Question 1

Which independent nursing action is appropriate for a 2-month-old infant who is a direct admission to the pediatric unit with a diagnosis of ALTE?

Accepted Answer

ALTE stands for "apparent life-threatening event" and refers to an episode in which an infant experiences one or more of the following: apnea (cessation of breathing), color change (usually to blue or pale), choking or gagging. Placing the infant on an apnea monitor, which detects episodes of apnea and bradycardia, is an appropriate independent nursing action to closely monitor the infant's breathing and heart rate. Placing a patient on contact isolation or drawing blood for arterial blood gases would require a physician's order. Placing the child on nasal cannula oxygen may or may not be necessary based on the infant's oxygen saturation levels, which would need to be assessed through an arterial blood gas test.

Question 2

The nurse is providing care to an infant who is diagnosed as having Pseudomonas aeruginosa pneumonia.Which respiratory condition should the nurse suspect?

Accepted Answer

Pseudomonas aeruginosa is a common bacterial infection in patients with cystic fibrosis.

Question 3

A pediatric nurse explains discharge instructions to the parents of a child who is postoperative from a tonsillectomy.Which instruction does the nurse stress?

Accepted Answer

After a tonsillectomy, the affected area can be sore and sensitive, so avoiding highly seasoned and "sharp" foods will reduce the risk of discomfort and possible harm to the site. The other options are not appropriate or potentially harmful. Vigorous toothbrushing may cause bleeding, coughing may worsen the pain and lead to bleeding, and avoiding popsicles is not necessary as long as they are given slowly and carefully to prevent choking or aspiration.

Question 4

Which should the nurse anticipate when providing care to a child who aspirated a foreign body (FB)?

Accepted Answer

The best choice for a child who aspirated a foreign body is bronchoscopy, as it allows for visualization and removal of the foreign body. CT scan, chest x-ray, and fluoroscopy may be used in conjunction with bronchoscopy, but alone cannot provide the same level of intervention.

Question 5

The pediatric nurse recognizes that normal breath sounds are equal bilaterally in intensity,rhythm,and pitch.Which respiratory sign may indicate that a child is hypoxic?

Accepted Answer

Anxiety can be a sign of hypoxia in children, as the body's response to low oxygen levels can lead to feelings of restlessness or anxiety due to the brain and other organs not receiving enough oxygen.

Question 6

Which data collected during the pediatric respiratory assessment require further action by the nurse? (Select all that apply.)

Accepted Answer

Stridor, nasal flaring, and substernal retractions indicate respiratory distress and require further assessment and intervention by the nurse. A strong cry and clear lung sounds do not necessarily indicate a problem with the respiratory system.

Question 7

Which nursing actions are essential for safety when providing care to a pediatric patient at risk for respiratory compromise? (Select all that apply.)

Accepted Answer

A) Identifying distress is crucial for prompt intervention and prevention of respiratory compromise in pediatric patients.
C) Supporting a compromised airway is essential to maintain oxygenation and prevent further respiratory distress.
E) Choosing the appropriate method of oxygen delivery is important to ensure effective oxygenation and prevent complications. Documenting care and keeping parents informed of changes are important nursing actions but not directly related to preventing respiratory compromise in the pediatric patient.

Question 8

A pediatric nurse is performing a respiratory assessment on an 18-month-old child.The nurse most likely uses which recommended techniques?

Accepted Answer

The recommended technique for a respiratory assessment on a child is to assess breath sounds by listening to all lung fields and alternating sides for comparison. This allows the nurse to properly evaluate the child's respiratory function and detect any abnormalities or signs of respiratory distress. Palpation may also be used to assess for chest expansion and any areas of tenderness or discomfort, but the primary method of assessment for breath sounds should be through auscultation. It is also important to assess the child's respiratory status in various positions and during different levels of activity, as respiratory distress may become more apparent during periods of increased activity.

Question 9

Which question should the nurse include in the health history to determine the causative factor for the diagnosis of croup?

Accepted Answer

Croup is most commonly caused by a viral infection that affects the upper respiratory tract. Therefore, asking if the child has recently been diagnosed with the flu can help determine if this is the causative factor. Other options, such as asthma, vaccine history, and immunizations, may not necessarily be directly related to the development of croup.

Question 10

Which information should the nurse include when teaching information regarding peak flow to a child diagnosed with severe asthma?

Accepted Answer

The green zone on a peak flow meter indicates that the person's asthma is under good control, and they can continue their normal activities and medication regimen. This is a key point in asthma management education. The yellow zone, not the red, is a caution zone indicating that the asthma is getting worse and adjustments in medication may be needed. The red zone indicates a medical emergency requiring immediate action, contrary to the misinformation provided in options B and C. Regular monitoring with a peak flow meter is usually recommended more frequently than once a week, especially for someone with severe asthma, making option A incorrect.

Question 11

On which patient at the greatest risk for croup should the nurse focus information regarding prevention?

Accepted Answer

Croup most commonly affects children between the ages of 6 months and 3 years. Therefore, the 3-year-old preschooler is at the greatest risk for croup and would benefit the most from information regarding prevention.

Question 12

Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented?

Accepted Answer

Replacing carpet with tile is a good step to control the environment for a child with asthma as carpets can harbor dust mites and other particles that can trigger asthma symptoms. Using pesticides can actually worsen asthma symptoms, and having a pet sleep in the child's room can also worsen asthma. Additionally, using a fireplace can also worsen asthma symptoms by releasing smoke and other irritants into the air.

Question 13

Which prescribed medications should the nurse educate the parents of a child with asthma to administer on a daily basis? (Select all that apply.)

Accepted Answer

Theophylline is a long-term control medication used to manage symptoms of asthma, and leukotriene modifiers are also used on a daily basis to help control and prevent asthma symptoms. Albuterol and racemic epinephrine are rescue medications used for quick relief of asthma symptoms, and ipratropium is typically used for quick relief in chronic obstructive pulmonary disease (COPD) rather than for daily asthma management.

Question 14

Which is the priority nursing action for a premature neonate who is experiencing intermittent apnea?

Accepted Answer

Providing stimulation by stroking the back is often the first action to stimulate breathing in a premature neonate experiencing intermittent apnea, as it can help to prompt the baby to resume breathing.

Question 15

Which statement by the nurse accurately describes the difference between the respiratory systems of a child and an adult?

Accepted Answer

The epiglottis in younger children is indeed longer and more flaccid compared to adults, which makes it more prone to swelling and potentially leading to airway occlusion. This anatomical difference is a key consideration in pediatric respiratory care.

Question 16

Which nursing action is appropriate for the parents of a 4-month-old infant who died as a result of sudden infant death syndrome (SIDS)?

Accepted Answer

Allowing the parents to hold, touch and rock the infant is appropriate because it can provide comfort and support as they grieve the loss of their child. This is a therapeutic and appropriate intervention for the parents who just lost a child to SIDS. Option B is not appropriate because an infant autopsy may be necessary to determine the cause of death or rule out other potential medical conditions. Option C is not appropriate because the nurse should not assume or investigate any cause of death but should offer condolences and support to the family through the grieving process. Option D is not appropriate since giving the parents personal items of the infant such as footprints, clothes can help them heal better from the shock and grief they experience.

Question 17

The mother of a toddler-aged patient states,"My daughter seems to be at an increased risk for complications associated with respiratory infections." Which response by the nurse is accurate?

Accepted Answer

The statement that younger children are at increased risk for complications associated with respiratory infections is accurate. This is because the younger child's airway is smaller and more easily occluded. Younger children also have less developed immune systems, making them more susceptible to infections. Option A is incorrect as it dismisses the mother's concern without providing accurate information. Option B is not entirely accurate as younger children have smaller airways, not just a difference in respiratory depth. Option D is not entirely accurate as the amount of mucus produced is not necessarily the reason why younger children are at increased risk, but rather the size of their airways.

Question 18

A toddler-aged patient presents to the emergency department with a sore throat and difficulty swallowing.The nurse suspects acute epiglottitis.Which nursing action is avoided on the basis of the current assessment data?

Accepted Answer

Throat culture should be avoided as it can stimulate the child's airway and trigger a sudden and life-threatening closure of the epiglottis. This procedure can be performed after the airway is secured through intubation. Vital signs, medical history, and auscultation of breath sounds are all appropriate assessments for a patient with suspected acute epiglottitis.

Question 19

Which action should the nurse include in the plan of care for an infant who is diagnosed with acute respiratory distress?

Accepted Answer

Suctioning the airway is important in managing acute respiratory distress, as it helps to remove secretions and improve air exchange. Placing the infant in a prone position can actually worsen their breathing, and daily peak flow readings and breathing exercises are not typically used in the management of acute respiratory distress in infants.

Question 20

When assisting with the respiratory assessment of a pediatric patient,which should the nurse include to determine oxygenation? (Select all that apply.)

Accepted Answer

The nurse should assess the skin, nailbeds, and mucous membranes to determine oxygenation in a pediatric patient, as these areas can show signs of cyanosis or pallor indicating poor oxygenation.

Quiz 32: Child With a Respiratory Condition