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RNUR 234 Final Exam Review: 100
Comprehensive Questions and Answers with
Detailed Rationales for Pediatric Nursing,
Covering Respiratory, Cardiac,
Gastrointestinal, Neurological, and
Musculoskeletal Conditions, Graded A+.
1) A child is showing signs of acute respiratory distress. Which position will the
nurse place this child?
1. Upright
2. Side-lying
3. Flat
4. In semi-Fowler's
Answer: 1
Explanation: 1. Upright is correct because it allows for optimal chest expansion.
Side-lying, flat, and semi-Fowler's (head up slightly) do not allow for as optimal
chest expansion as the upright position.
2) A nurse delegates the task of neonatal vital-sign assessment to a nurse
technician. Which instruction will the nurse give to the technician prior to assign
care?
1. Report any neonate using abdominal muscles to breathe.
2. Report any neonate with apnea for 10 seconds.
3. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute.
4. Report any neonate with a breathing pause that lasts 20 seconds or longer.
Answer: 4
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Explanation: 1. The abnormal assessment finding for vital signs that the nurse
should instruct a nurse technician to report is any breathing pause by a neonate
lasting longer than 20 seconds. This can indicate apnea and could lead to an
apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is
called periodic breathing and is a normal pattern for a neonate. Respirations should
be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal
muscles for breathing.
6) Which nursing diagnosis is most appropriate for an infant with acute
bronchiolitis due to respiratory syncytial virus (RSV)?
1. Activity Intolerance
2. Decreased Cardiac Output
3. Pain, Acute
4. Tissue Perfusion, Ineffective (peripheral)
Answer: 1
Explanation: 1. Activity intolerance is a problem because of the imbalance
between oxygen supply and demand. Cardiac output is not compromised during an
acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis.
Tissue perfusion (peripheral) is not affected by this respiratory-disease process.
7) A child is admitted to the hospital with pneumonia. The child's oximetry reading
is 88 percent upon admission to the pediatric floor. Which is the priority nursing
intervention for this child?
1. Obtain a blood sample to send to the lab for electrolyte analysis.
2. Begin oxygen per nasal cannula.
3. Medicate for pain.
4. Begin administration of intravenous fluids.
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Answer: 2
Explanation: 1. Pulse oximetry reading should be 92 or greater. Oxygen by nasal
cannula should be started initially. Medicating for pain, administering IV fluids,
and sending lab specimens can be done once the child's oxygenation status has
been addressed.
12) A child with asthma will be receiving an oral dose of prednisone. The order
reads prednisone 2 mg/kg per day. The child weighs 50 lbs. The child will receive
________ milligrams daily. (Round the answer.)
Round the answer to the nearest whole number.
Answer: 45.5 = 46
Explanation: 22.7 × 2 = 45.5 (46)
13) Parents of a child admitted with respiratory distress are concerned because the
child won't lie down and wants to sit in a chair leaning forward. Which response by
the nurse is the most appropriate?
1. "This helps the child feel in control of his situation."
2. "The child needs to be encouraged to lie flat in bed."
3. "This position helps keep the airway open."
4. "This confirms the child has asthma."
Answer: 3
Explanation: 1. Leaning forward helps keep the airway open. The child is not in
control just because he is leaning forward. Lying flat in bed will increase the
respiratory distress. This position does not confirm asthma.
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15) The nurse is providing care to an infant who is diagnosed with bronchiolitis.
Which breath sounds indicate the infant is experiencing respiratory distress? Select
all that apply.
1. Tachypnea
2. Wheezing
3. Grunting
4. Retractions
5. Eupnea
Answer: 1, 2, 3
Explanation: 1. Wheezing and grunting are adventitious respiratory sounds that
indicate respiratory distress in the neonate. Tachypnea is the term used to indicate
a respiratory rate of greater than 60 breaths per minute in an infant. While this does
indicate respiratory distress, tachypnea is not a type of breath sound. Retractions,
or the use of accessory muscles, are indicative of respiratory distress in the
neonate, but this is not a type of breath sound. Eupnea is the medical term for
"normal breathing."
16) The nurse educator is teaching a group of nursing students how to perform a
respiratory assessment for a newborn in the newborn intensive care unit (NICU)
diagnosed with respiratory distress syndrome (RDS). Which normal characteristics
of the newborn's respiratory system increase the risk for obstruction?
Select all that apply.
1. Shorter and narrower airway
2. Higher trachea
3. Bronchial branching at different angles
4. Inadequate smooth muscle bundles
5. Diaphragmatic breather
RNUR 234 Final Exam Review: 100
Comprehensive Questions and Answers with
Detailed Rationales for Pediatric Nursing,
Covering Respiratory, Cardiac,
Gastrointestinal, Neurological, and
Musculoskeletal Conditions, Graded A+.
1) A child is showing signs of acute respiratory distress. Which position will the
nurse place this child?
1. Upright
2. Side-lying
3. Flat
4. In semi-Fowler's
Answer: 1
Explanation: 1. Upright is correct because it allows for optimal chest expansion.
Side-lying, flat, and semi-Fowler's (head up slightly) do not allow for as optimal
chest expansion as the upright position.
2) A nurse delegates the task of neonatal vital-sign assessment to a nurse
technician. Which instruction will the nurse give to the technician prior to assign
care?
1. Report any neonate using abdominal muscles to breathe.
2. Report any neonate with apnea for 10 seconds.
3. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute.
4. Report any neonate with a breathing pause that lasts 20 seconds or longer.
Answer: 4
,2|Page
Explanation: 1. The abnormal assessment finding for vital signs that the nurse
should instruct a nurse technician to report is any breathing pause by a neonate
lasting longer than 20 seconds. This can indicate apnea and could lead to an
apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is
called periodic breathing and is a normal pattern for a neonate. Respirations should
be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal
muscles for breathing.
6) Which nursing diagnosis is most appropriate for an infant with acute
bronchiolitis due to respiratory syncytial virus (RSV)?
1. Activity Intolerance
2. Decreased Cardiac Output
3. Pain, Acute
4. Tissue Perfusion, Ineffective (peripheral)
Answer: 1
Explanation: 1. Activity intolerance is a problem because of the imbalance
between oxygen supply and demand. Cardiac output is not compromised during an
acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis.
Tissue perfusion (peripheral) is not affected by this respiratory-disease process.
7) A child is admitted to the hospital with pneumonia. The child's oximetry reading
is 88 percent upon admission to the pediatric floor. Which is the priority nursing
intervention for this child?
1. Obtain a blood sample to send to the lab for electrolyte analysis.
2. Begin oxygen per nasal cannula.
3. Medicate for pain.
4. Begin administration of intravenous fluids.
,3|Page
Answer: 2
Explanation: 1. Pulse oximetry reading should be 92 or greater. Oxygen by nasal
cannula should be started initially. Medicating for pain, administering IV fluids,
and sending lab specimens can be done once the child's oxygenation status has
been addressed.
12) A child with asthma will be receiving an oral dose of prednisone. The order
reads prednisone 2 mg/kg per day. The child weighs 50 lbs. The child will receive
________ milligrams daily. (Round the answer.)
Round the answer to the nearest whole number.
Answer: 45.5 = 46
Explanation: 22.7 × 2 = 45.5 (46)
13) Parents of a child admitted with respiratory distress are concerned because the
child won't lie down and wants to sit in a chair leaning forward. Which response by
the nurse is the most appropriate?
1. "This helps the child feel in control of his situation."
2. "The child needs to be encouraged to lie flat in bed."
3. "This position helps keep the airway open."
4. "This confirms the child has asthma."
Answer: 3
Explanation: 1. Leaning forward helps keep the airway open. The child is not in
control just because he is leaning forward. Lying flat in bed will increase the
respiratory distress. This position does not confirm asthma.
, 4|Page
15) The nurse is providing care to an infant who is diagnosed with bronchiolitis.
Which breath sounds indicate the infant is experiencing respiratory distress? Select
all that apply.
1. Tachypnea
2. Wheezing
3. Grunting
4. Retractions
5. Eupnea
Answer: 1, 2, 3
Explanation: 1. Wheezing and grunting are adventitious respiratory sounds that
indicate respiratory distress in the neonate. Tachypnea is the term used to indicate
a respiratory rate of greater than 60 breaths per minute in an infant. While this does
indicate respiratory distress, tachypnea is not a type of breath sound. Retractions,
or the use of accessory muscles, are indicative of respiratory distress in the
neonate, but this is not a type of breath sound. Eupnea is the medical term for
"normal breathing."
16) The nurse educator is teaching a group of nursing students how to perform a
respiratory assessment for a newborn in the newborn intensive care unit (NICU)
diagnosed with respiratory distress syndrome (RDS). Which normal characteristics
of the newborn's respiratory system increase the risk for obstruction?
Select all that apply.
1. Shorter and narrower airway
2. Higher trachea
3. Bronchial branching at different angles
4. Inadequate smooth muscle bundles
5. Diaphragmatic breather
