chin lift technique and the
jawthrust maneuver are used with children over the age of 1 year.
A child is learning to ride a bicycle. He should be instructed to use a(an)
a) Helmet
b) Knee pads
c) Light
d) Wrist guard - ANSWER - Helmet
Correct
Explanation:
Children should wear properly fitted helmets when cycling, riding, or playing
contact sports
The nurse is assessing the neurologic status of an infant. Which of the following
would the nurse identify as a nonreassuring finding?
a) Vigorous crying
b) Soft flat anterior fontanel
c) Lack of interest in surroundings
d) Making eye contact with the nurse - ANSWER- Lack of interest in surroundings
Correct Explanation:
An infant who is not interested in the environment is a cause for concern. Vigorous
crying is a reassuring sign. Making eye contact with the nurse is a reassuring
finding. A normal anterior fontanel is soft and flat and would be considered a
reassuring finding.
A 2-year-old boy is in respiratory distress. Which nursing assessment finding
, would suggest the child aspirated a foreign body?
a) Noting absent breath sounds in one lung
b) Hearing a hyperresonant sound on percussion
c) Hearing dullness when percussing the lungs
d) Auscultating a low-pitched, grating breath sound - ANSWER- Noting absent
breath sounds in one lung Explanation:
Unilateral absent breath sounds are associated with foreign body aspiration.
Dullness on percussion over the lung is indicative of fluid consolidation in the lung
as with pneumonia. Auscultating a low-pitched, grating breath sound suggests
inflammation of the pleura. Hearing a hyperresonant sound on percussion may
indicate pneumothorax or asthma.
The nurse is ventilating a 9-year-old girl with a bag valve mask. Which action
would most likely reduce the effectiveness of ventilation?
a) Referring to Broselow tape for bag size
b) Setting the oxygen flow rate at 15 L/minute
c) Pressing down on the mask below the mouth
d) Checking the tail for free fl ow of oxygen - ANSWER- Setting the oxygen flow
rate at 15 L/minute
Correct
Explanation:
An adolescent, not a 9-year-old, would most likely require an oxygen flow rate of
15 L/minute for effective ventilation. A flow rate of 10 L/minute is appropriate for
infants and children. All other options are valid for preparing to ventilate with a
bag valve mask.
A 14-month-old trauma victim has arrived in the emergency department. Which of
the following challenges will the nurse need to address first?
a) Risks from reduced core temperature
b) Inadequate systemic perfusion
c) Increased metabolic demands
d) Possible tissue damage from hypoxia - ANSWER- Possible tissue damage from
hypoxia Explanation:
VERIFIED 100% CORRECT
Cardiopulmonary resuscitation (CPR) is in progress on an 8-year-old boy who is in
shock. Which is the priority nursing intervention?
a) Using a large bore catheter for peripheral venous access
b) Inserting an indwelling urinary catheter to measure urine output
c) Attaining central venous access via the femoral route
d) Drawing a blood sample for arterial blood gas analysis - ANSWER- Attaining
central venous access via the femoral route Correct Explanation:
Attaining central venous access is the priority intervention for a child in shock who
is receiving respiratory support. Gaining access via the femoral route will not
interfere with CPR efforts. Peripheral venous access may be unattainable in
children who have significant vascular compromise. Blood samples and urinary
catheter placement can wait until fluid is administered.
A 13-year-old boy has had a near-drowning experience. The nurse notices he has
labored breathing and a cough. Which of the following is the priority intervention?
a) Provide sedation as ordered.
b) Check his capillary refill time.
c) Administer 100% oxygen by mask.
d) Have the child sit up straight in a chair. - ANSWER- Administer 100% oxygen
by mask. Explanation:
Management of the near-drowning victim focuses on assessing his airway,
breathing, and circulation (ABCs) and correcting hypoxemia. Administering
oxygen is the primary intervention to assist breathing. It is best to let the child
assume the most comfortable position for him. Checking capillary refill time helps
determine ineffective tissue perfusion. Providing sedation is an intervention for
pain that will be assessed after effective breathing is established.
An 8-year-old girl with tachycardia is alert, breathing comfortably, and exhibiting
signs of adequate tissue perfusion. Which nursing intervention would be most
appropriate for this child?
,a) Administering epinephrine as ordered
b) Oxygenating and ventilating the child
c) Applying ice to the child's face
d) Initiating cardiac compressions - ANSWER- Applying ice to the child's face
Explanation:
The child is exhibiting compensated supraventricular tachycardia (SVT). Vagal
maneuvers such as ice to the face or blowing through a straw that is obstructed are
priority interventions for compensated SVT. Oxygenating and ventilating the child
as ordered are interventions for bradycardia. Epinephrine is given for bradycardia.
Initiating cardiac compressions is the priority intervention for collapsed (pulseless)
rhythms.
Which of the following nursing diagnoses would be appropriate for teaching
interventions for a single mother who leaves her toddler unattended in the bathtub?
a) Risk for Falls
b) Risk for Imbalanced Body Temperature
c) Noncompliance
d) Risk for Suffocation - ANSWER- Risk for Suffocation Correct Explanation:
Death from drowning occurs from suffocation. Nearly half of all drowning victims
are children under the age of 5. Most drowning deaths in young children occur
because of inadequate supervision of a bathtub or pool.
The nurse has performed an across-the-room assessment of an 8-year-old child and
has classified her as emergent. Which of the following signs and symptoms has the
nurse seen?
a) The child is guarding one hand.
b) The child is asleep on the mother's lap.
c) The child is scratching a rash.
d) There is a blue color to the lips. - ANSWER- There is a blue color to the lips.
Correct Explanation:
Blue lips is a sign of cyanosis. The child is in respiratory distress and should be
cared for on an emergency basis. An injured hand and a rash are not emergencies.
The sleeping child could have a fever that may be the result of an underlying
pathology; however, this cannot be determined from across the room.
The nurse is caring for a 10-month-old infant with signs of respiratory distress.
,Which is the best way to maintain this child's airway?
a) Inserting a small towel under shoulders
b) Using the head tilt chin lift technique
c) Employing the jaw-thrust maneuver
d) Placing the hand under the neck - ANSWER- Inserting a small towel under
shoulders Explanation:
Inserting a small, folded towel under shoulders best positions the infant's airway in
the "sniff" position as is recommended by the American Heart Association (AHA)
Basic Cardiac Life Support (BCLS) guidelines. The hand should never be placed
under the neck to open the airway. The head tilt chin lift technique and the
jawthrust maneuver are used with children over the age of 1 year.
A child is learning to ride a bicycle. He should be instructed to use a(an)
a) Helmet
b) Knee pads
c) Light
d) Wrist guard - ANSWER - Helmet
Correct
Explanation:
Children should wear properly fitted helmets when cycling, riding, or playing
contact sports
The nurse is assessing the neurologic status of an infant. Which of the following
would the nurse identify as a nonreassuring finding?
a) Vigorous crying
b) Soft flat anterior fontanel
c) Lack of interest in surroundings
d) Making eye contact with the nurse - ANSWER- Lack of interest in surroundings
Correct Explanation:
An infant who is not interested in the environment is a cause for concern. Vigorous
crying is a reassuring sign. Making eye contact with the nurse is a reassuring
finding. A normal anterior fontanel is soft and flat and would be considered a
reassuring finding.
A 2-year-old boy is in respiratory distress. Which nursing assessment finding
, would suggest the child aspirated a foreign body?
a) Noting absent breath sounds in one lung
b) Hearing a hyperresonant sound on percussion
c) Hearing dullness when percussing the lungs
d) Auscultating a low-pitched, grating breath sound - ANSWER- Noting absent
breath sounds in one lung Explanation:
Unilateral absent breath sounds are associated with foreign body aspiration.
Dullness on percussion over the lung is indicative of fluid consolidation in the lung
as with pneumonia. Auscultating a low-pitched, grating breath sound suggests
inflammation of the pleura. Hearing a hyperresonant sound on percussion may
indicate pneumothorax or asthma.
The nurse is ventilating a 9-year-old girl with a bag valve mask. Which action
would most likely reduce the effectiveness of ventilation?
a) Referring to Broselow tape for bag size
b) Setting the oxygen flow rate at 15 L/minute
c) Pressing down on the mask below the mouth
d) Checking the tail for free fl ow of oxygen - ANSWER- Setting the oxygen flow
rate at 15 L/minute
Correct
Explanation:
An adolescent, not a 9-year-old, would most likely require an oxygen flow rate of
15 L/minute for effective ventilation. A flow rate of 10 L/minute is appropriate for
infants and children. All other options are valid for preparing to ventilate with a
bag valve mask.
A 14-month-old trauma victim has arrived in the emergency department. Which of
the following challenges will the nurse need to address first?
a) Risks from reduced core temperature
b) Inadequate systemic perfusion
c) Increased metabolic demands
d) Possible tissue damage from hypoxia - ANSWER- Possible tissue damage from
hypoxia Explanation:
