NURSING CHILD CARE QUESTIONS AND
ANSWERS
A,.6-month-
old,.infant,.with,.congestive,.heart,.failure,.(CHF),.is,.receiving,.digoxin,.elixi
r.,.Which,.observation,.by,.the,.nurse,.warrants,.immediate,.intervention?
,. Apical,.heart,.rate,.of,.60.
, . Sweating, . across, . the,. forehead.
, . Doesn't, . suck, . well.
,. Respiratory,.rate,.of,.30,.breaths,.per,.minute.,.-,.Apical,.heart,.rate,.of,.60.
A,.heart,.rate,.of,.60,.(A),.is,.much,.lower,.than,.normal,.for,.a,.6-month-
old,.and,.warrants,.immediate,.intervention.,.The,.normal,.heart,.rate,.for,.a,.6-
month-
old,.is,.80,.to,.150,.BPM,.when,.awake,,.and,.a,.rate,.of,.70,.while,.sleeping,.is,.co
nsidered,.within,.normal,.limits.,.(B,.and,.C),.are,.expected,.symptoms,.of,.heart
,.failure,.in,.an,.infant.,.(D),.is,.within,.normal,.limits,.for,.an,.infant.
The,.nurse,.is,.teaching,.the,.parents,.of,.a,.5-year-
old,.with,.cystic,.fibrosis,.about,.respiratory,.treatments.,.Which,.statement,.
indicates,.to,.the,.nurse,.that,.the,.parents,.understand?
, . Perform,. postural,.drainage,.before,. starting,. aerosol,. therapy.
, . Give,. respiratory,. treatments,. when,.the,.child,. is,. coughing,. a,.lot.
, . Administer,. aerosol,. therapy,.followed,. by,. postural,.drainage,.before,. meals.
,.Ensure,.respiratory,.therapy,.is,.done,.daily,.during,.any,.respiratory,.infection.
,.-
,.Administer,.aerosol,.therapy,.followed,.by,.postural,.drainage,.before,.meals.
Postural,.drainage,.for,.a,.child,.with,.cystic,.fibrosis,.is,.most,.effective,.when,
.performed,.after,.nebulization,.and,.before,.meals,.(C),.or,.at,.least,.1,.hour,.a
fter,.eating,.to,.prevent,.nausea,.and,.vomiting.,.Postural,.drainage,.uses,.gravi
ty,.to,.promote,.mucous,.removal,.after,.nebulization,.(A),.treatments,.which,.
open,.the,.airways.,.Pulmonary,.toileting,.or,.respiratory,.treatments,.should,.
be,.given,.3,.to,.4,.times,.daily,,.not,.episodically,.(B,.and,.D).
A,.female,.teenager,.is,.taking,.oral,.tetracycline,.HCL,.(Achromycin,.V),.for,.a
cne,.vulgaris.,.What,.is,.the,.most,.important,.instruction,.for,.the,.nurse,.to,.i
nclude,.in,.this,.client's,.teaching,.plan?
,.Use,.sunscreen,.when,.lying,.by,.the,.pool.
,.Cleanse,.the,.skin,.at,.least,.4,.times,.a,.day.
, . Take,.the,.medication,.with,.a,.glass,.of,.milk.
,.Menstrual,.periods,.may,.become,.irregular.,.-
,,.Use,.sunscreen,.when,.lying,.by,.the,.pool.
Photosensitivity,.is,.a,.common,.side,.effect,.of,.tetracycline,.HCL,.(Achromyci
n,.V),.therapy.,.Severe,.sunburn,.can,.occur,.with,.minimal,.sun,.exposure,.and,
.clients,.should,.be,.instructed,.to,.avoid,.sunlight,.and,.to,.use,.sunscreen,.(A).,
.(B,.and,.D),.are,.not,.related,.to,.tetracycline,.HCL,.(Achromycin,.V),.therapy.,.
(C),.should,.be,.avoided,.because,.dairy,.products,.interfere,.with,.the,.absorpt
ion,.of
,tetracyclines.
, What,.preoperative,.nursing,.intervention,.should,.be,.included,.in,.the,.plan,.
of,.care,.for,.an,.infant,.with,.pyloric,.stenosis?
,. Monitor,.for,.signs,.of,.metabolic,.acidosis.
,. Estimate,.the,.quantity,.of,.diarrhea,.stools.
,. Place,.in,.a,.supine,.position,.after,.feeding.
,.Observe,.for,.projectile,.vomiting.,.-,.Observe,.for,.projectile,.vomiting.
Projectile,.vomiting,.(D),,.which,.contributes,.to,.metabolic,.alkalosis,.(A),,.is,.th
e,.classic,.sign,.of,.pyloric,.stenosis.,.(B),.is,.not,.indicated.,.(C),.is,.dangerous,,.d
ue,.to,.the,.potential,.for,.aspiration,.with,.frequent,.vomiting.
An,.infant,.is,.born,.with,.a,.ventricular,.septal,.defect,.(VSD),.and,.surgery,.is,.p
lanned,.to,.correct,.the,.defect.,.The,.nurse,.recognizes,.that,.surgical,.correcti
on,.is,.designed,.to,.achieve,.which,.outcome?
, . Stop,. the,.flow,.of,. unoxygenated,. blood,. into,. systemic,. circulation.
, . Increase,.the,.flow,.of,.unoxygenated,. blood,.to,.the,.lungs.
,. Prevent,.the,.return,.of,.oxygenated,.blood,.to,.the,.lungs.
,.Reduce,.peripheral,.tissue,.hypoxia,.and,.nailbed,.clubbing,.-
,.Prevent,.the,.return,.of,.oxygenated,.blood,.to,.the,.lungs.
Closure,.of,.VSDs,.stops,.oxygenated,.blood,.from,.being,.shunted,.from,.the,.l
eft,.ventricle,.to,.the,.right,.ventricle,.(C).,.VSDs,.are,.acyanotic,.defects,,.whic
h,.means,.that,.no,.unoxygenated,.blood,.enters,.the,.systemic,.circulation,.(A,.a
nd,.B).,.(D),.is,.common,.with,.Tetrology,.of,.Fallot,,.which,.is,.a,.cyanotic,.defect
.
A,.3-week-old,.newborn,.is,.brought,.to,.the,.clinic,.for,.follow-
up,.after,.a,.home,.birth.,.The,.mother,.reports,.that,.her,.child,.bottle,.feeds,.fo
r,.5,.minutes,.only,.and,.then,.falls,.asleep.,.The,.nurse,.auscultates,.a,.loud,.mur
mur,.characteristic,.of,.a,.ventricular,.septal,.defect,.(VSD),,.and,.finds,.the,.ne
wborn,.is,.acyanotic,.with,.a,.respiratory,.rate,.of,.64,.breaths,.per,.minute.,.Wh
at,.instruction,.should,.the,.nurse,.provide,.the,.mother,.to,.ensure,.the,.infant,.i
s,.receiving,.adequate,.intake?,.(Select,.all,.that,.apply.)
A., . Monitor, . the, . the, . infant's, . weight, . and, . number, . of, . w
et,.diapers,.per,.day.,.B.,.Increase,.the,.infant's,.intake,.per,.fee
ding, . by,.1,.to,.2,.ounces,.per,.week.,.C.,.Mix,.the,.dose,.of,.pro
phylactic,.antibiotic,.in,.a,.full,.bottle,.of,.formula.
D.,.Allow,.the,.infant,.to,.rest,.and,.refeed,.on,.demand,.or,.every,.2,.hours.
E.,.Use,.a,.softer,.nipple,.or,.increase,.the,.size,.of,.the,.nipple,.opening
.,.-
,.A.,.Monitor,.the,.the,.infant's,.weight,.and,.number,.of,.wet,.diapers,.p
er,.day.
B.,.Increase,.the,.infant's,.intake,.per,.feeding,.by,.1,.to,.2,.oun
ces,.per,.week.,.D.,.Allow,.the,.infant,.to,.rest,.and,.refeed,.on
,.demand,.or,.every,.2,.hours.
E.,.Use,.a,.softer,.nipple,.or,.increase,.the,.size,.of,.the,.nipple,.opening.
Antibiotic,.prophylaxis,.is,.recommended,.for,.infants,.with,.VSDs,,.but,.should,.
not,.be,.mixed,.in,.a,.bottle,.of,.formula,.(C),.because,.it,.is,.difficult,.to,.ensure,.
ANSWERS
A,.6-month-
old,.infant,.with,.congestive,.heart,.failure,.(CHF),.is,.receiving,.digoxin,.elixi
r.,.Which,.observation,.by,.the,.nurse,.warrants,.immediate,.intervention?
,. Apical,.heart,.rate,.of,.60.
, . Sweating, . across, . the,. forehead.
, . Doesn't, . suck, . well.
,. Respiratory,.rate,.of,.30,.breaths,.per,.minute.,.-,.Apical,.heart,.rate,.of,.60.
A,.heart,.rate,.of,.60,.(A),.is,.much,.lower,.than,.normal,.for,.a,.6-month-
old,.and,.warrants,.immediate,.intervention.,.The,.normal,.heart,.rate,.for,.a,.6-
month-
old,.is,.80,.to,.150,.BPM,.when,.awake,,.and,.a,.rate,.of,.70,.while,.sleeping,.is,.co
nsidered,.within,.normal,.limits.,.(B,.and,.C),.are,.expected,.symptoms,.of,.heart
,.failure,.in,.an,.infant.,.(D),.is,.within,.normal,.limits,.for,.an,.infant.
The,.nurse,.is,.teaching,.the,.parents,.of,.a,.5-year-
old,.with,.cystic,.fibrosis,.about,.respiratory,.treatments.,.Which,.statement,.
indicates,.to,.the,.nurse,.that,.the,.parents,.understand?
, . Perform,. postural,.drainage,.before,. starting,. aerosol,. therapy.
, . Give,. respiratory,. treatments,. when,.the,.child,. is,. coughing,. a,.lot.
, . Administer,. aerosol,. therapy,.followed,. by,. postural,.drainage,.before,. meals.
,.Ensure,.respiratory,.therapy,.is,.done,.daily,.during,.any,.respiratory,.infection.
,.-
,.Administer,.aerosol,.therapy,.followed,.by,.postural,.drainage,.before,.meals.
Postural,.drainage,.for,.a,.child,.with,.cystic,.fibrosis,.is,.most,.effective,.when,
.performed,.after,.nebulization,.and,.before,.meals,.(C),.or,.at,.least,.1,.hour,.a
fter,.eating,.to,.prevent,.nausea,.and,.vomiting.,.Postural,.drainage,.uses,.gravi
ty,.to,.promote,.mucous,.removal,.after,.nebulization,.(A),.treatments,.which,.
open,.the,.airways.,.Pulmonary,.toileting,.or,.respiratory,.treatments,.should,.
be,.given,.3,.to,.4,.times,.daily,,.not,.episodically,.(B,.and,.D).
A,.female,.teenager,.is,.taking,.oral,.tetracycline,.HCL,.(Achromycin,.V),.for,.a
cne,.vulgaris.,.What,.is,.the,.most,.important,.instruction,.for,.the,.nurse,.to,.i
nclude,.in,.this,.client's,.teaching,.plan?
,.Use,.sunscreen,.when,.lying,.by,.the,.pool.
,.Cleanse,.the,.skin,.at,.least,.4,.times,.a,.day.
, . Take,.the,.medication,.with,.a,.glass,.of,.milk.
,.Menstrual,.periods,.may,.become,.irregular.,.-
,,.Use,.sunscreen,.when,.lying,.by,.the,.pool.
Photosensitivity,.is,.a,.common,.side,.effect,.of,.tetracycline,.HCL,.(Achromyci
n,.V),.therapy.,.Severe,.sunburn,.can,.occur,.with,.minimal,.sun,.exposure,.and,
.clients,.should,.be,.instructed,.to,.avoid,.sunlight,.and,.to,.use,.sunscreen,.(A).,
.(B,.and,.D),.are,.not,.related,.to,.tetracycline,.HCL,.(Achromycin,.V),.therapy.,.
(C),.should,.be,.avoided,.because,.dairy,.products,.interfere,.with,.the,.absorpt
ion,.of
,tetracyclines.
, What,.preoperative,.nursing,.intervention,.should,.be,.included,.in,.the,.plan,.
of,.care,.for,.an,.infant,.with,.pyloric,.stenosis?
,. Monitor,.for,.signs,.of,.metabolic,.acidosis.
,. Estimate,.the,.quantity,.of,.diarrhea,.stools.
,. Place,.in,.a,.supine,.position,.after,.feeding.
,.Observe,.for,.projectile,.vomiting.,.-,.Observe,.for,.projectile,.vomiting.
Projectile,.vomiting,.(D),,.which,.contributes,.to,.metabolic,.alkalosis,.(A),,.is,.th
e,.classic,.sign,.of,.pyloric,.stenosis.,.(B),.is,.not,.indicated.,.(C),.is,.dangerous,,.d
ue,.to,.the,.potential,.for,.aspiration,.with,.frequent,.vomiting.
An,.infant,.is,.born,.with,.a,.ventricular,.septal,.defect,.(VSD),.and,.surgery,.is,.p
lanned,.to,.correct,.the,.defect.,.The,.nurse,.recognizes,.that,.surgical,.correcti
on,.is,.designed,.to,.achieve,.which,.outcome?
, . Stop,. the,.flow,.of,. unoxygenated,. blood,. into,. systemic,. circulation.
, . Increase,.the,.flow,.of,.unoxygenated,. blood,.to,.the,.lungs.
,. Prevent,.the,.return,.of,.oxygenated,.blood,.to,.the,.lungs.
,.Reduce,.peripheral,.tissue,.hypoxia,.and,.nailbed,.clubbing,.-
,.Prevent,.the,.return,.of,.oxygenated,.blood,.to,.the,.lungs.
Closure,.of,.VSDs,.stops,.oxygenated,.blood,.from,.being,.shunted,.from,.the,.l
eft,.ventricle,.to,.the,.right,.ventricle,.(C).,.VSDs,.are,.acyanotic,.defects,,.whic
h,.means,.that,.no,.unoxygenated,.blood,.enters,.the,.systemic,.circulation,.(A,.a
nd,.B).,.(D),.is,.common,.with,.Tetrology,.of,.Fallot,,.which,.is,.a,.cyanotic,.defect
.
A,.3-week-old,.newborn,.is,.brought,.to,.the,.clinic,.for,.follow-
up,.after,.a,.home,.birth.,.The,.mother,.reports,.that,.her,.child,.bottle,.feeds,.fo
r,.5,.minutes,.only,.and,.then,.falls,.asleep.,.The,.nurse,.auscultates,.a,.loud,.mur
mur,.characteristic,.of,.a,.ventricular,.septal,.defect,.(VSD),,.and,.finds,.the,.ne
wborn,.is,.acyanotic,.with,.a,.respiratory,.rate,.of,.64,.breaths,.per,.minute.,.Wh
at,.instruction,.should,.the,.nurse,.provide,.the,.mother,.to,.ensure,.the,.infant,.i
s,.receiving,.adequate,.intake?,.(Select,.all,.that,.apply.)
A., . Monitor, . the, . the, . infant's, . weight, . and, . number, . of, . w
et,.diapers,.per,.day.,.B.,.Increase,.the,.infant's,.intake,.per,.fee
ding, . by,.1,.to,.2,.ounces,.per,.week.,.C.,.Mix,.the,.dose,.of,.pro
phylactic,.antibiotic,.in,.a,.full,.bottle,.of,.formula.
D.,.Allow,.the,.infant,.to,.rest,.and,.refeed,.on,.demand,.or,.every,.2,.hours.
E.,.Use,.a,.softer,.nipple,.or,.increase,.the,.size,.of,.the,.nipple,.opening
.,.-
,.A.,.Monitor,.the,.the,.infant's,.weight,.and,.number,.of,.wet,.diapers,.p
er,.day.
B.,.Increase,.the,.infant's,.intake,.per,.feeding,.by,.1,.to,.2,.oun
ces,.per,.week.,.D.,.Allow,.the,.infant,.to,.rest,.and,.refeed,.on
,.demand,.or,.every,.2,.hours.
E.,.Use,.a,.softer,.nipple,.or,.increase,.the,.size,.of,.the,.nipple,.opening.
Antibiotic,.prophylaxis,.is,.recommended,.for,.infants,.with,.VSDs,,.but,.should,.
not,.be,.mixed,.in,.a,.bottle,.of,.formula,.(C),.because,.it,.is,.difficult,.to,.ensure,.
