Combo with "Child with Cardiovascular disorder" and 6 others

congenital heart defects
Patent ductus arteriosus, Atrial septal defect, Ventricular septal defect, Tetralogy of fallot, Coarctation of Aorta
Coarctation of Aorta
narrowing of the descending portion of the aorta, resulting in a limited flow of blood to the lower part of the body
Tetralogy of fallot
Combination of four congenital anomalies: pulmonary stenosis, an interventricular septal defect, abnormal blood supply to the aorta, and hypertrophy of the right ventricle. Needs immediate surgery to correct.
pulmonary stenosis
narrowing of the valve between the right ventricle and pulmonary artery decreases the flow of blood to the lungs
hypertrophy of the right ventricle
Myocardium works harder and gets bigger to pump blood through a narrowed pulmonary artery.
interventricular septal defect
***most common type of heart defect***, abnormalities in membranous part are associated with abnormalities in partioning or development in conotruncal region, defects are usually more problematic, left to right shunt:increased pulmonary blood flow and hypertension
abnormal blood supply to the aorta (dextroposition)
In tetralogy of Fallot, the aorta is located between the left and right ventricles, directly over the VSD. As a result, oxygen-poor blood from the right ventricle flows directly into the aorta instead of into the pulmonary artery.
In a healthy heart, the aorta is attached to the left ventricle. This allows only oxygen-rich blood to flow to the body.
Patent ductus arteriousus
In some babies, however, the ductus arteriosus remains open (patent). The opening allows oxygen-rich blood from the aorta to mix with oxygen-poor blood from the pulmonary artery. This can strain the heart and increase blood pressure in the lung arteries.
Patent ductus arteriousus s/s
as child grows :
dyspnea
radial pulse full and bounding
unusually wide range between systolic and diastolic blood pressure or pulse pressure
machinery type of murmer may be heard
twice as many times girls
Patent ductus arteriousus treatment
Premature infants with hypoxia often respond to indomethacin that closes the PDA
Heart surgery on full term newborns to prevent CHF
Non surgical insertion of coils to occlude the PDA cardic catherization lab good prognosis
indomethacin
NSAID prototype: highly potent. Usually reserved for acute inflammation (eg, acute gout), not chronic; neonatal patent ductus arteriosus. Tox: GI (bleeding), renal damage
Coarctation of Aorta S/S
increased BP and O2 saturation in upper extremities compared to lower extremities, nosebleeds, headaches, vertigo, leg pain, weak or absent lower extremity pulses
notching of the ribs caused by vessels developed by collateral circulation
Coarctation of Aorta treatment
Balloon angioplasty until lesion can be surgically corrected.then stent
or anastomosis after resection
significant blood pressure difference between upper extremities and lower extremities is a classic sign of
Coarctation of Aorta
heart condition that cause cyanosis
Tetralogy of fallot
Tetralogy of fallot S/S
cyanosis, hypoxia, delayed growth, polycythemia, metabolic acidosis; exercise intolerance, clubbing of fingers; systolic murmur; “tet spell”; Dx: chest x-ray, ECG, echocardiogram, cardiac cath
Tetralogy of fallot
child rest in an squatting position to breath more easy
Tet spell
A child with Tetralogy of Fallot (TOF) responds to this by squatting, which will increase blood flow back to the heart. It is a period of cyanosis.
hold baby in knee-chest position
tet spells
Children with tetralogy of Fallot may develop “tet spells”. The precise mechanism of these episodes is in doubt, but presumably results from a transient increase in resistance to blood flow to the lungs with increased preferential flow of desaturated blood to the body. Tet spells are characterized by a sudden, marked increase in cyanosis followed by syncope, and may result in hypoxic brain injury and death. Older children will often squat during a tet spell, which increases systemic vascular resistance and allows for a temporary reversal of the shunt.
Foods high in potassium
Bananas
Oranges
Milk
Potatoes
Plums (prunes)
tomatoes
rheumatic fever classic signs
Polyarthritis
Skin eruptions
Chorea -fine tremors
Inflammation of the heart
The adolescent who is hypertensive should
exercise,
limit sodium intake,
control weight,
have nutritional counseling;
and avoid smoking
Kawaski disease causes
inflammation,of the vessels in the cardiovascular system which can lead to an aneurysm
most common congenitial heart defect in children is
ventricluar septal defect
Digoxin is with held if the pulse of a newborn is below
100 bpm the medication is withheld and
the physician notified
Three medications that may be used to treat Kawasaki’s disease
Gamma globulin
Aspirin therapy
Warfarin (Coumadin)
infant receiving digoxin the nurse should be alert to which finding as a sign of toxicity.
nausea and vomiting
child is taking diuretics nurse should be watching
Electrolytes- they should be monitored
in the child receiving diuretics to prevent
electrolyte imbalance, particularly potassium depletion
signs an infant has a congenital heart defect
Failure to thrive
Poor weight gain
Cyanosis or pallor
Pulsations in neck veins
Tachypnea
Dyspnea
Irregular pulse
Finger clubbing
Fatigue with feeding or activity
11 year old girl with hypertension initial treatment
nutritional counseling,
weight reduction,
and exercise program.
Infant with Tetralogy of fallot becomes hypercyanotic
the infant is placed in a knee-chest position
Infant with congenital heart defect would have a hard time
Children with congenital heart
defects have difficulty eating because of the
energy used in the process. They should be
given frequent, small feedings so that they will not get tired
congenital heart defect that results in decreased pulmonary blood flow
tetralogy
of Fallot: pulmonary stenosis, ventricular septal defect, dextraposition of the aorta, and right
ventricular hypertrophy result in decreased
pulmonary blood flow
blood pressure higher in the arms than legs in an infant would be associated with what congenital heart defect
coarctation of the aorta.
A significant difference in blood
pressure between the upper and lower extremities is a sign of coarctation of the aorta.
clubbing
abnormal enlargement of the distal phalanges (fingers and toes) associated with cyanotic heart disease or advanced chronic pulmonary disease
lack of O 2
pulse pressure
the difference between systolic and diastolic pressure
hypoplastic left heart syndrome
underdevelopment of the left side of the heart, usually resulting in an absent or nonfunctional left ventricle and hypoplasia of the ascending aorta
hypoplastic left heart syndrome S/S
grayish blue color of skin
mucus membranes
signs of CHF
dyspnea, weak pulse and cardiac murmur
hypoplastic left heart syndrome treatment
Prostaglandin E1 to open ductus arteriosus, staged surgical repair
immunizations of children with congenital heart defect that are having a transplant
do not get immunizations because the transplant heart will reject.
acquired heart disease
Kawasaki disease
Myocarditis
Cardiomyopathy
Rheumatic heart disease
Infective endocarditis
CHF
Congestive Heart Failure failure of the heart to pump blood away from the heart causing accumulation of fluid in the tissues and lungs
Congestive Heart Failure in infants s/s
tachycardia
tachypnea
fatigue during feeding
sweating around scalp and forehead
dyspnea
sudden weight gain
cyanosis
bluish color of the skin, nail beds, and/or lips due to an insufficient amount of oxygen in the blood
is it general or localized
exact location if localized
treatment nursing care for a child with heart failure
reduce work load on heart
improve respiration’s
maintain nutrition
prevent infection
reduce the anxiety of patient
support and instruct the parents
digoxin dose should be checked
by two nurses any dose larger than 0.05 mg or 50 mcg should be checked with DR
diuretics like lasix furosemide or diuril are for edema nurse should watch for
potassium depletion = electrolyte imbalance feed the child high potassium foods.
rheumatic fever
a severe disease chiefly of children and characterized by painful inflammation of the joints and frequently damage to the heart valves CNS known as a collagen disease scarring of the Mitral valve kids 5 to 15 years old.
group A strep infection complication causes RF
rheumatic fever diagnosis

Use the revised Jones criteria (may be over-rigorous). There must be evidence of recent strep infection plus 2 major criteria, or 1 major + 2 minor.

Evidence of group A β-haemolytic streptococcal infection:
• Positive throat culture (but this is usually negative by the time symptoms of rheumatic fever appear)
• Rapid streptococcal antigen test
• Elevated or rising streptococcal antibody titre (eg ASO or DNase B titre)
• Recent scarlet fever

Major criteria:
• Carditis: Tachycardia, murmurs (mitral or aortic regurgitation, Carey Coombs’ murmur, [link]), pericardial rub, CCF, cardiomegaly, conduction defects (45-70%). An apical systolic murmur may be the only sign.102
• Arthritis: A migratory, ‘flitting’ polyarthritis; usually affects larger joints (75%).
• Subcutaneous nodules: Small, mobile painless nodules on extensor surfaces of joints and spine (2-20%).
• Erythema marginatum: (fig 1) Geographical-type rash with red, raised edges and clear centre; occurs mainly on trunk, thighs, arms in 2-10% ([link]).
• Sydenham’s chorea (St Vitus’ dance): Occurs late in 10%. Unilateral or bilateral involuntary semi-purposeful movements. May be preceded by emotional lability and uncharacteristic behaviour.103

Minor criteria:
• Fever
• Raised ESR or CRP
• Arthralgia (but not if arthritis is one of the major criteria)
• Prolonged PR interval (but not if carditis is major criterion)
• Previous rheumatic fever

rheumatic fever treatment
1. Penicillin 10 days
2. Erythromycin for penicillin sensitive
3. Aspirin (salicylates) to control inflammation
4, Prophylactic treatment against recurrence monthly IM injections of benzathine penicillin. susceptible to recurrence should be monitored for 5 years
rheumatic fever diagnosis
Use the revised Jones criteria (may be over-rigorous). There must be evidence of recent strep infection plus 2 major criteria, or 1 major + 2 minor.
blood pressure cuff
should encircle two thirds of the length of the upper arm for accurate reading
systemic hypertension
BP above 90th or 95th percentile for age and sex on three separate visits
causes primary-uknown, secondary- renal disease or cardio disorders
Treatment- Ace inhibitors, beta blockers, diuretics
hypertension treatment
Lifestyle (weight loss, diet, exercise, low alcohol)
Diuretics
Beta Blockers
Alpha blockers
ACE inhibitors
ARBs
Calcium Channel Blockers (CCB)
Vasodilators
hyperlipidemia
presence of excess lipids in the blood, Elevation of cholesterol and or triglycerides in the blood
ldl
Low-Density Lipoprotein — carrier system for saturated fat to the cells which aids in cellular respiration and steroid production . Levels in blood should be LOW. High blood concentrations are predictors for fatal heart attack or stroke — the higher the LDL, the earlier the episode is expected to occur.
hdl
high density lipoprotien, good cholestrol, carrier protien that carries cholestrol from body to liver for processing and elimination
children with the cholesterol levels of over
240mg/dl or history of cardiac death should be tested — or two consecutive readings of 170 mg/dl should be followed closely and nutritional guidance
Kawasaki disease
Mucosal erythema fever above 104 F does not respond to antibiotics (lips, tongue, and pharynx), strawberry tongue, cherry red lips, polymorphous rash (primarily on trunk), erythema of palms and soles with later desquamation of fingertips peeling the peeling is painless ****
Kawasaki disease treatment
intravenous gamma globulin and aspirin
paroxysmal hypercyanotic episodes, or “tet” spells
paroxysmal hypercyanotic episodes, or “tet” spells, occur during the first 2 years of life. Spontaneous cyanosis, respiratory distress, weakness, and syncope occur.
They can last a few minutes to a 2-3 hours and are followed by lethargy and sleep. Parents must be instructed to place the child in a knee-chest position when a tet spell occurs. Recovery is usually rapid.
four defects in tetralogy of Fallot.
Pulmonary artery stenosis;
hypertrophy of the right ventricle;
dextroposition of the aorta;
and ventricular septal defect.
Tachycardia at rest; fatigue during feedings; sweating around the scalp and forehead; dyspnea; and sudden weight gain
early signs of congestive heart failure in infants?
nursing goals significant to the care of children with heart failure.
Reducing the work of the heart; improving respiration; maintaining proper nutrition; preventing infection; reducing the patient’s anxiety; and supporting and instructing the parents.
symptoms of digitalis toxicity.
Nausea; vomiting; anorexia; irregularity in rate and rhythm of the pulse; and a sudden change in pulse –bradycardia
symptoms of rheumatic carditis.
Symptoms of poor circulation and heart failure may appear. The child has an irregular low-grade fever, is pale and listless, and has a poor appetite. Moderate anemia and weight loss are apparent. The child may experience dyspnea on exertion. The pulse and respiration are out of proportion to the body temperature. The physician may detect a soft murmur over the apex of the heart.
permanent damage to the heart can be prevented in a child with rheumatic fever by
Permanent damage to the heart can be prevented with antibacterial therapy; physical and mental rest; relief of pain and fever; and management of cardiac failure should it occur.
nonpharmacological methods for preventing and treating high blood pressure in children.
Nonpharmacological methods include aerobic exercise; reduction of sedentary activities such as computer, TV, and video games; weight reduction; dietary management with fresh vegetables and low-fat foods; adequate intake of potassium and calcium; and avoidance of smoking and those who smoke.
manifestations of Kawasaki disease?
The onset is abrupt with a sustained fever, sometimes above 40° C (104° F), which does not respond to antipyretics or antibiotics. The fever lasts for more than 5 days. Conjunctivitis without discharge, fissured lips, a “strawberry tongue,” inflamed mouth and pharyngeal membranes, and enlarged nontender lymph nodes are seen. An erythematous skin rash develops, with swollen hands and desquamation of the palms and soles. The child is very irritable and may develop signs of cardiac problems.
infective endocarditis
a microbial infection that affects the endocardial and endothelium and the heart valves.
infective endocarditis treatment
Prolonged course of antibiotics, Step treated with combination of penicillin and gentamycin, Staph treated with nafcillin or gentamycin, IV drug therapy for 2-8 weeks
infective endocarditis number one cause
is streptococcus viridans
infective endocarditis s/s
INSIDIOUS onset, low grade fever, chills, weakness, malaise, pallor of fingers/lips, splinter hemorrages of nails, Janeway Lesions (non tender macules) mostly on palms/soles, Roths Spots (retinal hemorragging, Oslers Nodes (painful nodes on fingertips and toes), petachiae, murmurs/arrhythmia’s, congestive heart failure, chorea(tremors) movements
Oslers Nodes
painful nodules on finger and toe pads….seen in endocarditis caused by strep viridans
Janeway Lesions
Janeway Lesions (non tender macules) mostly on palms/soles,seen in endocarditis caused by staph
rheumatic fever treatment
Aspirin for the pain
Coarctation of Aorta treatment
Signs: systolic murmur, hypertension, diminished femoral pulses
Diagnosis: echocardiography
Treatment: pre-op prostaglandins to reopen ductus arteriosus + surgical repair
antidote for digoxin ?

Treating severe, possibly life-threatening digoxin or digitoxin overdose.

Digibind is an antidote for digoxin toxicity. It works by binding to digoxin and preventing it from working in the body.

nurse Amy explains that which congenital cardiac defects cause increased pulmonary blood flow
Ventricular septal defects
Atrial septal defects (foramen ovalis)
Patent ductus arteriosus
A child with tetralogy of Fallot seems to favor a squatting position why ?
When the kid is in the squatting position it allows the child to breathe more easily because systemic venous return is increased.
What assessment made by nurse Amy would lead her to suspect a ventricular septal defect :
she felt a systolic thrill and hears a loud, harsh murmur.
a ventricular septal defect will allow:
blood to shunt left to right, causing increased pulmonary flow and no cyanosis.
nurse Amy observes an infant that is experiencing dyspnea related to patent ductus arteriosus (PDA).Amy knows that dyspnea occurs because blood is:
circulated through the lungs again from the aorta to the pulmonary artery, causing pulmonary circulatory congestion.
NUrse Amy knows that a a complication that may occur after a cardiac catheterization is ?
Cardiac arrhythmia which usually go away but may return
after an cardiac catheterization of a little guy 2-5 yr old
his leg must stay straight for 4- 6 hours –leave the band aid on
Kawaski disease causes
peeling of the soles and feet it is PAINLESS
Kawaski HALLMARK SIGN
irritability
Transposition of the great vessels
Congenital heart defect
2 major vessels that carry blood away from the heart (aorta and pulmonary artery) are switched (transposed).
Give Prostaglandin E1 to keep PDA open
Which of the following would be included in the care of an infant in heart failure?

Begin formulas with increased calories.

Explanation:
Infants with heart failure need increased calories for growth. The infants are typically given smaller, more frequent feedings to decrease the amount given and to help conserve energy for feeding. They often times are given a higher-calorie formula. The infant should be placed in an upright position or in a car seat to increase oxygenation. The infant should not have any pressure on the diaphragm while in this position. Vomiting is a sign of digoxin toxicity and this should be considered before administering.

On assessment immediately following cardiac surgery, which of the following conditions would you expect to find in an infant?

Hypothermia

Explanation:
Cardiac surgery is often performed under hypothermia to decrease the child’s oxygen needs during surgery.

After a cardiac catheterization, the nurse monitors the child’s fluid balance closely based on the understanding of which of the following?

The contrast material used has a diuretic effect.

Explanation:
The contrast material has a diuretic effect so the nurse assesses the child closely for signs and symptoms of dehydration and hypovolemia. Although blood loss can occur, this is not the reason for monitoring the child’s fluid balance. Catheter insertion into the heart does not initiate a diuretic response. Typically, food and fluid is withheld for 4 to 6 hours before the procedure.

The nurse is implementing the plan of care for a child with acute rheumatic fever. Which of the following would the nurse expect to administer if ordered? Select all that apply.
• Nonsteroidal anti-inflammatory drugs
• Penicillin
• CorticosteroidsExplanation:
A full 10-day course of penicillin or equivalent is used. Corticosteroids are used as part of the treatment for acute rheumatic fever. Nonsteroidal anti-inflammatory drugs are used as part of the treatment for acute rheumatic fever. Digoxin is used to treat heart failure, atrial fibrillation, atrial flutter, and supraventricular tachycardia. Intravenous immunoglobulin is used to treat Kawasaki disease.

A group of nurses is reviewing the cardiovascular system and its function. Which of the following statements is the most accurate regarding the cardiovascular system in the child?

At birth the right and left ventricle are about the same size.

Explanation:
At birth, both the right and left ventricles are about the same size, but by a few months of age, the left ventricle is about two times the size of the right. If the infant has a fever, respiratory distress, or any increased need for oxygen, the pulse rate goes up to increase the cardiac output. Although the size is smaller, by the time the child is 5 years old, the heart has matured, developed, and functions just as the adult’s heart.

When educating the family of an ill infant with a large, symptomatic ventricular septic defect (VSD), which of the following would be included in the education if the doctor is planning on performing palliative care until the infant is healthier?

Palliative pulmonary artery banding should help the infant grow.

Explanation:
Palliative pulmonary artery banding should help the infant grow enough so that the large VSD can be repaired. The pulmonary artery banding will help, but the defect will still need to be fixed. Most infants will need surgery for a large, symptomatic VSD. The medication indomethacin is used for a PDA.

When developing a teaching plan for the parents of a child diagnosed with tricuspid atresia, the nurse would integrate knowledge of which of the following as the major mechanism involved?

Obstruction of blood flow to the lungs

Explanation:
Tricuspid atresia is a congenital heart defect in which the valve between the right atrium and right ventricle fails to develop, resulting in no opening to allow blood to flow from the right atrium to the right ventricle and subsequently through the pulmonary artery into the lungs. It is classified as a disorder of decreased pulmonary blood flow due to obstruction of blood flow to the lungs. Defects with connections involving the left and right sides, such as atrial or ventricular septal defects, will shunt blood from the higher-pressure left side to the lower-pressure right side and subsequently more blood will go to the lungs. A narrowed major vessel leads to an obstructive defect, interfering with the ability of the blood to flow freely through the vessel. Mixed defects such as transposition of the great vessels involve the mixing of well-oxygenated with poorly oxygenated blood, leading to a systemic blood flow that contains a lower oxygen content.

A nursing instructor is preparing for a class about the structural and functional differences in the cardiovascular system of infants and children as compared to adults. Which of the following would the instructor include in the class discussion?
The heart’s apex is higher in the chest in children younger than the age of 7 years.
Explanation:
In infants and children younger than age 7 years, the heart lies more horizontally, resulting in the apex lying higher in the chest. Right ventricular function predominates at birth, and over the first few months of life, left ventricular function becomes dominant. A normal infant’s blood pressure is about 80/40 mm Hg and increases over time to adult levels. Between the ages of 1 and 6 years, the heart is four times the birth size; between 6 and 12 years of age, the heart is 10 times its birth size.
In caring for the child with rheumatic fever which medication would the nurse likely administer?

Aspirin

Explanation:
Salicylates are administered in the form of aspirin to reduce fever and to relieve joint inflammation and pain in the child with rheumatic fever. Although salicylates as a general rule are not given to children, they continue to be the treatment of choice for rheumatic fever. Tylenol is not effective for the inflammation. Insulin would be given for diabetes and dilantin for seizure disorders.

A child is being placed on a cardiopulmonary bypass machine. The nurse understands the heart will pump again on its own when which of the following occurs?

The child starts getting warm again.

Explanation:
The child is placed in a hypothermic state when placed on a cardiopulmonary bypass. When the child is warmed, the heart starts pumping again.

A group of students are reviewing information about acute rheumatic fever. The students demonstrate a need for additional review when they identify which of the following as a major Jones criterion?

Arthralgia

Explanation:
Arthralgia is considered a minor criterion. Carditis is a major criterion. Erythema marginatum is considered a major criterion. Subcutaneous nodules are considered a major criterion.

A nurse is caring for a newborn with congenital heart disease (CHD). Which of the following would the nurse interpret as indicating distress?

Subbcostal retraction at the time of feeding

Explanation:
Subcostal retraction during feeding is indicative of distress associated with feeding in newborn infants with CHD. Feeding can be a stress to newborns with CHD who are seriously compromised. Additional features indicating distress in infants with CHD include increased respiratory rate, perspiration along the hairline during feeding and feeding time longer than 30 minutes.

The nurse is assessing a child with suspected rheumatic fever. Which of the following would the nurse expect to find? Select all that apply.
• Involuntary limb movement
• Macular rash on trunk
• Tender swollen jointsExplanation:
Signs and symptoms of rheumatic fever include systolic murmur, involuntary limb movement, macular rash on the trunk, tender swollen joints, and subcutaneous nodules.

An 8-month-old has a ventricular septal defect. Which nursing diagnosis below would best apply?

Ineffective tissue perfusion related to inefficiency of the heart as a pump

Explanation:
A ventriculoseptal defect permits blood to flow across a septum, creating an ineffective pump.

The nurse is caring for a child with congestive heart failure and is administering the drug digoxin. At the beginning of this drug therapy the process of digitalization is done for which of the following reasons?

To build the blood levels to a therapeutic level

Explanation:
The use of large doses of digoxin at the beginning of therapy, administered to build up the blood levels of the drug to a therapeutic level, is known as digitalization. A maintenance dose is given, usually daily, after digitalization. Digoxin is used to improve the cardiac efficiency by slowing the heart rate and strengthening the cardiac contractility. Digoxin is not indicated for relief of pain.

A nurse is examining a 10-year-old girl who has a heart murmur. On auscultation, the nurse finds that the murmur occurs only during systole, is short, and sounds soft and musical. When she has the girl stand, she can no longer hear the murmur on auscultation. Which of the following should the nurse say to the girl’s mother in response to these findings?

“Your daughter has an innocent heart murmur, which is nothing to worry about.”

Explanation:
The symptoms described indicate an innocent heart murmur. Although innocent murmurs are of no consequence, parents need to be told when their child has one because this finding will undoubtedly be discovered again at a future health assessment or during a febrile illness, anxiety, or pregnancy. Activities need not be restricted when a child has an innocent murmur and the child requires no more frequent health appraisals than other children. If a murmur is present as the result of heart disease or a congenital disorder, it is an organic heart murmur.

The nurse is providing education to parents of a child with a blood pressure in the 90th percentile. Which of the following would be included in the intervention strategies?

The nurse would review the child’s 24-hour diet recall.

Explanation:
With a child in the 90th percentile for blood pressure, diet and physical activity should be the main focus. Blood pressures should be measured, but daily is not necessary. Children are not routinely put on beta blockers and the child should be allowed to participate in sports if monitored.

A nurse is giving discharge instructions to the parents of a newborn with a congenital heart disorder. Which of the following should the nurse instruct the parents to do in the event that the child becomes cyanotic?

Place him in a knee-chest position

Explanation:
Before parents leave the hospital with a newborn who has a congenital heart disorder, be certain they have the name and number of the health professional to call if they have a question about their infant’s health. Review with them the steps to take if their child should become cyanotic, such as placing the child in a knee-chest position. “Hands on” CPR is not recommended for children as it is for adults. Remind parents that children with many types of congenital heart disorders or rheumatic fever need prophylactic low-dose aspirin therapy to avoid blood clotting; although becoming a controversial practice, they may be prescribed antibiotic therapy such as oral amoxicillin before oral surgery.

A nurse suspects a child is experiencing cardiac tamponade after heart surgery. Which of the following would be the priority nursing intervention?

Notify the doctor immediately.

Explanation:
The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed. The child can die if intervention is postponed. It would not be appropriate to perform any interventions until confirming that this is the actual diagnosis.

The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed?

Digoxin

Explanation:
Digoxin is indicated for atrial fibrillation. It increases the contractility of the heart muscle by decreasing conduction and increasing force. Alprostadil is indicated for temporary maintenance of ductus arteriosus patency in infants with ductal-dependent congenital heart defects. Furosemide is used for the management of edema associated with heart failure. Indomethacin is used to close a patent ductus arteriosus

After assessing a child, the nurse suspects coarctation of the aorta based on which of the following?

Femoral pulse weaker than brachial pulse

Explanation:
A femoral pulse that is weak or absent in comparison to the brachial pulse is associated with coarctation of the aorta. Bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. A narrow or thread pulse is associated with heart failure or severe aortic stenosis. Hepatomegaly is a sign of right-sided heart failure

A school nurse finds a 10-year-old’s blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect?

The child will need the blood pressure checked two more times.

Explanation:
The child will need the blood pressure checked two more times. It is routine to check the blood pressure on three separate occasions to get the most accurate analysis of the blood pressure. The child usually does not need surgery or need to go to the emergency room. This is not a normal result in a blood pressure finding

The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which of the following reactions?

Wheezing

Explanation:
The nurse must report any hypersensitivity reactions such as wheezing and pruritus, as these could be a sign of anaphylaxis. Stomach upset is common with oral antibiotics and is not something that needs to be reported immediately. Nausea with diarrhea is common with oral antibiotics and does not need to be reported immediately. Abdominal distress is common with oral antibiotics and does not need to be reported immediately.

A child with heart disease is receiving digoxin and a diuretic. Which laboratory test result would be most important for the nurse to monitor?

Serum potassium level

Explanation:
Children receiving diuretics should have serum potassium levels obtained because diuretics tend to deplete the body of potassium. This is even more important if the child is also receiving digoxin because low serum potassium levels potentiate or increase the effect of the drug. Serum sodium levels may be obtained in children with heart failure to ensure that an increased sodium level is not causing edema. The erythrocyte sedimentation rate identifies inflammation and is unrelated to the use of diuretics and digoxin. Oxygen saturation levels may be done to evaluate for hypoxemia, but these results would be unrelated to the use of digoxin and diuretics.

A parent brings an infant in for poor feeding. Which of the following assessment data would most likely indicate a coarctation of the aorta?

Pulses weaker in lower extremities compared to upper extremities

Explanation:
An infant with coarctation of the aorta has decreased systemic circulation causing this problem. The cyanosis would be associated with tetralogy of Fallot.

When caring for a child that has just had a cardiac catheterization, which of the following would indicate a sign of hypotension?

Cold clammy skin and increased heart rate

Explanation:
Cold, clammy skin, increased heart rate, and dizziness are signs of hypotension that may be a complication after a cardiac catheterization. Decreased heart rate, syncope, and tachypnea would also be very concerning, but not necessarily a sign of hypotension.

A nurse is providing education to a family about cardiac catheterization. Which of the following would be included in the education?

The catheter will be placed in the femoral artery.

Explanation:
The femoral artery is the correct placement of the cardiac catheter. The child will need to lie still for several hours after the procedure. The procedure is usually postponed if the child has a fever.

A parent is asking for more information about their infant’s patent ductus arteriosus (PDA). What would be included in the education?

This is caused by an opening that usually closes by 1 week of age.

Explanation:
A PDA is caused by an opening that usually closes by 1 week of age called the ductus arteriosus. The defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants.

An infant girl is prescribed digoxin. You would teach her parents that the action of this drug is to

Slow and strengthen her heartbeat.

Explanation:
Digoxin is a cardiac glycoside that slows and strengthens the heartbeat.

When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. Which of the following would most likely explain this assessment finding?

The liver increases in right-sided heart failure.

Explanation:
The liver increases in size due to right-sided heart failure. This is one of the cardinal signs of congestive heart failure. The spleen is in the upper left quadrant of the abdomen and would increase in size under certain circumstances, but this is asking for the upper right quadrant information. There are certain medications that can affect the liver, but this would not be the most likely reason for hepatomegaly.

Parents are told their infant has a hypoplastic left heart. What is the type of education that would be included for this family?

This is a problem where the left side of the heart did not develop properly.

Explanation:
This is a problem where the left side of the heart did not develop properly. There is a three-step palliative surgery that can be implemented or the child will need a heart transplant.

The nurse is providing child and family education prior to discharge following a cardiac catheterization. The nurse is teaching about signs and symptoms of complications. Which statement by the mother indicates a need for further teaching?

“The feeling of the heart skipping a beat is common.”

Explanation:
Reports of heart “fluttering” or “skipping a beat” should be reported to the doctor as this can be a sign of a complication. This statement is appropriate because tub baths should be avoided for about 3 days. This statement is appropriate because strenuous activity is limited for about 3 days. Changes in skin color or difficulty breathing indicate potential complications that need to be reported.

At 3 years of age, a child has a cardiac catheterization. After the procedure, which of the following interventions would be most important?

Taking pedal pulses for the first 4 hours

Explanation:
Insertion of a catheter into the femoral vein can cause vessel spasm, interfering with blood circulation in the leg. Assessing pedal pulses ensures circulation is adequate.

The nurse is caring for a child diagnosed with rheumatic fever. The nurse would do all of the following nursing interventions. Which two interventions would be the priority for the nurse? Select all that apply.
• Carefully handle the child’s knees, ankles, elbows and wrists when moving the child.
• Administer salicylates after meals or with milkExplanation:
Pain control and relief are the highest priorities for the child with rheumatic fever. Position the child to relieve joint pain. Large joints, including the knees, ankles, wrists, and elbows, are usually involved. Carefully handle the joints when moving the child to help minimize pain. Salicylates are administered in the form of aspirin to reduce fever and relieve joint inflammation and pain

A parent asks why their infant with a cyanotic heart defect turns blue. What is the best response by the nurse?

This is due to a decreased amount of oxygen to the peripheral tissue.

Explanation:
Cyanosis associated with certain congenital heart defects is due to the body naturally compensating and decreasing the amount of oxygen to the peripheral tissue. This keeps the oxygen with the vital organs to sustain life. The lack of oxygen is not in the brain; it is in the systemic flow of the body. Cyanosis is a common finding with these types of heart defects and in general, does not usually need immediate surgery or is a sign of heart failure

A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?

Peeling hands and feet and fever

Explanation:
One of the signs of Kawasaki disease is the peeling hands and feet. The other symptoms are not necessarily characteristic of Kawasaki disease.

A child is having surgery for a congenital heart defect. The parent asks about their 1-year-old’s growth and developmental delays and what they can expect after surgery. What is the best response by the nurse?

“After surgery, most children will catch up.”

Explanation:
A child with a congenital heart defect who has growth and developmental delays will usually catch up after the defect is fixed. There is no way of predicting exactly what each child will do and it is not appropriate to tell a parent that these delays are permanent when that is unknown until the defect is corrected by surgery.

You would teach the mother of a boy with tetralogy of Fallot that if he suddenly becomes cyanotic and dyspneic to

place him in a knee-chest position.

Correct
Explanation:
Placing a child in a knee-chest or squatting position traps blood in the legs, allowing the child to better oxygenate that remaining in the trunk.

A child is diagnosed with tetralogy of Fallot and during a temper tantrum turns blue. Which of the following would the nurse do first?

Place child in the knee-to-chest position.

Explanation:
Place child in the knee-to-chest position. This position is the first priority of the child with tetralogy of Fallot. Cyanosis is caused by the heart defect and placing the child in this position will decrease the cyanosis.

You take an infant’s apical pulse before administering digoxin. What is the usually accepted level of pulse rate considered safe for administering digoxin to an 8-month-old infant?

100 beats per minute

Explanation:
Because digoxin slows the heart rate, it is important that it is not already beating at a slow rate before administration.

The nurse is explaining possible side effects of corticosteroids to the caregiver of a child diagnosed with rheumatic fever. The caregiver comments, “I don’t understand what hirsutism means.” The nurse would be correct in explaining that hirsutism is which of the following?

Abnormal hair growth

Explanation:
The child whose pain is not con trolled with salicylates may be ad ministered corticosteroids. Side effects such as hirsutism (abnormal hair growth) and “moon face” may be noted. Facial grimaces and repetitive involuntary movements are symptoms of chorea.

An 8-year-old child is scheduled for an exercise stress test. Which instruction would be most important for the nurse to emphasize?

“You need to report any symptoms you are having during the test.”

Explanation:
It is important for the child to report any symptoms felt during the test to help quantify the child’s exercise tolerance. Exercise stress testing involves activity. Ambulatory electrocardiographic monitoring is performed over 24 hours. Sedation is not used for an exercise stress test. It is used for an arteriogram.

The nurse is administering medications to the child with congestive heart failure. Large doses of which of the following medications are used initially in the treatment of CHF to attain a therapeutic level?

Digoxin (Lanoxin)

Explanation:
The use of large doses of digoxin, at the beginning of therapy, to build up the blood levels of the drug to a therapeutic level is known as digitalization.

A 6-year-old girl is diagnosed with pulmonary stenosis. The mother asks the nurse what the likely treatment for this condition will involve. The nurse should tell the mother which of the following?

Insertion of a catheter with an uninflated balloon tip into the affected valve, followed by inflation of the balloon to break up adhesions

Explanation:
Balloon angioplasty by way of cardiac catheterization is the procedure of choice for pulmonary stenosis. With this procedure, a catheter with an uninflated balloon at its tip is inserted and passed through the heart into the stenosed valve. As the balloon is inflated, it breaks valve adhesions and relieves the stenosis. The other answers refer to interventions related to patent ductus arteriosus, not pulmonary stenosis.

A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed?

“We can stop the penicillin when her symptoms disappear.”

Explanation:
For a child with rheumatic fever, drug therapy must be given for the full 10 to 14 days to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.

The nurse is collecting data on a 5 year old child admitted with the diagnosis of congestive heart failure. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis?

Failure to gain weight

Explanation:
In infants and older children, one of the first signs of CHF is tachycardia. Other signs of CHF often seen in the older child include failure to gain weight, weakness, fatigue, restlessness, irritability, and a pale, mottled, or cyanotic color. Rapid respirations or tachypnea, dyspnea, and coughing with bloody sputum also are seen. Edema and enlargement of the liver and heart may be present. Jerking movements indicate seizure activity. Scissoring of the legs is seen in cerebral palsy, and clubbing of the fingers is seen in cystic fibrosis.

A nurse is reviewing blood work on a patient with a cyanotic heart defect. Which of the following results would most likely be seen in a patient experiencing polycythemia?

Increased RBC

Explanation:
Polycythemia can occur in patients with a cyanotic heart defect. The body tries to compensate for having low oxygen levels and produces more red blood cells (RBCs). This would cause an increased result on the lab tests. This problem does not affect the white blood cells (WBCs).

The nurse is teaching an inservice program to a group of nurses on the topic of children diagnosed with rheumatic fever. The nurses in the group make the following statements. Which statement is most accurate regarding the diagnosis of rheumatic fever?

“Children who have this diagnosis may have had strep throat.”

Explanation:
Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle.

An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority?

Place the infant in the knee-chest position.

Explanation:
Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot. Starting IV fluids and preparing the child for surgery would not be necessary since it is known that the infant has a cyanotic birth defect. Raising the head of the bed would not be a priority since the infant needs to be placed in the knee-chest position.

A newborn has been diagnosed with a congenital heart disease. Which of the following congenital heart diseases is associated with cyanosis?

Tetralogy of Fallot

Explanation:
Tetralogy of Fallot is associated with cyanosis. The defects include ventricular septal defect (VSD), right ventricular hypertrophy, right outflow obstruction, and overriding aorta. Coarctation of aorta, pulmonary stenosis, and aortic stenosis are acyanotic heart diseases and are not associated with cyanosis.

Infants with congenital heart disease should not be allowed to become dehydrated because this makes them prone to

cerebrovascular accident.

Explanation:
Children who have polycythemia from cardiovascular disease can develop thrombi if they become dehydrated.

The infant has been hospitalized and develops hypercyanosis. The physician has ordered the nurse to administer 0.1 mg of morphine sulfate per every kilogram of the infant’s body weight. The infant weighs 15.2 pounds. Calculate the infant’s morphine sulfate dose. Round your answer to the nearest tenth.

0.7

Explanation:
The infant weighs 15.2 pounds (2.2 pounds = 1 kg.) 15.2 pounds x 1 kg/2.2 pounds = 6.818 kg The infant weighs 6.818 kg. For each kilogram of body weight, the infant should receive 0.1 mg of morphine sulfate. 6.818 kg x 0.1 mg/1 kg = 0.6818 mg Rounded to the tenth place = 0.7 mg The infant will receive 0.7 mg of morphine sulfate.

When a child is scheduled for a cardiac catheterization, an important health teaching point for parents is that the

child will return with a bulky pressure dressing over the catheter insertion area.

Explanation:
Cardiac catheterization is typically performed with the child awake but using conscious sedation. A dressing will be placed on the catheter insertion site.

A nurse is interviewing a mother who is about to deliver her baby. Which of the following responses would alert the nurse for a higher potential for a heart defect in the infant?

The mother states she has lupus.

Explanation:
Having lupus while pregnant could contribute to a congenital heart defect. Acetaminophen and sleeping do not have an effect on a child developing a heart defect. The seizure medication can have an impact on the child having a heart defect, but not necessarily a history of seizures in the mother.

The nurse is assessing an infant for peripheral edema. Based on the nurse’s knowledge, the nurse would expect edema to occur in which area first?

Face

Explanation:
In infants, peripheral edema occurs first in the face, then the presacral region, and then the extremities. Edema of the lower extremities is characteristic of right ventricular heart failure in older children.

The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority?

Place the child in a knee-to-chest position.

Explanation:
The priority nursing action is to place the infant or child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as ordered. A calm, comforting approach should be used but is not the priority action. Once a child is placed in the knee-to-chest position, supplemental oxygen would be provided as ordered. Once a child is placed in the knee-to-chest position, medications would be given as ordered.

A nurse is taking the history of a 4-year-old boy who will undergo a cardiac catheterization. Which of the following statements by his mother may necessitate rescheduling of the procedure?

“He seems listless and slightly warm.”

Explanation:
Fever and other signs and symptoms of infection may necessitate rescheduling the procedure. Although information about allergies is important, not all contrast media contain iodine as a base. The nurse should address the child’s fears in a developmentally appropriate way, but fear of the procedure does not warrant rescheduling. Not using any medication would not be a reason for rescheduling the procedure.

The nurse is reviewing the laboratory test results of several children who have come to the clinic for evaluation. Which child would the nurse identify as having the least risk for hyperlipidemia?

Child A with a total cholesterol of 150 mg/dL and low-density lipoprotein (LDL) of 80 mg/dL.

Explanation:
Total cholesterol levels below 170 mg/dL and LDL levels less than 100 mg/dL are considered within the acceptable range. Total cholesterol levels between 170 and 199 mg/dL and LDL levels between 100 and 129 mg/dL are considered borderline. Total cholesterol levels between 170 and 199 mg/dL and LDL levels between 100 and 129 mg/dL are considered borderline. Total cholesterol levels greater than or equal to 200 mg/dL and LDL levels greater than or equal to 130 mg/dL are considered elevated and place this child at greatest risk.

A nurse is caring for a child who is experiencing heart failure. Which of the following assessment data was most likely seen when initially examined?

Tachycardia

Explanation:
If a child were experiencing heart failure, the most likely sign of this would be tachycardia, not bradycardia. The child may also experience hepatomegaly or oliguria, but not splenomegaly or polyuria.

A pregnant client tells her nurse that a friend of hers recently gave birth to an infant who was found to have congenital heart disease. She asks the nurse whether there is anything she can to reduce the risk of this type of condition occurring in her baby. Which of the following should the nurse mention to this patient?

“Make sure you are fully immunized.”

Explanation:
The cause of congenital heart disease often cannot be documented, although it is associated with familial patterns of inheritance and possibly triggers such as rubella (German measles) and varicella (chickenpox) infection during pregnancy. Women need to enter pregnancy fully immunized to help prevent infection during pregnancy. Encouraging the child to eat a low-sodium diet and exercise as he grows up will help prevent acquired heart disease, not congenital heart disease

Which of the following nursing diagnoses would best apply to a child with rheumatic fever?

Activity intolerance related to inability of heart to sustain extra workload

Explanation:
Children with rheumatic fever need to reduce activity to relieve stress during the course of the illness.

A nurse is caring for a child that just had open-heart surgery and the parents are asking why there are wires coming out of the chest of the infant. What is the best response by the nurse?

These wires are connected to the heart and will detect if your child’s heart gets out of rhythm.

Explanation:
The wires may be connected to a pacemaker. Connection to the temporary pacemaker is usually until the child is out of danger for arrhythmia.

A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. Which of the following interventions should the nurse take to prevent infection?

Avoid drawing a blood specimen from the right femoral vein before the procedure

Explanation:
Because the vessel site chosen for catheterization must not be infected at the time of catheterization (or obscured by a hematoma), never draw blood specimens from the projected catheterization entry site before the procedure (generally a femoral vein). The other interventions listed are performed for reasons other than prevention of infection. Children scheduled for the procedure are usually kept NPO for 2 to 4 hours beforehand to reduce the danger of vomiting and aspiration during the procedure. Be certain to record pedal pulses for a baseline assessment. The site for catheter insertion is locally anesthetized with EMLA cream or intradermal lidocaine.

When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure?

Tachycardia

Explanation:
Tachycardia is one of the signs of heart failure. Bradycardia, inability to sweat, and splenomegaly are not necessarily signs of heart failure.

A nurse is administering digoxin to a 3-year-old. Which of the following would be a reason to hold the dose of digoxin?

Nausea and vomiting

Explanation:
Nausea and vomiting are signs of digoxin toxicity. The other symptoms listed here are not necessarily signs of a digoxin toxicity.

An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. Which of the following is the best response from the nurse?

It will determine if the heart is enlarged.

Explanation:
Chest x-rays are performed to see if the heart is enlarged. This will determine if the heart muscle is increasing in size. Disturbances in heart conduction are detected by an EKG. Visualizing where blood is being shunted is through the echocardiogram. The image used to clarify the structures of the heart is the MRI.

The nurse is performing echocardiography on a newborn who is suspected of having a congenital heart defect. The child’s mother is concerned about the safety of using this on a newborn and wants to know how this technology works. The nurse assures her that this technology is very safe and may be repeated frequently without added risk. Which of the following should the nurse mention in explaining how this diagnostic test works?

High-frequency sound waves are directed toward the heart

Explanation:
Echocardiography, or ultrasound cardiography, has become the primary diagnostic test for congenital heart disease. For this, high-frequency sound waves, directed toward the heart, are used to locate and study the movement and dimensions of cardiac structures, such as the size of chambers, thickness of walls, relationship of major vessels to chambers, and the thickness, motion, and pressure gradients of valves. You can remind parents echocardiography does not use x-rays so it can be repeated at frequent intervals without exposing their child to the possible risk of radiation. The other answers refer to other types of diagnostic tests, including X-ray studies, radioangiocardiography, and phonocardiography.

When educating the family of an infant with a small, asymptomatic atrial septal defect (ASD), which of the following would be included in the education?

“Most infants do not need surgical repair for this.”

Explanation:
Most infants do not need surgical repair for an ASD unless they are symptomatic. The hole will close spontaneously 87% of the time. The medication indomethacin is used to help close the opening of a PDA and the medication prostaglandin E1 is used to keep a patent ductus arteriosus (PDA) open. These medications are not used for ASDs.

A parent asks if the reason her infant has a congenital heart defect is because of something she did while she was pregnant. What is the best response by the nurse?

There are several reasons a baby can have a heart defect, let’s talk about those causes.

Explanation:
Focus on the therapeutic communication in this situation, while still obtaining more information. This will help the nurse explore various options for the cause of the defect with the parent.

A child with heart disease is receiving digoxin and a diuretic. Which laboratory test result would be most important for the nurse to monitor?

Serum potassium level

Explanation:
Children receiving diuretics should have serum potassium levels obtained because diuretics tend to deplete the body of potassium. This is even more important if the child is also receiving digoxin because low serum potassium levels potentiate or increase the effect of the drug. Serum sodium levels may be obtained in children with heart failure to ensure that an increased sodium level is not causing edema. The erythrocyte sedimentation rate identifies inflammation and is unrelated to the use of diuretics and digoxin. Oxygen saturation levels may be done to evaluate for hypoxemia, but these results would be unrelated to the use of digoxin and diuretics.

The nurse is reviewing the health history and physical examination of a child diagnosed with heart failure. Which of the following would the nurse expect to find? Select all that apply.
• Shortness of breath when playing
• Crackles on lung auscultation
• Tiring easily when eating
Correct
Explanation:
Manifestations of heart failure include difficulty feeding or eating or becoming tired easily when feeding or eating, shortness of breath with exercise intolerance, crackles and wheezes on lung auscultation, tachycardia, and hypotension.
A nurse is caring for an infant who is experiencing heart failure. Which of the following would be the most appropriate care for this infant?

Administer oxygen.

Explanation:
If a child is experiencing heart failure, the infant will need oxygen. One of the medications the infant would be on is a diuretic. An infant with heart failure will need smaller, more frequent feedings to conserve energy for feeding. Infants are not usually put on fluid restriction.

When reviewing the record of a child with tetralogy of Fallot, which of the following would you expect to discover?

Polycythemia

Explanation:
Children who cannot oxygenate red cells well often produce excess red blood cells or develop polycythemia.

When caring for a child with Kawasaki Disease, the nurse would know which of the following?

Management includes administration of aspirin and IVIG.

Explanation:
Kawasaki disease is managed with IVIG and aspirin to prevent cardiac complications. Joint pain is not necessarily a permanent problem associated with Kawasaki disease. Antibiotics and steroid creams are not used for this disorder.

A client’s newborn is diagnosed with Tetralogy of Fallot. When explaining this condition to the client, which of the following defects would the nurse’s description include?

Overriding of the aorta

Explanation:
One of the components in the Tetralogy of Fallot is overriding of the aorta. Tetralogy of Fallot is a congenital heart disease with 4 components. The defects in the Tetralogy of Fallot include ventricular septal defect, overriding of the aorta, pulmonary stenosis, and right ventricular hypertrophy. Atrial septal defect, stenosis of the aorta and left ventricular hypertrophy are not components of Tetralogy of Fallot.

A parent asks about the risk of a congenital heart defect being passed on to another child since they already have one child that has it, but no one else in the family has one. What is the best response by the nurse?

There is a less than 7% chance a sibling would inherit a heart defect.

Explanation:
The risk to subsequent siblings of a child with CHD is approximately 2% to 6% so genetics can play a role in the child having a cardiac defect

A child with a congenital heart defect is getting an echocardiogram. How would the nurse describe this test to the parent?

This is a test that will check how blood is flowing through the heart.

Explanation:
Echocardiograms can determine the size of the heart and how the heart is pumping blood. An echocardiogram does not check the electrical impulses or the size of the heart. This is a non-invasive test.

A school nurse is caring for a child with a severe sore throat and fever. Which of the following would be the best recommendation by the nurse to the parent?

Have the child be seen by the primary care provider.

Explanation:
Children with sore throats and fevers should be seen by their primary care provider to rule out strep throat. This is extremely important due to the fact they may contract an acquired heart disease called rheumatic fever. Taking acetaminophen, resting, and drinking fluids are all good recommendations, but the best recommendation is to see the provider. Going to the emergency room is not necessary at this time.

Which of the following would be most important to implement for an infant who develops heart failure?

Placing her in a semi-Fowler’s position

Explanation:
Placing an infant with heart failure in a semi-Fowler’s position reduces the pressure of abdominal contents against the chest and gives the heart the opportunity to function more effectively.

A nurse admits an infant with a possible diagnosis of congestive heart failure. Which of the following signs and symptoms would the infant most likely be exhibiting?

Feeding problems

Explanation:
The indications of CHF vary in children of different ages. Signs in the infant may be hard to detect because they are subtle, but in infants, feeding problems are often seen. In infants and older children, tachycardia is one of the first signs of CHF. The heart beats faster in an attempt to increase blood flow. Failure to gain weight, weakness, and an enlarged liver and heart are other possible indicators of CHF but are not as common as tachycardia and may take longer to develop

The nurse is performing an ECG on a 12-year-old boy. On completion, she notices that boy’s P-R interval is lengthened. Which of the following does this finding indicate?

Difficulty with coordination between the SA and AV nodes (first-degree heart block)

Explanation:
On an ECG tracing, a longer-than-usual P wave suggests the atria are hypertrophied making it take longer than usual for the electrical conduction to spread over the atria. A lengthened P-R interval suggests there is a difficulty with coordination between the SA and AV nodes (first-degree heart block). A heightened R wave indicates ventricular hypertrophy is present. An R wave which is decreased in height suggests the ventricles are not contracting fully, as happens if they are surrounded by fluid (pericarditis). Elongation of the T wave occurs in hyperkalemia; depression of the T wave is associated with anoxia; depression of the ST segment is associated with abnormal calcium levels.

Coarctation of the aorta demonstrates few symptoms in newborns. Which of the following is an important assessment to make on all newborns to help reveal this condition?

Assessing for the presence of femoral pulses

Explanation:
Infants with a narrowing (coarctation) of the aorta have decreased pressure in the lower extremities or absence of femoral pulses.

An 8-year-old child is scheduled for an exercise stress test. Which instruction would be most important for the nurse to emphasize?

“You need to report any symptoms you are having during the test.”

Explanation:
It is important for the child to report any symptoms felt during the test to help quantify the child’s exercise tolerance. Exercise stress testing involves activity. Ambulatory electrocardiographic monitoring is performed over 24 hours. Sedation is not used for an exercise stress test. It is used for an arteriogram.

The nurse is collecting data on a child being evaluated for rheumatic fever. The caregiver reports that over the past several weeks she has noticed that the child seems to have lack of coordination. In addition she reports the child has had facial grimaces and repetitive involuntary movements. The signs the caregiver reports indicate the child has which of the following?

Chorea

Explanation:
Chorea is a disorder characterized by emotional instability, purposeless movements, and muscular weakness. The onset of chorea is gradual, with increasing incoordination, facial grimaces, and repetitive involuntary movements.

A parent is told their infant has a heart defect with a left to right shunt. What is the best way for the nurse to explain this type of shunting to the parent?

This type of shunting causes an increase of blood to the lungs.

Explanation:
This type of shunting causes an increase of blood to the lungs. A right to left shunt causes an increase in blood to the systemic circulation that is mixed with deoxygenated blood.

The nurse is assessing the blood pressure of a toddler. Which finding would the nurse document as a normal finding?

90/64 mm Hg

Explanation:
The toddler’s or preschooler’s blood pressure averages 80 to 100/64 mm Hg. The normal infant’s blood pressure is about 80/40 mm Hg. The school-age child’s blood pressure averages 94 to 112/56 mm Hg. An adolescent’s blood pressure averages 100 to 120/50 to 70 mm Hg.

The nurse is caring for a 10-year-old boy following a cardiac catheterization. Four hours after the procedure, the nurse notes some minor bleeding at the site. Which action would be most appropriate?

Apply pressure 1 inch above the site.

Explanation:
If bleeding occurs after a cardiac catheterization, apply pressure 1 inch above the site to create pressure over the vessel, thereby reducing the blood flow to the area. The nurse should first apply pressure and then notify the physician if this measure is ineffective or the bleeding increases. The child should maintain the leg in a straight position for about 4 to 8 hours. However, this would not address the bleeding assessed at the site. Changing the dressing would not be effective.

A nurse is assessing the skin of a 12-year-old with suspected right ventricular heart failure. Which of the following findings would the nurse expect to note?
The nurse is caring for an 8-month-old infant with a suspected congenital heart defect. The nurse examines the child and documents the following expected finding:
A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed?
The nurse is assessing the past medical history of an infant with a suspected cardiovascular disorder. Which of the following responses by the mother warrants further investigation?
“I am on a low dose of steroids”
Explanation:
Some medications, like corticosteroids, taken by pregnant women may be linked with the development of congenital heart defects. Reports of nausea during pregnancy and an Apgar score of eight would not trigger further questions. Febrile illness during the first trimester, not the third, may be linked to an increased risk of congenital heart defects.
The care provider has ordered the drug furosemide (Lasix) to treat a child diagnosed with congestive heart failure. The nurse knows that this drug will be used to:
Eliminate excess fluids
Explanation:
Diuretics, such as furosemide (Lasix), thiazide diuretics, or spironolactone (Aldac tone), and fluid restriction in the acute stages of CHF help to eliminate excess fluids in the child with congestive heart failure. Vasodilators are used to dilate the blood vessels. Digoxin is used to improve the cardiac efficiency by slowing the heart rate and strengthening the cardiac contractility.
The pediatric nurse has digoxin ordered for each of the five children. The nurse will withhold digoxin for which of the following children? Select all that apply.
• The 16-year-old child has a heart rate of 54 beats per minute
• The 5-year-old child has developed vomiting, diarrhea and is difficult to arouse
• The 2-year-old child has a digoxin level of 2.4 ng/mL from a blood draw this morning
Correct
Explanation:
The nurse should not administer digoxin to children with the following issues: The adolescent with an apical pulse under 60 beats per minute, the child with a digoxin level above 2 ng/mL, and the child who exhibiting signs of digoxin toxicity
The nurse is conducting a physical examination of a 7-year-old girl prior to a cardiac catheterization. The nurse knows to pay particular attention to assessing the child’s pedal pulses. How can the nurse best facilitate their assessment after the procedure?
Mark the child’s pedal pulses with an indelible marker, then document
Explanation:
The nurse should pay particular attention to assessing the child’s peripheral pulses, including pedal pulses. Using an indelible pen, the nurse should mark the location of the child’s pedal pulses as well as document the location and quality in the child’s medical records.
A nurse is palpating the pulse of a child with suspected aortic regurgitation. Which of the following assessment findings would the nurse expect to note?
Bounding pulse
Explanation:
A bounding pulse is characteristic of patent ductus arteriosis or aortic regurgitation. Narrow or thready pulses may occur in children with heart failure or severe aortic stenosis. A normal pulse would not be expected with aortic regurgitation.
The nurse is auscultating heart sounds of a child with a mitral valve prolapse. The nurse would expect which assessment finding?
A mild to late ejection click at the apex
Correct
Explanation:
A mild to late ejection click at the apex is typical of a mitral valve prolapse. Abnormal splitting or intensifying of S2 sounds occurs in children with r heart problems, not mitral valve prolapse. Clicks on the upper left sternal border are related to the pulmonary area
The nurse performs a cardiac assessment and notes a loud heart murmur with a precordial thrill. This murmur would be classified as a:
Grade IV
Explanation:
A heart murmur characterized as loud with a precordial thrill is classified as Grade IV. Grade II is soft and easily heard. Grade I is soft and hard to hear. Grade III is loud without thrill
The nurse is conducting a physical examination of a baby with a suspected cardiovascular disorder. Which of the following assessment findings is suggestive of sudden ventricular distention?
Accentuated third heart sound
Explanation:
An accentuated third heart sound is suggestive of sudden ventricular distention. Decreased blood pressure, cool, clammy, and pale extremities, and a heart murmur are all associated with cardiovascular disorders; however, these findings do not specifically indicate sudden ventricular distention.

Which of the following is a complication of cystic fibrosis?

a) Pneumothorax
b) UTI
c) Crohn disease
d) Kidney disease

Pneumothorax
Correct
Explanation:
A pneumothorax is a complication of cystic fibrosis. A rupture of the subpleural blebs through the visceral pleura takes place. There is also a high reoccurrence rate and incidence increases with age.

After teaching the parents of an 8-year-old girl with asthma about common allergens their child should avoid, the nurse determines that the parents need additional teaching when they identify which of the following as a common allergen for asthma?

a) Dust mites
b) Indoor molds
c) Shellfish
d) Pet dander

Shellfish
Correct
Explanation:
Eating shellfish is not a typical asthma trigger. Allergic reactions can occur with shellfish, but usually not an exacerbation of asthma. Indoor molds are a common asthma trigger. Pet dander is a common asthma trigger. Dust mites are a common asthma trigger.

Pancreatic enzymes are part of the treatment in cystic fibrosis. When should the nurse administer the enzymes?

a) Three times a day with water
b) At night after dinner
c) Before meals and snacks with milk
d) Once a day

Before meals and snacks with milk
Correct
Explanation:
Enzymes should be administered before all meals and snacks to help in normal absorption of nutrients from the food. The other choices do not promote absorption of foods or are not taken with food.

A 4-year-old girl has been admitted to the hospital with a diagnosis of pneumococcal pneumonia. Her parents are extremely distraught over her condition and the fact she has not wanted to eat anything for the past 2 days. Which nursing approach would be most important to take to help alleviate the high anxiety level of these parents?

a) Avoid telling the parents unnecessary facts regarding her prognosis.
b) Tell the parents that their child is receiving the best care possible.
c) Allow the parents to remain with the child as much as possible.
d) Encourage the parents to return home and get some rest.

Allow the parents to remain with the child as much as possible.
Correct
Explanation:
Pneumonia is a frightening disease for parents because before the age of antibiotics, it was fatal to children. Encouraging them to visit and offer support can increase self-esteem and decrease anxiety.

What is a definitive test for cystic fibrosis?

a) Blood culture
b) Blood gas
c) Sweat chloride
d) Complete blood count

Sweat chloride
Explanation:
The definitive test in diagnosing CF is the sweat chloride test. This test is performed by stimulating a small patch of sweat glands on the inner aspect of the forearm. There must be two positive tests and clinical symptoms to confirm the diagnosis. The other choices are routine diagnostic tests.

The nurse is collecting data on a child admitted with a respiratory concern. The nurse notes that the child is anxious and sitting up and leaning forward in a tripod position to breath. The nurse further notes that the child’s mouth is open and the tongue is out. The signs the nurse noted indicate the child likely has which of the following?

a) Cystic fibrosis
b) Epiglottitis
c) Asthma
d) Tuberculosis

Epiglottitis
Correct
Explanation:
The child with epiglottitis is very anxious and prefers to breathe by sitting up and leaning forward with the mouth open and the tongue out. This is called the “tripod” position. Immediate emergency attention is necessary.

The child has been diagnosed with asthma and the child’s physician is using a stepwise approach. Rank the following in order of occurrence as the child’s condition worsens.

The nurse administers albuterol as needed.
The nurse administers a low-dose inhaled corticosteroid.
The nurse administers a medium-dose inhaled corticosteroid.
The nurse administers a medium-dose inhaled corticosteroid and salmeterol.

The nurse administers albuterol as needed.
The nurse administers a low-dose inhaled corticosteroid.
The nurse administers a medium-dose inhaled corticosteroid.
The nurse administers a medium-dose inhaled corticosteroid and salmeterol.
Explanation:
The first step is to administer a short acting beta 2-agonist as needed. The second step is to administer a low-dose inhaled corticosteroid. The third step is to administer a medium-dose inhaled corticosteroid. The fourth step is to administer a medium-dose inhaled corticosteroid and a long-acting beta 2-agonist.

Which of the following is a side effect of bronchodilator medications?

a) Muscle cramps
b) Increased heart rate
c) Hypoactivity
d) Smooth tone

Increased heart rate
Correct
Explanation:
Side effects of bronchodilators include an increased heart rate, shakiness or tremors, and hyperactivity.

A young child is prescribed pancreatic enzymes as part of his treatment plan for cystic fibrosis. The child has difficulty swallowing medications. After teaching the parents of a young child with cystic fibrosis about how to administer pancreatic enzymes, the parents demonstrate understanding by stating which of the following?

a) “We need to dissolve the capsule in water.”
b) “We should crush the capsule to make it smaller.”
c) “We can open the capsule and sprinkle it on his cereal.”
d) “We can puncture the capsule and pour the liquid on his tongue.”

“We can open the capsule and sprinkle it on his cereal.”
Correct
Explanation:
If the child has difficulty swallowing the pancreatic enzyme capsules, the parents can open the capsule and sprinkle the contents onto the child’s cereal or applesauce. Dissolving the capsule in water or crushing it would be appropriate. The capsule does not contain liquid so there would not be any liquid to pour on the child’s tongue.

The student nurse is collecting data on a child diagnosed with cystic fibrosis and notes the child has a barrel chest and clubbing of the fingers. In explaining this manifestation of the disease, the staff nurse explains the cause of this symptom to be which of the following?

a) Impaired digestive activity
b) Chronic lack of oxygen
c) Decreased respiratory capacity
d) High sodium chloride concentration in the sweat

Chronic lack of oxygen
Correct
Explanation:
In the child with cystic fibrosis the development of a barrel chest and clubbing of fingers indicate chronic lack of oxygen. Impaired digestive activity may occur due to a lack of pancreatic enzymes. The high sodium concentration makes the child taste salty, but is not related to the barrel chest and clubbing of the fingers. Respiratory issues are a concern, but the barrel chest and clubbing of the fingers are not because of the child’s respiratory capacity.

The caregiver of a 6-week-old boy calls the nurse, concerned about her child. The child has been vomiting, has diarrhea, and is sneezing. The child’s temperature is normal. The nurse suspects that the cause of the symptoms is which of the following?

a) Pneumonia
b) Cystic fibrosis
c) A pollen-based allergy
d) A common cold

A common cold
Correct
Explanation:
The child with a common cold sneezes and becomes irritable and restless. The congested nasal passages can interfere with nursing, increasing the infant’s irritability. Because an older child can mouth breathe, nasal congestion in him or her is not as great a concern as it is in the infant. The child might have vomiting or diarrhea, which might be caused by mucous drainage into the digestive system. Younger infants usually are afebrile. The child with an allergy will not likely have vomiting and diarrhea. The infant with pneumonia will most likely have an elevated temperature. The child with cystic fibrosis will have a hard, nonproductive chronic cough, a barrel chest, and clubbing of fingers. The abdomen be comes distended, and body muscles become flabby.

The caregivers of a child report that their child had a cold and complained of a sore throat. When interviewed further they report that the child has a high fever, is very anxious, and is breathing by sitting up and leaning forward with the mouth open and the tongue out. The nurse recognizes these symptoms as those seen with which of the following disorders?

a) Spasmodic laryngitis
b) Epiglottitis
c) Tonsillitis
d) Laryngotracheobronchitis

Epiglottitis
Correct
Explanation:
The child with epiglottitis may have had a mild upper respiratory infection before the development of a sore throat, and then became anxious and prefers to breathe by sitting up and leaning forward with the mouth open and the tongue out. The child with tonsillitis may have a fever, sore throat, difficulty swallowing, hypertrophied tonsils, and erythema of the soft palate. Exudate may be visible on the tonsils. The child with acute laryngotracheobronchitis develops hoarseness and a barking cough with a fever, cyanosis, heart failure and acute respiratory embarrassment can result.

The nurse working at the child community clinic must administer the influenza vaccine to the high-risk kids first. Which child would she choose?

a) 12-month-old Sally who is very healthy
b) 22-month-old Jared who has a wound from touching a hot pan at home
c) 21-month-old Chris who has a cold
d) 23-month-old Ava who had heart surgery as an infant for a defect

23-month-old Ava who had heart surgery as an infant for a defect
Correct
Explanation:
Children who are considered high risk and could benefit from the influenza vaccine are: immunocompromised; have a chronic pulmonary disease; have had a congenital abnormality, chronic renal or metabolic diseases, sickle-cell disease, HIV, and any type of neurological disorder (seizures). The other choices would be considered normal and the child is not at high risk.

The nurse is caring for a 10-year-old girl with cystic fibrosis who receives pancreatic enzymes. Which comment by a parent demonstrates understanding of the instructions regarding the medication?

a) “I should give the enzymes before each meal or snack.”
b) “Between meals is the best time to give the enzymes.”
c) “I should reduce the dose if she has large, malodorous stools.”
d) “I should stop the enzymes if my child is taking antibiotics.”

“I should give the enzymes before each meal or snack.”
Correct
Explanation:
The enzymes are necessary for appropriate digestion and absorption of food and nutrients. There is no interaction between enzymes and antibiotics. Large, malodorous stools are a sign of no pancreatic enzyme activity. Pancreatic enzymes must be given each time the child eats, usually in smaller doses for snacks than for meals.

The nurse is admitting a child who is experiencing an asthma attack. Which of the following clinical manifestations would likely be noted in this child?

a) Circumoral cyanosis
b) Chest retractions
c) Hoarseness
d) Wheezing

Wheezing
Correct
Explanation:
The onset of an attack can be very abrupt or can progress over several days, as evidenced by a dry hacking cough, wheezing (the sound of expired air being pushed through obstructed bronchioles), and difficulty breathing.

During a class for caregivers of children with asthma, a caregiver asks the nurse the following question when medications are being discussed. “They told me about a plastic device my child can hold in his a hand which will give him a premeasured and exact amount of his corticosteroid.” The nurse recognizes that the caregiver is most likely referring to which of the following devices?

a) Nebulizer
b) Medication cup
c) Needleless syringe
d) Metered-dose inhaler

Metered-dose inhaler
Correct
Explanation:
In the treatment of asthma corticosteroids are most often delivered by metered-dose inhaler ([MDI], which is a hand-held plastic device that delivers a premeasured dose). The medication cup and needleless syringe may deliver PO medications, but most often corticosteroids are not given PO in the treatment of asthma, and those would not be premeasured and an exact dosage like a metered-dose inhaler would be. Corticosteroids are not administered by nebulizer.

A child with a severe lower respiratory tract infection has been prescribed an antibiotics and a bronchodilator. The nurse recognizes that which of the following treatments would be best for delivering the medication directly into the respiratory tract, as well as providing moisture to promote removal of mucus?

a) Nebulizer
b) Flutter device
c) Percussion
d) Vaporizer

Nebulizer
Correct
Explanation:
Nebulizers are mechanical devices that provide a stream of moistened air directly into the respiratory tract. Nebulizers also serve as an important means for the delivery of respiratory tract medications. Drugs such as antibiotics or bronchodilators can be combined with the nebulized mist and sprayed into the lungs. Vaporizers humidify the air by emitting a stream of air moistened by fine droplets of water into the air, providing either a cool or a warm mist to the entire room. A mucus-clearing device (a Flutter device), which looks like a small plastic pipe, has a stainless-steel ball inside that moves when the child breathes out, causing vibrations in the lungs, which help loosen mucus so that it can be moved up the airway and expectorated. Percussion involves striking a cupped or curved palm against the chest to determine the consistency of tissue beneath the surface area.

An 8-year-old girl presents with drooling and a complaint of painful swallowing. She has a high fever and is lethargic. On examination the nurse sees that her palatine tonsils are bright red and swollen. The girl’s mother says that she has never had these symptoms before. A throat culture indicates a streptococcus infection. Which of the following is the course of treatment that the nurse most expects in this situation?

a) Tonsillectomy
b) Antipyretic, analgesic, and antibiotic
c) Adenoidectomy
d) Antipyretic and analgesic

Antipyretic, analgesic, and antibiotic
Correct
Explanation:
These symptoms are consistent with bacterial tonsillitis. Therapy for bacterial tonsillitis includes an antipyretic for fever, an analgesic for pain, and a full 7 to 10-day course of an antibiotic such as penicillin or amoxicillin. If the cause is viral, no therapy other than comfort or fever reduction strategies is necessary. Tonsillectomy is removal of the palatine tonsils. Adenoidectomy is removal of the pharyngeal tonsils. In the past, tonsillectomy was recommended for children after an episode of tonsillitis. This is no longer recommended as tonsillar tissue is an important component of the immune system.

Newborns who are born more than 24 hours after rupture of the amniotic membranes are particularly prone to developing pneumonia in their first few days of life.

a) True
b) False

True

The nurse is taking a respiratory history of a newly admitted child. While documenting the symptoms the child has, what other item is important to document when taking a history on an altered respiratory status?

a) The triggers for the environment
b) The child’s diet
c) The child’s hospital history
d) The child’s weight

The triggers for the environment
Correct
Explanation:
When assessing a respiratory history, it is very important for the nurse to find out what in the environment worsens the child’s symptoms. These are called “triggers.” The other choices would be part of a general health history.

Pneumonia is a disorder involving infection and inflammation of the fine bronchioles and bronchi.

a) False
b) True

False
Explanation:
Pneumonia is a disorder involving infection and inflammation of the alveoli. Bronchitis is inflammation and infection of the fine bronchioles and bronchi.

A child is at risk for infection related to a respiratory disorder. What would the nurse educate the family on to prevent infection?

a) Hygiene, hand washing
b) Which friends can come and play
c) The type of medication needed
d) The amount of exercise the patient needs

Hygiene, hand washing
Explanation:
The nurse should evaluate the child and family understanding of techniques to prevent infection (hand washing, hygiene, rest, nutrition, and avoiding sick people). The other choices are important in the care of the patient but are not the number-one way to prevent the spread of infection.

Which of the following is the most accurate regarding the structure and function of the infant or child’s respiratory system?

a) The respiratory tract in the child is fully developed by age 2
b) Most infants are nasal breathers rather than mouth breathers
c) The diameter of the child’s trachea is the same as that of adults.
d) Infants and young children have smaller tongues in proportion to their mouths.

Most infants are nasal breathers rather than mouth breathers
Explanation:
The infant is a nasal breath er and it is essential to keep the nasal passages clear to enable the infant to breath and to eat. The diameter of the infant and child’s trachea is about the size of the child’s little finger. The respiratory tract grows and changes until the child is about 12 years of age. Dur ing the first 5 years infants and young children have larger tongues in proportion to their mouths.

Which of the following nursing diagnoses would be most appropriate for a child with pneumonia during the acute phase of illness?

a) Pain related to swelling of abdominal lymph nodes
b) Excess fluid volume related to excessive mucus production
c) Activity intolerance related to poor oxygen-carbon dioxide exchange
d) Altered urinary elimination related to hypervolemic state

Activity intolerance related to poor oxygen-carbon dioxide exchange
Correct
Explanation:
Children with pneumonia generally feel exhausted during their illness and the immediate period following.

The nurse is examining a 4-year-old who is injured and crying. What might the nurse document about the child’s breathing?

a) Tachypnea
b) Respirations are slow and shallow
c) Tachycardia
d) Respirations are regular

Tachypnea
Correct
Explanation:
Tachypnea (rapid breathing or panting) may be observed in a child with fear, anxiety, or stress. Slow, shallow, or regular respirations are normal. Tachycardia is an increased heart rate.

The caregivers of an 8-year-old bring their child to the pediatrician and report that the child has not had breathing problems before, but since taking up lacrosse the child has been coughing and wheezing at the end of every practice and game. Their friend’s child has often been hospitalized for asthma; they are concerned that their child has a similar illness. The nurse knows that because the problems seem to be directly related to exercise, it is likely that the child will be able to be treated with

a) A bronchodilator and mast cell stabilizers
b) Corticosteroids and leukotriene inhibitors
c) Decreased activity and increased fluids
d) Removal of allergens in the home and school

A bronchodilator and mast cell stabilizers
Explanation:
Mast cell stabilizers are used to help decrease wheezing and exercise-induced asthma attacks. A bronchodilator often is given to open up the airways just before the mast cell stabilizer is used. Corticosteroids are anti-inflammatory drugs used to control severe or chronic cases of asthma. Leukotriene inhibitors are given by mouth along with other asthma medications for long-term control and prevention of mild, persistent asthma.

If there is a foreign body in the larynx, how will the patient present?

a) Speaks clearly
b) With stridor
c) Edematous
d) Quietly

With stridor
Correct
Explanation:
If a foreign body is in the larynx, the patient presents with a cough, stridor, trouble with phonation, and maybe severe respiratory distress.

The nurse identifies a nursing diagnosis of ineffective airway clearance related to inflammation and copious thick secretions. Which of the following would be the priority?

a) Monitoring oxygen saturation by pulse oximeter
b) Administering oxygen as ordered
c) Administering analgesics as ordered
d) Suctioning secretions from the airway

Suctioning secretions from the airway
Correct
Explanation:
The priority intervention is suctioning secretions to provide a patent airway. Administering oxygen as ordered, monitoring oxygen saturation by pulse oximeter, and administering analgesics as ordered would be secondary interventions.

A 7-year-old child has been scheduled for a tonsillectomy. Which of the following would be most important to assess prior to surgery?

a) Bleeding and clotting time
b) Blood pressure both lying down and sitting up
c) Specific gravity of urine
d) Pulse and respiratory rate

Bleeding and clotting time
Correct
Explanation:
Because removal of tonsils leaves a large denuded area, not a simple suture line, hemorrhage following surgery can occur.

Which of the following child’s history puts them at increased risk for asthma-related death?

a) A child who has never been hospitalized
b) Compliance with an asthma treatment plan
c) No history of psychosocial or psychiatric disease
d) Current use of corticosteroids

Current use of corticosteroids
Correct
Explanation:
Current use of corticosteroids is a risk factor for an asthma-related death. Prior hospitalization, a history of psychosocial issues, and noncompliance with an asthma treatment plan also put children at risk for an asthma-related death.

You see a 3-year-old boy in an ambulatory setting for localized wheezing on auscultation. Which statement by his mother would be most important to report?

a) She gives the child hard candy as an afternoon treat.
b) She likes the child to play by himself for 15 minutes every afternoon.
c) The child was eating peanuts yesterday.
d) The child has two cousins who have many allergies.

The child was eating peanuts yesterday.
Correct
Explanation:
Localized wheezing suggests only a small portion of a lung is involved, such as occurs following aspiration.

A child is brought to the emergency department late one evening and is diagnosed with croup. The child was noted to have a shrill, harsh respiratory sound when breathing in. This symptom is referred to as which of the following?

a) Stridor
b) Barking cough
c) Hoarseness
d) Wheezing

Stridor
Correct
Explanation:
In the child with croup syndrome, inspiratory stridor (shrill, harsh respiratory sound) is often noted.

A group of nurses is reviewing the diagnosis of cystic fibrosis. With regard to the effect of this disease on the body, in addition to the lungs which of the following are most affected by this disease?

a) Kidney and bladder
b) Pancreas and liver
c) Brain and spinal cord
d) Heart and blood vessels

Pancreas and liver
Explanation:
The major organs affected are the lungs, pancreas, and liver. The brain, spinal cord, heart, blood vessels, kidney and bladder are not the most affected organs.

The nurse is doing teaching with the caregivers of a child with cystic fibrosis. Of the following, which is most important for the nurse to teach this family?

a) Watch for signs that the family unit is stressed.
b) Encourage everyone in the family to use good handwashing.
c) Avoid overprotecting the child.
d) Be sure the patient exercises daily.

Encourage everyone in the family to use good handwashing.
Correct
Explanation:
The child with cystic fibrosis has low resistance especially to respiratory infections. For this reason, take care to protect the child from any exposure to infectious organisms. Good handwashing techniques should be practiced by the whole family; teach the child and family the importance of this first line of defense. Practice and teach other good hygiene habits.

The caregivers of a 2-year-old who has had a common cold for 4 days calls the nurse in the Emergency Department at 2 AM on a cold winter night to say that the child has awakened with a barking cough and an elevated temperature; she seems blue around her mouth. The nurse would most appropriately recommend which of the following to the caregiver?

a) “Bundle the child up and take her out into the cold for a few minutes. Call back if the exposure to the cold air does not provide relief.”
b) “Turn on all of the hot water taps in the bathroom and close the door. Take the child into the steam filled room for 15 minutes. If there is no relief, bring the child to the emergency room.”
c) “Bring the child to the emergency room immediately.”
d) “Put a cool mist humidifier or vaporizer in the room to see if that relieves the cough. Call back if there’s no relief in an hour.”

“Bring the child to the emergency room immediately.”
Correct
Explanation:
Acute laryngotracheobronchitis generally occurs after an upper respiratory infection with fairly mild rhinitis and pharyngitis. The child develops hoarseness and a barking cough with a fever that may reach 104 to 105 degrees Fahrenheit. As the disease progresses, marked laryngeal edema occurs and the child’s breathing becomes difficult; the pulse is rapid and cyanosis may appear. Heart failure and acute respiratory embarrassment can result. The child needs to be treated immediately. Humidified air is helpful in reducing laryngospasm; humidifiers may be used in the child’s bedroom to provide high humidity. Cool humidifiers are recommended, but vaporizers also may be used. Taking the child into the bathroom and opening the hot water taps with the door closed is a quick method for providing moist air, if the water runs hot enough. Sometimes the spasm is relieved by exposure to cold air: for instance, when the child is taken out into the night to go to the emergency department or to see the physician.

The nurse is caring for a child who has been admitted with a possible diagnosis of cystic fibrosis. Which of the following laboratory/diagnostic tools would likely be used to help determine the diagnosis of this child?

a) Purified protein derivative test
b) Sweat sodium choloride test
c) Pulmonary functions test
d) Blood culture and sensitivity

Sweat sodium choloride test
Correct
Explanation:
Sweat sodium choloride tests are used for determining the diagnosis of cystic fibrosis. Purified protein derivative tests are used to detect TB. Blood culture and sensitivity is done to determine the causative agent as well as the antiinfective needed to treat an infection. Pulmonary function tests are diagnostic tools for the child with asthma and indicate the amount of obstruction in the bronchial airways, especially in the smallest airways of the lungs.

The nurse is administering medications to a child with cystic fibrosis. Which of the following methods would the nurse most likely use to give medications to treat the pancreatic involvement seen in this disease?

a) Shake inhaler and hold close to mouth
b) Draw up in syringe and administer subcutaneously
c) Pour in medication cup and have child drink
d) Open capsule and sprinkle on food

Open capsule and sprinkle on food
Correct
Explanation:
Pancreatic enzymes come in capsules that can be swallowed or opened and sprinkled on the child’s food.

Which of the following is a symptom of bacterial pharyngitis?

a) Fever as high as 104 °F
b) WBC in normal range
c) Symptoms have a gradual onset
d) Rhinitis

Fever as high as 104 °F
Correct
Explanation:
A fever of up to 104 °F is a symptom of bacterial pharyngitis; others symptoms are an elevated white blood count (WBC), abrupt onset, headache, sore throat, abdominal discomfort, enlargement of tonsils, and firm cervical lymph nodes.

The nurse is obtaining the history from the parents of an infant who suffered an acute life-threatening event. Which of the following would the nurse expect the parents to report? Select all that apply.

a) Apnea
b) Respiratory distress
c) Coughing
d) Wheezing
e) Change in color

• Apnea
• Change in color
• Coughing
Explanation:
An acute life-threatening event is characterized by some combination of apnea, color change, muscle tone alteration, coughing, or gagging. Respiratory distress or wheezing would not be present.

Marcy is 4 years old with CF. The nurse is trying to pick a method to teach Marcy a good way to exercise her lungs. Which would be the developmentally correct strategy to help Marcy?

a) Teach Marcy to jump rope.
b) Teach Marcy to hop on one foot.
c) Teach Marcy to ride a bike.
d) Teach Marcy to blow bubbles.

Teach Marcy to blow bubbles.
Correct
Explanation:
A helpful exercise for Marcy would be to blow bubbles, a horn, or a pinwheel. This would help her exercise her lung capacity and is age appropriate for early childhood. The other exercises are all normal activities for school-aged children.

In caring for the child with asthma, the nurse recognizes that which of the following nursing diagnoses would be the highest priority in this child’s plan of care?

a) Delayed growth and development related to physical restrictions.
b) Risk for infection related to anatomic structures of involved body system
c) Risk for fluid volume excess related to medications
d) Ineffective airway clearance related to the diagnosis

Ineffective airway clearance related to the diagnosis
Correct
Explanation:
The highest priority for the child with asthma is to keep the airway clear because of the bronch o spasms and increased pulmonary secretions the child may have. The child is more likely to have deficient fluid volume related to tachypnea and diaphoresis. Infections can occur, but they are less of a concern than the airway clearance. Growth and development issues can occur because the child may have to limit activities, but these issues are not the priority.

What would the appropriate nursing intervention be for a child with an ineffective breathing pattern?

a) Only give medications if condition worsens.
b) Have everyone leave child’s room so it isn’t crowded.
c) Place child in a supine position in bed.
d) Provide oxygen as needed to maintain oxygen saturation above 93%.

Provide oxygen as needed to maintain oxygen saturation above 93%.
Correct
Explanation:
Provide oxygen to increase oxygen saturation. A decrease in oxygen saturation will cause the child to have an increase in the work of breathing. The other choices do not promote an open airway, decrease anxiety, or give reassurance; medications will not decrease inflammation.

A 6-month-old infant who was born premature is being seen for a follow-up examination. The child is to receive an intramuscular injection monthly through the winter and spring season. Which of the following would the nurse expect to be ordered?

a) Nedocromil
b) Zanamivir
c) Amantadine
d) Palivizumab

Palivizumab
Explanation:
Palivizumab is a monoclonal antibody used for prevention of serious lower respiratory syncytial virus (RSV) disease. RSV bronchiolitis occurs most often in infants and toddlers, with a peak incidence around 6 months of age. Infants born prematurely are more at risk. The peak occurrence of bronchiolitis is in the winter and spring. Nedocromil decreases the frequency and intensity of allergic reactions. Amantadine is used to treat and prevent influenza A. Zanamivir is used to treat and prevent influenza A.

In caring for the child with asthma, the nurse recognizes that bronchodilator medications are administered to children with asthma for which of the following reasons?

a) Management of chronic pain
b) To stabilize the cell membranes
c) Relief of acute symptoms
d) Prevention of mild symptoms

Relief of acute symptoms
Correct
Explanation:
Bronchodilators are used for quick relief of acute exacerbations of asthma symptoms. Mast cell stabilizers help to stabilize the cell membrane by preventing mast cells from releasing the chemical mediators that cause bronchospasm and mucous membrane inflammation. Leukotriene inhibitors are given by mouth along with other asthma medications for long-term control and prevention of mild, persistent asthma. Brochodilators are not effective for pain.

The nurse is caring for a 7-year-old boy who has just had a tonsillectomy. Which intervention is least appropriate for this child?

a) Discouraging the child from coughing
b) Applying an ice collar
c) Providing fluids by straw
d) Placing the child on his side

Providing fluids by straw
Correct
Explanation:
Providing fluids by straw may cause trauma to the surgical site and should be avoided. Applying an ice collar, if ordered, helps relieve pain. Placing the child on his side, until he is fully awake, facilitates safe drainage of secretions. The child should be discouraged from coughing, clearing his throat, and blowing his nose to avoid trauma to the surgical site.

What is the number-one treatment for hypoxemia?

a) Breathing treatment
b) Antibiotics
c) Fluids
d) Oxygen

Oxygen
Correct
Explanation:
Oxygen is the most indicated treatment and is needed to increase low PaO2 levels in the blood. Oxygen can be delivered by mask, nasal cannula, oxygen hood, oxygen tent, or mechanical ventilation.

The nurse is preparing a presentation for a local community parent group about measures to prevent the common cold. Which of the following would the nurse stress as a vital prevention measure?

a) Frequent hand washing
b) Minimizing exposure to crowds, especially during the spring
c) Avoiding second-hand smoke
d) Antibiotic use for household members with colds

Frequent hand washing
Correct
Explanation:
Frequent hand washing helps to decrease the spread of viruses that cause the common cold. The common cold is caused by viruses, so antibiotics would be of no assistance in preventing them. Although avoiding second-hand smoke is a preventive measure, it is not the most important measure. Crowds should be avoided, especially during the winter when the colds occur more frequently.

The nurse is caring for a child admitted with asthma. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis?

a) Clubbed fingers
b) Elevated temperature
c) Circumoral cyanosis
d) Wheezing

Wheezing
Correct
Explanation:
Symptoms of asthma include dry hacking cough, wheezing (the sound of expired air being pushed through obstructed bronchioles), and difficulty breathing. Elevated temperature is not usually seen. Circumoral cyanosis is seen with a diagnosis of pneumonia, and clubbing of the fingers is seen in cystic fibrosis.

A 6-year-old child is diagnosed as having streptococcal pharyngitis. When planning care, you should be aware that the chief danger of such an infection is that

a) four out of five children develop nephrosis afterward.
b) the infection may spread and cause a tooth abscess.
c) lymph nodes will swell and obstruct the airway.
d) a small proportion of children develop rheumatic fever.

a small proportion of children develop rheumatic fever.
Correct
Explanation:
Certain strains of streptococci can cause a hypersensitivity reaction that results in either rheumatic fever or glomerulonephritis.

Which test in a CF patient would help monitor airway function?

a) Pulmonary function
b) Peak flow measurement
c) Bronchoprovocation
d) Pulse oximetry

Pulmonary function
Explanation:
The pulmonary function tests help measure airway function, lung volumes, and gas exchange. Bronchoprovocation provokes bronchospasms to determine airway constriction. Peak flow measurement measures lung velocity. Pulse oximetry monitors blood level oxygen saturation.

The nurse is working with a group of caregivers of children diagnosed with asthma. Which of the following statements made by the caregivers is most accurate regarding the triggers that may cause an asthmatic attack?

a) “One person told me that asthma is caused by using antibiotics for infection.”
b) “My sister and her family love animals, and when we go to their house my daughter always has an asthma attack.”
c) “My neighbor told me that asthma attacks are caused by hot weather.”
d) “I always thought that a lack of exercise caused my child’s asthma.”

“My sister and her family love animals, and when we go to their house my daughter always has an asthma attack.”
Correct
Explanation:
Asthma may be a response to certain foods, or may be triggered by exercise or exposure to cold weather. Irritants such as wood-burning stoves, cigarette smoke, dust, pet dander, and foods such as chocolate, milk, eggs, nuts, and grains may also aggravate the condition. Additionally, infections such as bronchitis and upper respiratory infection can provoke asthma attacks. Using antibiotics to treat infections does not cause an asthmatic attack.

Which acute respiratory condition is the most common in early childhood?

a) Asthma
b) Croup
c) Broncholitis
d) Pneumonia

Croup
Explanation:
Croup is the most common acute respiratory condition in early childhood (6 months to 6 years). The cardinal sign is a “barking cough.” Croup is an upper airway obstruction caused by some type of inflammation.

A child with asthma has been monitoring his peak expiratory flow rate (PEFR) and has been maintaining it within 90% of his personal best. Today, the child is experiencing symptoms and his PEFR is at 40% of his personal best. The child’s mother calls the office and asks the nurse what she should do. Which of the following would the nurse instruct the mother to do first?

a) “Continue to watch his PEFR readings and call back if they go below 40%.”
b) “You need to take him to the emergency department right away.”
c) “Have him use his short-acting bronchodilator right away.”
d) “Have him use his low-dose steroid inhaler now and again in 15 minutes.”

“Have him use his short-acting bronchodilator right away.”
Correct
Explanation:
The child’s symptoms and drop in PEFR suggest a medical alert or “red” situation, indicating the need for the short-acting bronchodilator and then a trip to the office or emergency department. The child should use his short-acting bronchodilator first and then go to the physician’s or nurse practitioner’s office or emergency room. Waiting for a greater drop in his PEFR readings would be inappropriate because the child is experiencing an acute condition that warrants immediate attention. The child is experiencing an acute situation and requires immediate attention. A low-dose steroid inhaler would not be appropriate because it would not help his bronchospasm.

A worried mother calls the nurse and tells her that her son has developed a horrible croupy cough and is having trouble breathing. Which of the following would be the best intervention for the nurse to recommend to the mother?

a) Administer an analgesic to the boy
b) Administer cough syrup to the boy
c) Run a hot shower to fill the bathroom with steam and have the boy stay there
d) Have the boy drink a full glass of water to clear out the mucus

Run a hot shower to fill the bathroom with steam and have the boy stay there
Correct
Explanation:
One emergency method of relieving croup symptoms is for a parent to run the shower or hot water tap in a bathroom until the room fills with steam, then keep the child in this warm, moist environment as this relaxes the airway tissues and widens the bronchi lumens. If this does not relieve symptoms, parents should bring the child to an emergency department for further evaluation and care. Caution parents not to give cough syrup routinely to children as many produce little effect and the risk of overdose, incorrect dosing, and adverse events is greater than the benefit of the syrup. An analgesic might help alleviate pain due to inflammation and irritation of the throat from coughing, but it is not the priority intervention in this case. Drinking would likely be painful for this child and would not provide lasting benefit.

The nurse is caring for a 6-month-old infant who has chronic apneic episodes. Which intervention should the nurse institute?

a) Sit infant up in the infant seat to keep airway open.
b) Place on a cardiopulmonary monitor and do frequent assessments.
c) Place infant in a crib so he can rest and get stronger.
d) Help infant’s mother do his morning bath.

Place on a cardiopulmonary monitor and do frequent assessments.
Correct
Explanation:
The optimal treatments for kids with chronic apnea are hospitalization, frequent monitoring and observation, and parent education. The nurse should continuously monitor the infant on a cardiopulmonary monitor; frequently assess color, breathing patterns, and effort; and assess tone. The other choices do not include constant monitoring and assessments, which are crucial in treatment.

The nurse is reinforcing teaching with the parents of a 2-year-old who has cystic fibrosis regarding medications. The nurse suggest that pancreatic enzymes may be given by which method?

a) Using a nebulizer
b) Through a gastrostomy tube
c) Sprinkled onto the food
d) Directly into the vein

Sprinkled onto the food
Correct
Explanation:
Pancreatic enzymes are used in the treatment of cystic fibrosis and are given by opening the capsule and sprinkling the medication on the child’s food. If the child with cystic fibrosis has an infection, IV medications may be given, but this is not on a daily basis. Most children do not have a gastrostomy tube. Many of these drugs used in the treatment of asthma can be given either by a nebulizer (tube attached to a wall unit or cylinder that delivers moist air via a face mask) or a metered-dose inhaler ([MDI], which is a hand-held plastic device that delivers a premeasured dose).

Which medication is a bronchodilator?

a) Prednisolone
b) Spironolactone
c) Aminophylline
d) Furosemide

Aminophylline
Correct
Explanation:
Aminophylline is a bronchodilator that opens the airway of the lungs. It relaxes the smooth muscles around the airways.

Which of the following measures would be most effective in aiding bronchodilation in a child with laryngotracheobronchitis?

a) Assisting with racemic epinephrine nebulizer therapy
b) Teaching the child to take long, slow breaths
c) Administering an oral analgesic
d) Urging the child to continue to take oral fluids

Assisting with racemic epinephrine nebulizer therapy
Correct
Explanation:
A bronchodilator increases the lumen of airways.

You notice that a child is spitting up small amounts of blood in the immediate postoperative period after a tonsillectomy. Which of the following would be the best intervention?

a) Continue to assess for bleeding.
b) Encourage the child to cough.
c) Suction the back of the throat.
d) Notify the physician immediately.

Continue to assess for bleeding.
Correct
Explanation:
Children will have a small amount of blood mixed with saliva following a tonsillectomy. Suctioning or coughing could irritate the surgical site and cause hemorrhage.

The caregivers of a child who was diagnosed with cystic fibrosis 5 months ago report that they have been following all of the suggested guidelines for nutrition, fluid intake, and exercise but the child has been having bouts of constipation and diarrhea. The nurse will teach the caregiver that which of the following likely needs adjustment in the child’s diet? The amount of

a) Calories from protein
b) Saturated fat
c) Iodized salt
d) Pancreatic enzymes

Pancreatic enzymes
Explanation:
Adequate nutrition helps the child resist infections. Pancreatic enzymes must be administered with all meals and snacks. If the child has bouts of diarrhea or constipation, the dosage of enzymes may need to be adjusted. The child’s diet should be high in carbohydrates and protein with no restriction of fats. The child may need 1.5 to 2 times the normal caloric intake to promote growth. Low-fat products can be selected if desired. The child also may require additional salt in the diet. Increased caloric intake compensates for impaired absorption.

The most common cause of acute bronchiolitis is which of the following?

a) Viral infection
b) Bacterial infection
c) Hereditary factors
d) Prenatal complications

Viral infection
Explanation:
Acute bronchiolitis is caused by a viral infection. Hereditary and prenatal complications do not relate to this disorder and the respiratory syncytial virus which causes the infection is not bacterial.

A 4-year-old girl has acute nasopharyngitis (a common cold). Which of the following measures would you want to teach her parents?

a) Healthy children rarely have more than one cold per year.
b) Typically the child will pull her ear when a cold is present.
c) A cough that accompanies a cold should rarely be suppressed.
d) An antibiotic is prescribed for children under 5 years of age.

A cough that accompanies a cold should rarely be suppressed.
Correct
Explanation:
Coughing can be therapeutic because it raises respiratory secretions and prevents them from becoming infected.

A 2-year-old boy is seen for acute laryngotracheobronchitis. Which of the following observations would lead you to suspect that airway occlusion is occurring?

a) He states he is tired and wants to sleep.
b) His nasal discharge is increasing.
c) His cough is becoming harsher.
d) His respiratory rate is gradually increasing.

His respiratory rate is gradually increasing.
Explanation:
An increasing respiratory rate is a major sign of airway occlusion (breathing faster because less air is received with each breath).

A group of nursing students are reviewing information about variations in the anatomy of a child’s respiratory tract structures in comparison to adults. The students demonstrate an understanding of the information when they describe the shape of the larynx in infants as which of the following?

a) Spherical
b) Funnel
c) Cylindrical
d) Oval

Funnel
Correct
Explanation:
In infants and children (younger than the age of 10 years), the cricoid cartilage is underdeveloped, resulting in laryngeal narrowing and a funnel-shaped larynx. In teenagers and adults, the larynx is cylindrical and fairly uniform in width.

After tonsillectomy surgery, the preferred position of a child until fully awake is on the

a) abdomen with a pillow under the chest.
b) side with continuous oxygen by cannula at 30%.
c) back with warm compresses applied to the throat.
d) side with the head elevated.

abdomen with a pillow under the chest.
Explanation:
Lowering the child’s head slightly and placing the child on the stomach allows mouth and throat secretions to flow out, avoiding possible aspiration and allowing for better assessment of bleeding from the surgery site.

Which of the following is a symptom of allergic rhinitis?

a) Sinus pain
b) Purulent secretions
c) Laryngitis
d) Fever

Sinus pain
Correct
Explanation:
The following are the symptoms that occur with allergic rhinitis: sinus pain, family history of atopy, and conjunctival pruritis.

A nurse is applying a nasal cannula with prongs to a 10-year-old boy. Which of the following should the nurse be careful to observe for in this client?

a) Development of necrosis on the nasal septum
b) The device slipping and obscuring his view
c) The child being scalded by the device
d) Development of hypoxia in the child

Development of necrosis on the nasal septum
Explanation:
Most children do not like nasal prongs or catheters because they are intrusive. Assess their nostrils carefully when using these as the pressure of prongs can cause areas of necrosis, particularly on the nasal septum. Masks, rather than cannulas, tend to slip and obstruct the client’s view. Vaporizers, not cannulas, can cause a serious scald burn if children accidentally pull a vaporizer over on themselves. Development of hypoxia while receiving oxygen therapy is highly improbable.

The physician orders fluorescent antibody testing for a child with suspected respiratory syncytial virus infection. The nurse would obtain the specimen for testing from which of the following?

a) Nasopharyngeal secretions
b) Arterial blood
c) Sputum
d) Sweat

Nasopharyngeal secretions
Explanation:
A nasopharyngeal specimen is obtained for fluorescent antibody testing. Arterial blood gases require a specimen of arterial blood. A sputum specimen is used for a sputum culture. Collection of sweat on filter paper after stimulation is used for a sweat chloride test to diagnose cystic fibrosis.
Which of the following childhood diseases used to be fatal and now needs a
holistic approach to care?a) Cystic fibrosis
b) Pneumonia
c) BPD
d) Asthma

Cystic fibrosis
Correct
Explanation:
Cystic fibrosis is a highly complex disease that is autosomal and genetic in origin, in which a mucus layer covers and blocks ducts of major organs. Survival rate has greatly improved and life expectancy has risen to 37 years after many new advances.

Certain respiratory diseases in children result in hypoxia in a child. What should nurses focus on in the nursing care of these children?

a) Blood gases
b) Diet
c) Urine output
d) Vital signs

Blood gases
Explanation:
Infants may respond to low blood oxygen levels with increased respirations followed by a period of apnea. Conditions such as bronchopulmonary dysplasia, pneumonia, and bronchiolitis can put infants at risk. Nursing care should focus on blood oxygen levels. The other choices are basic nursing assessments.

The nurse caring for the child with asthma weighs the child daily. Which of the following is the most important reason for doing a daily weight on this child?

a) To determine fluid losses
b) To monitor the child’s growth pattern
c) To determine medication dosages
d) To ensure that the child’s food intake is adequate

To determine fluid losses
Correct
Explanation:
During an acute attack the child may lose a great quantity of fluid through the respiratory tract and may have poor oral intake because of coughing and vomiting. Theophylline administration also has a diuretic effect, which compounds the problem. Weigh the child daily to help determine fluid losses. The child’s weight is used to determine medication dosages, to ensure that the child is appropriately gaining weight and growing, and that the intake is adequate. However, the most important reason for a daily weight is to determine fluid loss.

The nurse is reinforcing teaching with a group of caregivers of children diagnosed with asthma. Which of the following statements best indicates an understanding of the management and treatment for this diagnosis?

a) “We have taken the carpet out of our house and let my mom take our dog.”
b) “Even the babysitter helps us keep up the diary with her symptoms.”
c) “He knows how and even when he needs to use his peak flow meter.”
d) “The medications she takes are all in one place, ready for her to take at any time.”

“We have taken the carpet out of our house and let my mom take our dog.”
Correct
Explanation:
Families must make every effort to eliminate any possible allergens from the home. Prevention is the most important aspect in the treatment of asthma. Learning how to use a peak flow meter, using a peak flow and symptom diary, and having the medications available are important aspects of treatment, but prevention is the best.

Which of the following age of children have a trachea 4 cm long?

a) Newborn
b) Toddler
c) Teenager
d) School-aged child

Newborn
Correct
Explanation:
Pediatric airways are much smaller in diameter and shorter in length than in adults. A newborn trachea is 4 cm long, a toddler’s is 7 cm long, and a teenager’s is 12 cm long.
You would teach the mother of a boy with tetralogy of Fallot that if he suddenly becomes cyanotic and dyspneic to
a) lie him supine with the head turned to one side.
b) lie him prone, being sure he can breathe easily.
c) place him in a semi-Fowler’s position in an infant seat.
d) place him in a knee-chest position.
place him in a knee-chest position.
Explanation:
Placing a child in a knee-chest or squatting position traps blood in the legs, allowing the child to better oxygenate that remaining in the trunk.

A newborn has been diagnosed with a congenital heart disease. Which of the following congenital heart diseases is associated with cyanosis?

a) Coarctation of aorta
b) Aortic stenosis
c) Pulmonary stenosis
d) Tetralogy of Fallot

Tetralogy of Fallot
Correct
Explanation:
Tetralogy of Fallot is associated with cyanosis. The defects include ventricular septal defect (VSD), right ventricular hypertrophy, right outflow obstruction, and overriding aorta. Coarctation of aorta, pulmonary stenosis, and aortic stenosis are acyanotic heart diseases and are not associated with cyanosis.

A parent asks if the reason her infant has a congenital heart defect is because of something she did while she was pregnant. What is the best response by the nurse?

a) No, heart defects are mainly caused by genetic factors.
b) The studies show it is impossible to know what causes heart defects.
c) Yes, there is a chance you caused this defect.
d) There are several reasons a baby can have a heart defect, let’s talk about those causes.

There are several reasons a baby can have a heart defect, let’s talk about those causes.
Correct
Explanation:
Focus on the therapeutic communication in this situation, while still obtaining more information. This will help the nurse explore various options for the cause of the defect with the parent.

A child with heart disease is receiving digoxin and a diuretic. Which laboratory test result would be most important for the nurse to monitor?

a) Erythrocyte sedimentation rate
b) Serum sodium level
c) Oxygen saturation level
d) Serum potassium level

Serum potassium level
Correct
Explanation:
Children receiving diuretics should have serum potassium levels obtained because diuretics tend to deplete the body of potassium. This is even more important if the child is also receiving digoxin because low serum potassium levels potentiate or increase the effect of the drug. Serum sodium levels may be obtained in children with heart failure to ensure that an increased sodium level is not causing edema. The erythrocyte sedimentation rate identifies inflammation and is unrelated to the use of diuretics and digoxin. Oxygen saturation levels may be done to evaluate for hypoxemia, but these results would be unrelated to the use of digoxin and diuretics.

A parent is asking for more information about their infant’s patent ductus arteriosus (PDA). What would be included in the education?

a) This is caused by an opening that usually closes by 1 week of age.
b) This type of defect is caused by having a genetic predisposition for it.
c) Your child may need multiple surgeries to correct this defect.
d) An IV for fluids will be started immediately.

This is caused by an opening that usually closes by 1 week of age.
Correct
Explanation:
A PDA is caused by an opening that usually closes by 1 week of age called the ductus arteriosus. The defect is usually fixed by a single surgery or during a cardiac catheterization procedure. IV fluids are not a routine intervention for the PDA. Most of the time a PDA occurs in premature infants.

After assessing a child, the nurse suspects coarctation of the aorta based on which of the following?

a) Hepatomegaly
b) Narrow pulse
c) Femoral pulse weaker than brachial pulse
d) Bounding pulse

Femoral pulse weaker than brachial pulse
Explanation:
A femoral pulse that is weak or absent in comparison to the brachial pulse is associated with coarctation of the aorta. Bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. A narrow or thread pulse is associated with heart failure or severe aortic stenosis. Hepatomegaly is a sign of right-sided heart failure.

The nurse is explaining possible side effects of corticosteroids to the caregiver of a child diagnosed with rheumatic fever. The caregiver comments, “I don’t understand what hirsutism means.” The nurse would be correct in explaining that hirsutism is which of the following?

a) Facial grimaces
b) Repetitive movements
c) A “moon face” appearance
d) Abnormal hair growth

Abnormal hair growth
Correct
Explanation:
The child whose pain is not con trolled with salicylates may be ad ministered corticosteroids. Side effects such as hirsutism (abnormal hair growth) and “moon face” may be noted. Facial grimaces and repetitive involuntary movements are symptoms of chorea.

Parents are told their infant has a hypoplastic left heart. What is the type of education that would be included for this family?

a) This is a problem where the left side of the heart did not develop properly.
b) This is a problem where the right side of the heart did not develop properly.
c) The infant will have immediate surgery to completely correct the heart defect.
d) There are no surgeries that can help the child live with this heart defect.

This is a problem where the left side of the heart did not develop properly.
Correct
Explanation:
This is a problem where the left side of the heart did not develop properly. There is a three-step palliative surgery that can be implemented or the child will need a heart transplant.

The nurse is providing child and family education prior to discharge following a cardiac catheterization. The nurse is teaching about signs and symptoms of complications. Which statement by the mother indicates a need for further teaching?

a) “We need to watch for changes in skin color or difficulty breathing.”
b) “Strenuous activity should be limited for the next 3 days.”
c) “We need to avoid a tub bath for the next 3 days.”
d) “The feeling of the heart skipping a beat is common.”

“The feeling of the heart skipping a beat is common.”
Explanation:
Reports of heart “fluttering” or “skipping a beat” should be reported to the doctor as this can be a sign of a complication. This statement is appropriate because tub baths should be avoided for about 3 days. This statement is appropriate because strenuous activity is limited for about 3 days. Changes in skin color or difficulty breathing indicate potential complications that need to be reported.

The nurse is reviewing the health history and physical examination of a child diagnosed with heart failure. Which of the following would the nurse expect to find? Select all that apply.

a) Shortness of breath when playing
b) Crackles on lung auscultation
c) Hypertension
d) Bradycardia
e) Tiring easily when eating

• Shortness of breath when playing
• Crackles on lung auscultation
• Tiring easily when eating
Correct
Explanation:
Manifestations of heart failure include difficulty feeding or eating or becoming tired easily when feeding or eating, shortness of breath with exercise intolerance, crackles and wheezes on lung auscultation, tachycardia, and hypotension.

An infant girl is prescribed digoxin. You would teach her parents that the action of this drug is to

a) slow and strengthen her heartbeat.
b) increase her heart rate.
c) prevent subacute bacterial endocarditis.
d) thicken the walls of the myocardium.

slow and strengthen her heartbeat.
Correct
Explanation:
Digoxin is a cardiac glycoside that slows and strengthens the heartbeat.

A nurse is giving discharge instructions to the parents of a newborn with a congenital heart disorder. Which of the following should the nurse instruct the parents to do in the event that the child becomes cyanotic?

a) Perform hands-on CPR
b) Administer prescribed amoxicillin
c) Place him in a knee-chest position
d) Administer low-dose aspirin

Place him in a knee-chest position
Explanation:
Before parents leave the hospital with a newborn who has a congenital heart disorder, be certain they have the name and number of the health professional to call if they have a question about their infant’s health. Review with them the steps to take if their child should become cyanotic, such as placing the child in a knee-chest position. “Hands on” CPR is not recommended for children as it is for adults. Remind parents that children with many types of congenital heart disorders or rheumatic fever need prophylactic low-dose aspirin therapy to avoid blood clotting; although becoming a controversial practice, they may be prescribed antibiotic therapy such as oral amoxicillin before oral surgery.

The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which of the following reactions?

a) Wheezing
b) Stomach upset
c) Nausea with diarrhea
d) Abdominal distress

Wheezing
Correct
Explanation:
The nurse must report any hypersensitivity reactions such as wheezing and pruritus, as these could be a sign of anaphylaxis. Stomach upset is common with oral antibiotics and is not something that needs to be reported immediately. Nausea with diarrhea is common with oral antibiotics and does not need to be reported immediately. Abdominal distress is common with oral antibiotics and does not need to be reported immediately.

The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed?

a) Indomethacin
b) Digoxin
c) Alprostadil
d) Furosemide

Digoxin
Correct
Explanation:
Digoxin is indicated for atrial fibrillation. It increases the contractility of the heart muscle by decreasing conduction and increasing force. Alprostadil is indicated for temporary maintenance of ductus arteriosus patency in infants with ductal-dependent congenital heart defects. Furosemide is used for the management of edema associated with heart failure. Indomethacin is used to close a patent ductus arteriosus.

A nurse is providing education to a family about cardiac catheterization. Which of the following would be included in the education?

a) The child will be able to move their leg again immediately after the procedure.
b) The procedure will be performed even if the child has a fever.
c) The catheter will be placed in the brachial artery.
d) The catheter will be placed in the femoral artery.

The catheter will be placed in the femoral artery.
Correct
Explanation:
The femoral artery is the correct placement of the cardiac catheter. The child will need to lie still for several hours after the procedure. The procedure is usually postponed if the child has a fever.

A child is having surgery for a congenital heart defect. The parent asks about their 1-year-old’s growth and developmental delays and what they can expect after surgery. What is the best response by the nurse?

a) “You can expect to continue to see delays.”
b) “As long as you decrease external stimuli, the child should catch up.”
c) “This was caused by the lack of oxygen and it is usually permanent.”
d) “After surgery, most children will catch up.”

“After surgery, most children will catch up.”
Correct
Explanation:
A child with a congenital heart defect who has growth and developmental delays will usually catch up after the defect is fixed. There is no way of predicting exactly what each child will do and it is not appropriate to tell a parent that these delays are permanent when that is unknown until the defect is corrected by surgery.

A parent brings an infant in for poor feeding. Which of the following assessment data would most likely indicate a coarctation of the aorta?

a) Cyanosis with feeding
b) Pulses weaker in lower extremities compared to upper extremities
c) Cyanosis with crying
d) Pulses weaker in upper extremities compared to lower extremities

Pulses weaker in lower extremities compared to upper extremities
Explanation:
An infant with coarctation of the aorta has decreased systemic circulation causing this problem. The cyanosis would be associated with tetralogy of Fallot.

A 6-year-old girl is diagnosed with pulmonary stenosis. The mother asks the nurse what the likely treatment for this condition will involve. The nurse should tell the mother which of the following?

a) No treatment is necessary, as the defect will resolve spontaneously
b) Surgical closure by ductal ligation
c) Insertion of a catheter with an uninflated balloon tip into the affected valve, followed by inflation of the balloon to break up adhesions
d) Insertion of Dacron-coated stainless-steel coils by interventional cardiac catheterization

Insertion of a catheter with an uninflated balloon tip into the affected valve, followed by inflation of the balloon to break up adhesions
Correct
Explanation:
Balloon angioplasty by way of cardiac catheterization is the procedure of choice for pulmonary stenosis. With this procedure, a catheter with an uninflated balloon at its tip is inserted and passed through the heart into the stenosed valve. As the balloon is inflated, it breaks valve adhesions and relieves the stenosis. The other answers refer to interventions related to patent ductus arteriosus, not pulmonary stenosis.

The infant has been hospitalized and develops hypercyanosis. The physician has ordered the nurse to administer 0.1 mg of morphine sulfate per every kilogram of the infant’s body weight. The infant weighs 15.2 pounds. Calculate the infant’s morphine sulfate dose. Round your answer to the nearest tenth.

_____mg

0.7
Correct
Explanation:
The infant weighs 15.2 pounds (2.2 pounds = 1 kg.) 15.2 pounds x 1 kg/2.2 pounds = 6.818 kg The infant weighs 6.818 kg. For each kilogram of body weight, the infant should receive 0.1 mg of morphine sulfate. 6.818 kg x 0.1 mg/1 kg = 0.6818 mg Rounded to the tenth place = 0.7 mg The infant will receive 0.7 mg of morphine sulfate.

A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?

a) Irritability and dry mucous membranes
b) Decreased heart rate and impalpable pulse
c) Low blood pressure and decreased heart rate
d) Peeling hands and feet and fever

Peeling hands and feet and fever
Explanation:
One of the signs of Kawasaki disease is the peeling hands and feet. The other symptoms are not necessarily characteristic of Kawasaki disease.

A nurse suspects a child is experiencing cardiac tamponade after heart surgery. Which of the following would be the priority nursing intervention?

a) Observe vitals every two hours.
b) Elevate the head of the bed.
c) Notify the doctor immediately.
d) Administer epinephrine.

Notify the doctor immediately.
Correct
Explanation:
The nurse would notify the doctor immediately. Cardiac tamponade is a medical emergency and should be addressed. The child can die if intervention is postponed. It would not be appropriate to perform any interventions until confirming that this is the actual diagnosis.

A school nurse finds a 10-year-old’s blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect?

a) The child will need the blood pressure checked two more times.
b) This is a normal result for a child this age.
c) The child will probably need surgery.
d) Advise the child go to the emergency room.

The child will need the blood pressure checked two more times.
Correct
Explanation:
The child will need the blood pressure checked two more times. It is routine to check the blood pressure on three separate occasions to get the most accurate analysis of the blood pressure. The child usually does not need surgery or need to go to the emergency room. This is not a normal result in a blood pressure finding.

A child is having surgery for a congenital heart defect. The parent asks about their 1-year-old’s growth and developmental delays and what they can expect after surgery. What is the best response by the nurse?

a) “After surgery, most children will catch up.”
b) “You can expect to continue to see delays.”
c) “This was caused by the lack of oxygen and it is usually permanent.”
d) “As long as you decrease external stimuli, the child should catch up.”

“After surgery, most children will catch up.”
Correct
Explanation:
A child with a congenital heart defect who has growth and developmental delays will usually catch up after the defect is fixed. There is no way of predicting exactly what each child will do and it is not appropriate to tell a parent that these delays are permanent when that is unknown until the defect is corrected by surgery.

A newborn has been diagnosed with a congenital heart disease. Which of the following congenital heart diseases is associated with cyanosis?

a) Aortic stenosis
b) Tetralogy of Fallot
c) Pulmonary stenosis
d) Coarctation of aorta

Tetralogy of Fallot
Explanation:
Tetralogy of Fallot is associated with cyanosis. The defects include ventricular septal defect (VSD), right ventricular hypertrophy, right outflow obstruction, and overriding aorta. Coarctation of aorta, pulmonary stenosis, and aortic stenosis are acyanotic heart diseases and are not associated with cyanosis.

A nurse is interviewing a mother who is about to deliver her baby. Which of the following responses would alert the nurse for a higher potential for a heart defect in the infant?

a) The mother states she slept all the time while pregnant.
b) The mother states she took acetaminophen while pregnant.
c) The mother has seizures, but did not take medication while pregnant.
d) The mother states she has lupus.

The mother states she has lupus.
Correct
Explanation:
Having lupus while pregnant could contribute to a congenital heart defect. Acetaminophen and sleeping do not have an effect on a child developing a heart defect. The seizure medication can have an impact on the child having a heart defect, but not necessarily a history of seizures in the mother.

When examining a child with congenital heart disease, an organ in the upper right quadrant of the abdomen can be palpated at 4 cm below the rib cage. Which of the following would most likely explain this assessment finding?

a) The spleen increases due to frequent infection.
b) The spleen increases due to increased destruction of red blood cells.
c) The liver increases in right-sided heart failure.
d) The liver increases due to cardiac medications.

The liver increases in right-sided heart failure.
Explanation:
The liver increases in size due to right-sided heart failure. This is one of the cardinal signs of congestive heart failure. The spleen is in the upper left quadrant of the abdomen and would increase in size under certain circumstances, but this is asking for the upper right quadrant information. There are certain medications that can affect the liver, but this would not be the most likely reason for hepatomegaly.

An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority?

a) Start an IV for fluids.
b) Prepare the infant for surgery.
c) Raise the head of the bed.
d) Place the infant in the knee-chest position.

Place the infant in the knee-chest position.
Correct
Explanation:
Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot. Starting IV fluids and preparing the child for surgery would not be necessary since it is known that the infant has a cyanotic birth defect. Raising the head of the bed would not be a priority since the infant needs to be placed in the knee-chest position.

A child with suspected dyslipidemia undergoes laboratory testing. The nurse is reviewing the results. Which of the following would the nurse interpret as supporting the diagnosis? Select all that apply.

a) LDL level of 90 mg/dL
b) Total cholesterol level of 180 mg/dL
c) LDL level of 120 mg/dL
d) LDL level of 140 md/dL
e) Total cholesterol level of 150 mg/dL
f) Total cholesterol level of 220 mg/dL

• LDL level of 140 md/dL
• Total cholesterol level of 220 mg/dL
Correct
Explanation:
A total cholesterol level over 200 mg/dL and LDL level above 130 mg/dL are considered high and would support the diagnosis of dyslipidemia. Total cholesterol levels between 170 to 199 mg/dL and LDL levels between 110 to 129 mg/dL are considered borderline. Total cholesterol levels less than 170 mg/dL and LDL levels less than 110 mg/dL are acceptable in children.

The nurse is teaching an inservice program to a group of nurses on the topic of children diagnosed with rheumatic fever. The nurses in the group make the following statements. Which statement is most accurate regarding the diagnosis of rheumatic fever?

a) “The onset and progression of this disorder is rapid.”
b) “This disorder is caused by genetic factors.”
c) “Being up to date on immunizations is the best way to prevent this disorder.”
d) “Children who have this diagnosis may have had strep throat.”

“Children who have this diagnosis may have had strep throat.”
Correct
Explanation:
Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle.

A parent asks why their infant with a cyanotic heart defect turns blue. What is the best response by the nurse?

a) This is a sign of heart failure.
b) This is due to a decreased amount of oxygen to the peripheral tissue.
c) This is considered a medical emergency and needs immediate surgery.
d) This is due to the lack of oxygen to the brain.

This is due to a decreased amount of oxygen to the peripheral tissue.
Correct
Explanation:
Cyanosis associated with certain congenital heart defects is due to the body naturally compensating and decreasing the amount of oxygen to the peripheral tissue. This keeps the oxygen with the vital organs to sustain life. The lack of oxygen is not in the brain; it is in the systemic flow of the body. Cyanosis is a common finding with these types of heart defects and in general, does not usually need immediate surgery or is a sign of heart failure.

At 3 years of age, a child has a cardiac catheterization. After the procedure, which of the following interventions would be most important?

a) Allowing the child to adapt to the light room gradually
b) Assuring the child that the procedure is now over
c) Taking pedal pulses for the first 4 hours
d) Allowing the child to talk about the procedure

Taking pedal pulses for the first 4 hours
Correct
Explanation:
Insertion of a catheter into the femoral vein can cause vessel spasm, interfering with blood circulation in the leg. Assessing pedal pulses ensures circulation is adequate.

You take an infant’s apical pulse before administering digoxin. What is the usually accepted level of pulse rate considered safe for administering digoxin to an 8-month-old infant?

a) 150 beats per minute
b) 100 beats per minute
c) 80 beats per minute
d) 60 beats per minute

100 beats per minute
Explanation:
Because digoxin slows the heart rate, it is important that it is not already beating at a slow rate before administration.

A parent is told their infant has a heart defect with a left to right shunt. What is the best way for the nurse to explain this type of shunting to the parent?

a) This type of shunting causes an increase of blood to the systemic circulation.
b) This type of shunting causes an increase of blood to the lungs.
c) This type of shunting causes a decrease of blood to the brain.
d) This type of shunting causes a decrease of blood to the lungs.

This type of shunting causes an increase of blood to the lungs.
Explanation:
This type of shunting causes an increase of blood to the lungs. A right to left shunt causes an increase in blood to the systemic circulation that is mixed with deoxygenated blood.

A nurse is reviewing blood work on a patient with a cyanotic heart defect. Which of the following results would most likely be seen in a patient experiencing polycythemia?

a) Increased WBC
b) Increased RBC
c) Decreased RBC
d) Decreased WBC

Increased RBC
Correct
Explanation:
Polycythemia can occur in patients with a cyanotic heart defect. The body tries to compensate for having low oxygen levels and produces more red blood cells (RBCs). This would cause an increased result on the lab tests. This problem does not affect the white blood cells (WBCs).

The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority?

a) Provide supplemental oxygen.
b) Use a calm, comforting approach.
c) Administer propranolol (0.1 mg/kg IV).
d) Place the child in a knee-to-chest position.

Place the child in a knee-to-chest position.
Correct
Explanation:
The priority nursing action is to place the infant or child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as ordered. A calm, comforting approach should be used but is not the priority action. Once a child is placed in the knee-to-chest position, supplemental oxygen would be provided as ordered. Once a child is placed in the knee-to-chest position, medications would be given as ordered.

A nurse is taking the history of a 4-year-old boy who will undergo a cardiac catheterization. Which of the following statements by his mother may necessitate rescheduling of the procedure?

a) “He is very scared and nervous about the procedure.”
b) “He is not taking any medication.”
c) “He is allergic to iodine and shellfish.”
d) “He seems listless and slightly warm.”

“He seems listless and slightly warm.”
Correct
Explanation:
Fever and other signs and symptoms of infection may necessitate rescheduling the procedure. Although information about allergies is important, not all contrast media contain iodine as a base. The nurse should address the child’s fears in a developmentally appropriate way, but fear of the procedure does not warrant rescheduling. Not using any medication would not be a reason for rescheduling the procedure.

The nurse is performing echocardiography on a newborn who is suspected of having a congenital heart defect. The child’s mother is concerned about the safety of using this on a newborn and wants to know how this technology works. The nurse assures her that this technology is very safe and may be repeated frequently without added risk. Which of the following should the nurse mention in explaining how this diagnostic test works?

a) A radioactive substance is injected intravenously into the bloodstream and is traced and recorded on video
b) High-frequency sound waves are directed toward the heart
c) A microphone is placed on the child’s chest to record heart sounds and translate them into electrical energy
d) X-rays are directed toward the heart

High-frequency sound waves are directed toward the heart
Correct
Explanation:
Echocardiography, or ultrasound cardiography, has become the primary diagnostic test for congenital heart disease. For this, high-frequency sound waves, directed toward the heart, are used to locate and study the movement and dimensions of cardiac structures, such as the size of chambers, thickness of walls, relationship of major vessels to chambers, and the thickness, motion, and pressure gradients of valves. You can remind parents echocardiography does not use x-rays so it can be repeated at frequent intervals without exposing their child to the possible risk of radiation. The other answers refer to other types of diagnostic tests, including X-ray studies, radioangiocardiography, and phonocardiography.

A nursing instructor is preparing for a class about the structural and functional differences in the cardiovascular system of infants and children as compared to adults. Which of the following would the instructor include in the class discussion?

a) The heart’s apex is higher in the chest in children younger than the age of 7 years.
b) Blood pressure is initially high at birth but gradually decreases to adult levels.
c) The heart is about four times the birth size between the ages of 6 and 12 years.
d) Left ventricular function predominates immediately after birth.

The heart’s apex is higher in the chest in children younger than the age of 7 years.
Correct
Explanation:
In infants and children younger than age 7 years, the heart lies more horizontally, resulting in the apex lying higher in the chest. Right ventricular function predominates at birth, and over the first few months of life, left ventricular function becomes dominant. A normal infant’s blood pressure is about 80/40 mm Hg and increases over time to adult levels. Between the ages of 1 and 6 years, the heart is four times the birth size; between 6 and 12 years of age, the heart is 10 times its birth size.

A nurse is caring for a newborn with congenital heart disease (CHD). Which of the following would the nurse interpret as indicating distress?

a) Reduced respiratory rate during feeding
b) Feeding lasting for 15-20 minutes
c) Perspiration on body after feeding
d) Subbcostal retraction at the time of feeding

Subbcostal retraction at the time of feeding
Correct
Explanation:
Subcostal retraction during feeding is indicative of distress associated with feeding in newborn infants with CHD. Feeding can be a stress to newborns with CHD who are seriously compromised. Additional features indicating distress in infants with CHD include increased respiratory rate, perspiration along the hairline during feeding and feeding time longer than 30 minutes.

When reviewing the record of a child with tetralogy of Fallot, which of the following would you expect to discover?

a) Anemia
b) Increased platelet level
c) Polycythemia
d) Leukopenia

Polycythemia
Correct
Explanation:
Children who cannot oxygenate red cells well often produce excess red blood cells or develop polycythemia.

A nurse is caring for a child who is experiencing heart failure. Which of the following assessment data was most likely seen when initially examined?

a) Bradycardia
b) Tachycardia
c) Splenomegaly
d) Polyuria

Tachycardia
Explanation:
If a child were experiencing heart failure, the most likely sign of this would be tachycardia, not bradycardia. The child may also experience hepatomegaly or oliguria, but not splenomegaly or polyuria.

A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed?

a) “We can stop the penicillin when her symptoms disappear.”
b) “She needs to take the drug for the full 14 days.”
c) “If she needs dental surgery, we might need additional medication.”
d) “To prevent another episode, she’ll need preventive antibiotic therapy for at least 5 years.”

“We can stop the penicillin when her symptoms disappear.”
Correct
Explanation:
For a child with rheumatic fever, drug therapy must be given for the full 10 to 14 days to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.

The nurse is reviewing the laboratory test results of several children who have come to the clinic for evaluation. Which child would the nurse identify as having the least risk for hyperlipidemia?

a) Child B with a total cholesterol level of 175 mg/dL and LDL of 105 mg/dL.
b) Child C with a total cholesterol level of 190 mg/dL and LDL of 125 mg/dL.
c) Child A with a total cholesterol of 150 mg/dL and low-density lipoprotein (LDL) of 80 mg/dL.
d) Child D with a total cholesterol level of 220 mg/dL and LDL of 138 mg/dL.

Child A with a total cholesterol of 150 mg/dL and low-density lipoprotein (LDL) of 80 mg/dL.
Explanation:
Total cholesterol levels below 170 mg/dL and LDL levels less than 100 mg/dL are considered within the acceptable range. Total cholesterol levels between 170 and 199 mg/dL and LDL levels between 100 and 129 mg/dL are considered borderline. Total cholesterol levels between 170 and 199 mg/dL and LDL levels between 100 and 129 mg/dL are considered borderline. Total cholesterol levels greater than or equal to 200 mg/dL and LDL levels greater than or equal to 130 mg/dL are considered elevated and place this child at greatest risk.

The nurse is collecting data on a 5 year old child admitted with the diagnosis of congestive heart failure. Which of the following clinical manifestations would likely have been noted in the child with this diagnosis?

a) Clubbing of the fingers
b) Scissoring of the legs with toes pointed down
c) Failure to gain weight
d) Jerking movements of the arms and legs

Failure to gain weight
Explanation:
In infants and older children, one of the first signs of CHF is tachycardia. Other signs of CHF often seen in the older child include failure to gain weight, weakness, fatigue, restlessness, irritability, and a pale, mottled, or cyanotic color. Rapid respirations or tachypnea, dyspnea, and coughing with bloody sputum also are seen. Edema and enlargement of the liver and heart may be present. Jerking movements indicate seizure activity. Scissoring of the legs is seen in cerebral palsy, and clubbing of the fingers is seen in cystic fibrosis.

The nurse is providing education to parents of a child with a blood pressure in the 90th percentile. Which of the following would be included in the intervention strategies?

a) The nurse would review the child’s 24-hour diet recall.
b) The child should not be allowed to participate in sports.
c) Blood pressures should be measured daily.
d) Beta blocker education should be given to the parents.

The nurse would review the child’s 24-hour diet recall.
Explanation:
With a child in the 90th percentile for blood pressure, diet and physical activity should be the main focus. Blood pressures should be measured, but daily is not necessary. Children are not routinely put on beta blockers and the child should be allowed to participate in sports if monitored.

When caring for a child that has just had a cardiac catheterization, which of the following would indicate a sign of hypotension?

a) Decreased heart rate and dizziness
b) Syncope and tachypnea
c) Diaphoresis and tachycardia
d) Cold clammy skin and increased heart rate

Cold clammy skin and increased heart rate
Explanation:
Cold, clammy skin, increased heart rate, and dizziness are signs of hypotension that may be a complication after a cardiac catheterization. Decreased heart rate, syncope, and tachypnea would also be very concerning, but not necessarily a sign of hypotension.

A child is diagnosed with tetralogy of Fallot and during a temper tantrum turns blue. Which of the following would the nurse do first?

a) Assess for an increased respiratory rate.
b) Place child in the knee-to-chest position.
c) Assess for an irregular heart rate.
d) Explain to the child the need to calm down since it is affecting the heart.

Place child in the knee-to-chest position.
Correct
Explanation:
Place child in the knee-to-chest position. This position is the first priority of the child with tetralogy of Fallot. Cyanosis is caused by the heart defect and placing the child in this position will decrease the cyanosis.

A child with a congenital heart defect is getting an echocardiogram. How would the nurse describe this test to the parent?

a) This test is an invasive test that will measure the blockage in the heart.
b) This is a test that will check how blood is flowing through the heart.
c) This is a test that will check the electrical impulses in the heart.
d) This test can only determine the size of the heart.

This is a test that will check how blood is flowing through the heart.
Explanation:
Echocardiograms can determine the size of the heart and how the heart is pumping blood. An echocardiogram does not check the electrical impulses or the size of the heart. This is a non-invasive test.

A nurse is caring for a child that just had open-heart surgery and the parents are asking why there are wires coming out of the chest of the infant. What is the best response by the nurse?

a) These wires are connected to the heart and will detect if your child’s heart gets out of rhythm.
b) The wires will administer ongoing electrical shocks to the heart to maintain rhythm.
c) The wires are left in the heart one month after surgery for potential arrhythmias.
d) The wires are measuring the fluid level in the heart.

These wires are connected to the heart and will detect if your child’s heart gets out of rhythm.
Correct
Explanation:
The wires may be connected to a pacemaker. Connection to the temporary pacemaker is usually until the child is out of danger for arrhythmia.

When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure?

a) Bradycardia
b) Inability to sweat
c) Tachycardia
d) Splenomegaly

Tachycardia
Correct
Explanation:
Tachycardia is one of the signs of heart failure. Bradycardia, inability to sweat, and splenomegaly are not necessarily signs of heart failure.

When caring for a child with Kawasaki Disease, the nurse would know which of the following?

a) Joint pain is a permanent problem.
b) Steroid creams are used for the hand peeling.
c) Management includes administration of aspirin and IVIG.
d) Antibiotics should be administered exactly every 8 hours by IV.

Management includes administration of aspirin and IVIG.
Correct
Explanation:
Kawasaki disease is managed with IVIG and aspirin to prevent cardiac complications. Joint pain is not necessarily a permanent problem associated with Kawasaki disease. Antibiotics and steroid creams are not used for this disorder.

The nurse is performing an ECG on a 12-year-old boy. On completion, she notices that boy’s P-R interval is lengthened. Which of the following does this finding indicate?

a) Difficulty with coordination between the SA and AV nodes (first-degree heart block)
b) Ventricular hypertrophy
c) Hypertrophied atria
d) Ventricles not fully contracting (pericarditis)

Difficulty with coordination between the SA and AV nodes (first-degree heart block)
Explanation:
On an ECG tracing, a longer-than-usual P wave suggests the atria are hypertrophied making it take longer than usual for the electrical conduction to spread over the atria. A lengthened P-R interval suggests there is a difficulty with coordination between the SA and AV nodes (first-degree heart block). A heightened R wave indicates ventricular hypertrophy is present. An R wave which is decreased in height suggests the ventricles are not contracting fully, as happens if they are surrounded by fluid (pericarditis). Elongation of the T wave occurs in hyperkalemia; depression of the T wave is associated with anoxia; depression of the ST segment is associated with abnormal calcium levels.

The nurse is caring for a 10-year-old girl with a suspected heart arrhythmia. The nurse would expect to prepare the child for which test to identify and quantitate the arrhythmia?

a) Ambulatory electrocardiographic monitoring
b) Arteriogram
c) Echocardiogram
d) Chest radiograph

Ambulatory electrocardiographic monitoring
Correct
Explanation:
Ambulatory electrocardiographic monitoring is indicated to identify and quantitate arrhythmias in a 24-hour period during normal daily activities. An echocardiogram is done to provide a specific diagnosis of structural defects, to determine hemodynamics, and to detect valvular defects. A chest radiograph is indicated to detect abnormalities of structures within the chest. An arteriogram is ordered to observe blood flow to parts of the body and detect lesions and confirm a diagnosis.

A group of nurses is reviewing the cardiovascular system and its function. Which of the following statements is the most accurate regarding the cardiovascular system in the child?

a) The heart rate of the child decreases if the child has a fever.
b) At birth the right and left ventricle are about the same size.
c) The heart matures and functions like an adult’s between 12 and 15 years of age.
d) Between the ages of 5 and 6 the left ventricle grows to about two times the size of the right.

At birth the right and left ventricle are about the same size.
Correct
Explanation:
At birth, both the right and left ventricles are about the same size, but by a few months of age, the left ventricle is about two times the size of the right. If the infant has a fever, respiratory distress, or any increased need for oxygen, the pulse rate goes up to increase the cardiac output. Although the size is smaller, by the time the child is 5 years old, the heart has matured, developed, and functions just as the adult’s heart.

Which of the following would be most important to implement for an infant who develops heart failure?

a) Restricting milk intake daily
b) Keeping her supine and playing quiet games
c) Placing her in a semi-Fowler’s position
d) Planning ways to reduce salt intake

Placing her in a semi-Fowler’s position
Correct
Explanation:
Placing an infant with heart failure in a semi-Fowler’s position reduces the pressure of abdominal contents against the chest and gives the heart the opportunity to function more effectively.

An 8-month-old has a ventricular septal defect. Which nursing diagnosis below would best apply?

a) Impaired skin integrity related to poor peripheral circulation
b) Ineffective tissue perfusion related to inefficiency of the heart as a pump
c) Ineffective airway clearance related to altered pulmonary status
d) Impaired gas exchange related to a right-to-left shunt

Ineffective tissue perfusion related to inefficiency of the heart as a pump
Correct
Explanation:
A ventriculoseptal defect permits blood to flow across a septum, creating an ineffective pump.

A nurse is administering digoxin to a 3-year-old. Which of the following would be a reason to hold the dose of digoxin?

a) Ataxia
b) Fever and tinnitus
c) Nausea and vomiting
d) Hypertension

Nausea and vomiting
Explanation:
Nausea and vomiting are signs of digoxin toxicity. The other symptoms listed here are not necessarily signs of a digoxin toxicity.

A client’s newborn is diagnosed with Tetralogy of Fallot. When explaining this condition to the client, which of the following defects would the nurse’s description include?

a) Atrial septal defect
b) Overriding of the aorta
c) Stenosis of the aorta
d) Left ventricular hypertrophy

Overriding of the aorta
Explanation:
One of the components in the Tetralogy of Fallot is overriding of the aorta. Tetralogy of Fallot is a congenital heart disease with 4 components. The defects in the Tetralogy of Fallot include ventricular septal defect, overriding of the aorta, pulmonary stenosis, and right ventricular hypertrophy. Atrial septal defect, stenosis of the aorta and left ventricular hypertrophy are not components of Tetralogy of Fallot.

Tetralogy of Fallot consists of the following four anomalies: aortic stenosis, atrial septal defect, dextroposition (overriding) of the aorta, and hypertrophy of the left ventricle.

a) False
b) True

False
Correct
Explanation:
Tetralogy of Fallot consists of four anomalies: pulmonary stenosis, ventricular septal defect (usually large), dextroposition (overriding) of the aorta, and hypertrophy of the right ventricle.

A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. Which of the following interventions should the nurse take to prevent infection?

a) Keep the child NPO for 2 to 4 hours before the procedure
b) Record pedal pulses
c) Apply EMLA cream to the catheter insertion site
d) Avoid drawing a blood specimen from the right femoral vein before the procedure

Avoid drawing a blood specimen from the right femoral vein before the procedure
Correct
Explanation:
Because the vessel site chosen for catheterization must not be infected at the time of catheterization (or obscured by a hematoma), never draw blood specimens from the projected catheterization entry site before the procedure (generally a femoral vein). The other interventions listed are performed for reasons other than prevention of infection. Children scheduled for the procedure are usually kept NPO for 2 to 4 hours beforehand to reduce the danger of vomiting and aspiration during the procedure. Be certain to record pedal pulses for a baseline assessment. The site for catheter insertion is locally anesthetized with EMLA cream or intradermal lidocaine.

Which of the following nursing diagnoses would best apply to a child with rheumatic fever?

a) Disturbed sleep pattern related to hyperexcitability
b) Activity intolerance related to inability of heart to sustain extra workload

Activity intolerance related to inability of heart to sustain extra workload
Explanation:
Children with rheumatic fever need to reduce activity to relieve stress during the course of the illness.

A nurse is caring for an infant who is experiencing heart failure. Which of the following would be the most appropriate care for this infant?

a) Provide large, less frequent feedings.
b) Administer oxygen.
c) Administer antidiuretic.
d) Restrict fluids.

Administer oxygen.
Explanation:
If a child is experiencing heart failure, the infant will need oxygen. One of the medications the infant would be on is a diuretic. An infant with heart failure will need smaller, more frequent feedings to conserve energy for feeding. Infants are not usually put on fluid restriction.

An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. Which of the following is the best response from the nurse?

a) It will show if blood is being shunted.
b) This image will clarify the structures within the heart.
c) It will determine if the heart is enlarged.
d) It will determine disturbances in heart conduction.

It will determine if the heart is enlarged.
Correct
Explanation:
Chest x-rays are performed to see if the heart is enlarged. This will determine if the heart muscle is increasing in size. Disturbances in heart conduction are detected by an EKG. Visualizing where blood is being shunted is through the echocardiogram. The image used to clarify the structures of the heart is the MRI.

Coarctation of the aorta demonstrates few symptoms in newborns. Which of the following is an important assessment to make on all newborns to help reveal this condition?

a) Auscultating for a cardiac murmur
b) Recording an upper extremity blood pressure
c) Assessing for the presence of femoral pulses
d) Observing for excessive crying

Assessing for the presence of femoral pulses
Correct
Explanation:
Infants with a narrowing (coarctation) of the aorta have decreased pressure in the lower extremities or absence of femoral pulses.

Which of the following would be included in the care of an infant in heart failure?

a) Maintain child in the supine position.
b) Encourage larger, less frequent feedings.
c) Begin formulas with increased calories.
d) Administer digoxin even if the infant is vomiting.

Begin formulas with increased calories.
Correct
Explanation:
Infants with heart failure need increased calories for growth. The infants are typically given smaller, more frequent feedings to decrease the amount given and to help conserve energy for feeding. They often times are given a higher-calorie formula. The infant should be placed in an upright position or in a car seat to increase oxygenation. The infant should not have any pressure on the diaphragm while in this position. Vomiting is a sign of digoxin toxicity and this should be considered before administering.

A parent asks about the risk of a congenital heart defect being passed on to another child since they already have one child that has it, but no one else in the family has one. What is the best response by the nurse?

a) There is a less than 7% chance a sibling would inherit a heart defect.
b) These occur related to medication the mother was taking while pregnant.
c) This was probably caused by environmental factors, not genetics.
d) There is no chance this will be passed to another child since we do not know what caused it.

There is a less than 7% chance a sibling would inherit a heart defect.
Correct
Explanation:
The risk to subsequent siblings of a child with CHD is approximately 2% to 6% so genetics can play a role in the child having a cardiac defect.

The nurse is collecting data on a child being evaluated for rheumatic fever. The caregiver reports that over the past several weeks she has noticed that the child seems to have lack of coordination. In addition she reports the child has had facial grimaces and repetitive involuntary movements. The signs the caregiver reports indicate the child has which of the following?

a) Chorea
b) Arthralgia
c) Carditis
d) Polyarthritis

Chorea
Correct
Explanation:
Chorea is a disorder characterized by emotional instability, purposeless movements, and muscular weakness. The onset of chorea is gradual, with increasing incoordination, facial grimaces, and repetitive involuntary movements.

The nurse is assessing the blood pressure of a toddler. Which finding would the nurse document as a normal finding?

a) 100/60 mm Hg
b) 110/60 mm Hg
c) 90/64 mm Hg
d) 80/40 mm Hg

90/64 mm Hg
Explanation:
The toddler’s or preschooler’s blood pressure averages 80 to 100/64 mm Hg. The normal infant’s blood pressure is about 80/40 mm Hg. The school-age child’s blood pressure averages 94 to 112/56 mm Hg. An adolescent’s blood pressure averages 100 to 120/50 to 70 mm Hg.

The nurse is administering medications to the child with congestive heart failure. Large doses of which of the following medications are used initially in the treatment of CHF to attain a therapeutic level?

a) Ferrous sulfate
b) Digoxin (Lanoxin)
c) Furosemide (Lasix)
d) Albuterol sulfate

Digoxin (Lanoxin)
Correct
Explanation:
The use of large doses of digoxin, at the beginning of therapy, to build up the blood levels of the drug to a therapeutic level is known as digitalization.

When a child is scheduled for a cardiac catheterization, an important health teaching point for parents is that the

a) child will have to remain NPO for 6 to 8 hours after the procedure to prevent vomiting.
b) child will return with a bulky pressure dressing over the catheter insertion area.
c) child will require a general anesthetic and needs to be prepared for this.
d) procedure is noninvasive and not frightening for children.

child will return with a bulky pressure dressing over the catheter insertion area.
Correct
Explanation:
Cardiac catheterization is typically performed with the child awake but using conscious sedation. A dressing will be placed on the catheter insertion site.

A school nurse is caring for a child with a severe sore throat and fever. Which of the following would be the best recommendation by the nurse to the parent?

a) Have the child drink fluids that contain electrolytes.
b) Have the child go to the emergency room.
c) Give acetaminophen for the fever and pain, and have the child rest.
d) Have the child be seen by the primary care provider.

Have the child be seen by the primary care provider.
Correct
Explanation:
Children with sore throats and fevers should be seen by their primary care provider to rule out strep throat. This is extremely important due to the fact they may contract an acquired heart disease called rheumatic fever. Taking acetaminophen, resting, and drinking fluids are all good recommendations, but the best recommendation is to see the provider. Going to the emergency room is not necessary at this time.

A nurse is examining a 10-year-old girl who has a heart murmur. On auscultation, the nurse finds that the murmur occurs only during systole, is short, and sounds soft and musical. When she has the girl stand, she can no longer hear the murmur on auscultation. Which of the following should the nurse say to the girl’s mother in response to these findings?

a) Not say anything, as the girl has an insignificant heart murmur and there is no reason to alarm the mother or her.
b) “Your daughter has an organic heart murmur, which indicates that she has some degree of heart disease. The doctor will provide a referral to a good cardiologist.”
c) “Your daughter has a functional heart murmur; I recommend that you limit her physical activity so that her heart rate is not elevated for long periods of time.”
d) “Your daughter has an innocent heart murmur, which is nothing to worry about.”

“Your daughter has an innocent heart murmur, which is nothing to worry about.”
Correct
Explanation:
The symptoms described indicate an innocent heart murmur. Although innocent murmurs are of no consequence, parents need to be told when their child has one because this finding will undoubtedly be discovered again at a future health assessment or during a febrile illness, anxiety, or pregnancy. Activities need not be restricted when a child has an innocent murmur and the child requires no more frequent health appraisals than other children. If a murmur is present as the result of heart disease or a congenital disorder, it is an organic heart murmur.

The nurse is administering the prescribed intravenous immunoglobulin to a 10-year-old boy. Which of the following would be most important for the nurse to do?

a) Administer with food.
b) Monitor for signs of Cushing syndrome.
c) Have epinephrine available.
d) Monitor urine for glucose.

Have epinephrine available.
Explanation:
The nurse should have epinephrine available during the infusion in case of an adverse reaction. Monitoring urine for glucose would be appropriate when corticosteroids are being given. Intravenous immunoglobulin does not need to be administered with food because it is being given as an intravenous infusion. Monitoring for signs of Cushing syndrome would be appropriate when corticosteroids are given.

When caring for a child experiencing anaphylactic shock, the most important nursing action would be to

a) enhance the action of histamine.
b) reverse sympathetic nervous system responses.
c) counteract hypertension.
d) facilitate breathing.

facilitate breathing.
Correct
Explanation:
The sudden release of histamine with an allergic reaction can cause severe bronchospasm, closing the airway.

Food allergies have become more and more common in the last few decades. Which of the following are common food allergies of childhood? Select all that apply.

a) Cheerios
b) Apples
c) Milk
d) Peanuts
e) Eggs

• Eggs
• Peanuts
• Milk
Explanation:
Allergies to eggs, peanuts, and milk are common in childhood. Cheerios are made of oats and are not known to be allergenic. Apples also are not allergenic, unlike bananas, which can cause problems for children who have latex allergies.

The nurse is caring for a child who is beginning to show signs and symptoms of anaphylaxis. Which intervention would be the priority?

a) Administering IV diphenhydramine (Benadryl)
b) Obtaining brief history of allergen exposure
c) Administering corticosteroids
d) Assessing patency of the airway

Assessing patency of the airway
Correct
Explanation:
The priority nursing intervention is to assess patency of the airway and breathing. If the child is stable, the next step would be to obtain a brief history of allergen exposure. If epinephrine is required, it would be administered prior to diphenhydramine. Corticosteroids would be used to prevent late-onset reactions.

Which is the immunoglobulin associated with allergic reactions?

a) IgA
b) IgM
c) IgG
d) IgE

IgE
Correct
Explanation:
IgE is responsible for immediate hypersensitivity reactions.

To avoid anaphylactic reactions in children, which question would be most important to ask a parent before administering penicillin to her infant?

a) “Is there any family history of allergy to penicillin?”
b) “Do you have a telephone to call us immediately if she develops trouble breathing?”
c) “What do you give her to alleviate itching?”
d) “Has she ever had penicillin before?”

“Has she ever had penicillin before?”
Correct
Explanation:
Penicillin is a drug frequently involved in allergic reactions. The reaction occurs after the child has first been sensitized to the drug.

A nurse is assisting with skin testing for allergies in a 14-year-old girl. Which of the following should the nurse do to ensure an accurate test?

a) Be certain that the child has not received an antihistamine in the past 8 hours
b) Read the test results within 40 minutes of administration
c) Apply a local anesthetic to the testing site, as the injections are painful
d) Inject the allergens into the muscle of the child’s forearm

Be certain that the child has not received an antihistamine in the past 8 hours
Correct
Explanation:
Skin testing is done to detect the presence of IgE in the skin, or to isolate an antigen (allergen) to which the IgE is responding or to which a child is sensitive. When an allergen is introduced into the child’s skin and the child is sensitive to that allergen, a wheal or flare response will appear at the site of the test from the release of histamine, which leads to local vasodilation. Because this reaction appears quickly, the test should be read in 20 minutes, not 40 minutes. Systemic or aerosol administration of an antihistamine will inhibit the flare response, so be certain the child has not received these drugs for 8 hours before skin testing. Because intracutaneous injections are given just below the epidermal layer of skin (not in the muscle), they are almost painless; thus, no anesthetic is needed.

A child with HIV, weighing 25 kg, is about to receive an infusion of IVIG. The recommended dose is 400 mg/kg/dose. The medication is available in a concentration of 50 mg/mL. What is the proper amount of infusion that the child will receive?

a) 1000 mL
b) 2000 mL
c) 200 mL
d) 100 mL

200 mL
Correct
Explanation:
The dose is calculated as 25 x 400 = 10,000 mg. Because the concentration is 50 mg/mL, calculate the volume as 10,000/50 = 200 mL.

The nurse is explaining patterns of incidence and transmission of HIV to a group of adolescent girls. She explains that the risks for this population are much higher because of the possibility of both vertical and horizontal transmission. Horizontal transmission refers to transmission of the disease during which of the following?

a) Sexual contact
b) The birthing process
c) Pregnancy
d) Feeding with breast milk

Sexual contact
Explanation:
Horizontal transmission refers to person-to-person transfer of the virus. Transmission by feeding with breast milk, birthing, and pregnancy are all examples of vertical transmission.

The nurse is preparing to administer an intravenous immunoglobulin infusion. While reconstituting the product according the manufacturer’s instructions, the nurse knows to take which step for proper preparation?

a) Reconstitute the medication 2 hours prior to administration.
b) Gently roll the vial to mix the medication.
c) Store the reconstituted medication no longer than 4 hours in the refrigerator
d) Shake the vial vigorously to disperse the diluent.

Gently roll the vial to mix the medication.
Correct
Explanation:
The nurse knows not the shake the intravenous immunoglobulin, as this may lead to foaming and may cause the immunoglobulin protein to degrade. Reconstituted intravenous immunoglobulin can be refrigerated overnight but should be brought to room temperature prior to administration. The nurse does not need to reconstitute the medication 2 hours prior to administration.

A young patient is admitted to the hospital directly from the clinic. The physician suspects a problem with the patient’s immune system. What test does the nurse anticipate the physician will order for this patient?

a) urine analysis
b) blood analysis
c) x-ray
d) EKG

blood analysis
Correct
Explanation:
When there is a deficiency of immunocompetent cells, an assessment will focus on analysis of blood components, particularly white blood cells.

A young patient comes to the clinic with multiple symptoms of an infection. The nurse realizes that the patient has been seen in the clinic every month for the last 6 months for the same problems. Which body system does the nurse suspect is malfunctioning in this patient?

a) cardiovascular
b) respiratory
c) immune
d) gastrointestinal

immune
Correct
Explanation:
Disorders of the immune system include deficiencies of immune substances and function that affect the body’s ability to ward off infection.

A child with primary immune deficiency is about to receive an infusion of IVIG. Which of the following is the most appropriate premedication to minimize the reaction?

a) Ketorolac
b) Ibuprofen
c) Diphenhydramine
d) Solu-Medrol

Diphenhydramine
Correct
Explanation:
Diphenhydramine and acetaminophen are the most commonly used medications for this purpose. Nonsteroidals and steroids typically are not used for this indication.

A group of nursing students are reviewing information about the immune system. The students demonstrate understanding of the information when they identify which of the following being produced by the thymus?

a) White blood cells
b) Stem cells
c) Lymphocyte T cells
d) Antibodies

Lymphocyte T cells
Correct
Explanation:
The thymus is responsible producing lymphocyte T cells. The bone marrow produces stem cells that are capable of differentiating into various blood cells. White blood cells arise from the stem cells in the bone marrow. Antibodies are formed by the B cells.

The nurse is instructing a group of women of childbearing age about HIV during pregnancy. Which of the following should be a priority recommendation in this setting?

a) Screening for HIV
b) Screening for STIs
c) Prophylactic treatment for HIV
d) Proper nutrition

Screening for HIV
Explanation:
No screening mandate has been put forth for HIV, but all pregnant women should be encouraged to undergo this test. Prophylactic treatment would be initiated only once the woman has been screened. Screening for STIs and ensuring proper nutrition are also part of health promotion for women in this age group, but they are of lower priority than identifying HIV-positive individuals.

The nurse is caring for an infant exposed to HIV. The polymerase chain reaction (PCR) test was negative at birth. The nurse tells the mother that the child will most likely be tested again at what age?

a) 12 months
b) 4 to 7 weeks
c) 8 to 10 weeks
d) 2 to 3 months

4 to 7 weeks
Correct
Explanation:
Virologic testing for HIV-exposed infants should be done with the polymerase chain reaction test at birth, at 4 to 7 weeks, and again at 8 to 16 weeks. Serologic testing is done at approximately 12 months of age to document disappearance of the HIV-1 antibody.

A nurse is preparing a presentation for a group of new parents and is planning to discuss nutrition during the first year. As part of the presentation, the nurse is planning to address foods that should be avoided to reduce the risk of possible food allergies. Which of the following would the nurse most likely include? Select all that apply.

a) Peanuts
b) Shrimp
c) Eggs
d) Carrots
e) Oranges
f) Potatoes

• Peanuts
• Shrimp
• Eggs
Correct
Explanation:
Foods that should be avoided in children younger than 1 year of age include: cow’s milk, eggs, peanuts, tree nuts, sesame seeds, kiwi fruit, and fish and shellfish (ie, shrimp). Carrots, potatoes, and oranges are not considered problematic.

The nursing instructor is describing the events of anaphylaxis. Place the assessment findings in the order that they would occur from first to last.

Hypoxia
Seizures
Bronchospasm
Urticaria, angioedema
Nausea, vomiting, diarrhea

Nausea, vomiting, diarrhea
Urticaria, angioedema
Bronchospasm
Hypoxia
Seizures
Correct
Explanation:
Initially, a child may be nauseous, with vomiting and diarrhea, because of the sudden increase in gastrointestinal secretions produced by the stimulation of histamine. This is followed by urticaria and angioedema. Bronchospasm can become so severe the child becomes dyspneic and hypoxemic. Continued bronchospasm leads to hypoxia. As blood vessels dilate, the blood pressure and pulse rate fall. Seizures and death may follow as soon as 10 minutes after the allergen is introduced into the child’s body.

When describing anaphylaxis to a group of parents whose children have experienced anaphylaxis from insect stings, the nurse integrates knowledge that this response is related to which immunoglobulin?

a) IgG
b) IgM
c) IgE
d) IgA

IgE
Correct
Explanation:
Anaphylaxis is an acute IgE-mediated response to an allergen that involves many organ systems and may be life-threatening.

A nursing student correctly identifies the inability to distinguish self from nonself, causing the immune system to carry out immune responses against normal cells, as which of the following?

a) immunity
b) autoimmunity
c) delayed hypersensitivity
d) allergen

autoimmunity
Correct
Explanation:
Autoimmunity results from an inability to distinguish self from nonself, causing the immune system to carry out immune responses against normal cells and tissue. Delayed hypersensitivity is when T-lymphocyte activity occurs without an accompanying humoral response. Immunity is the ability to destroy like antigens. An allergen is any mediating substance that when released causes tissue injury and allergic symptoms.

The parents of a child with juvenile idiopathic arthritis bring the child to the emergency department because the child is very drowsy and breathing heavily. The child also has been vomiting and complaining of ringing in her ears. The nurse suspects that the child is experiencing a toxic reaction to one of her medications. Which medication would the nurse suspect?

a) Aspirin
b) Corticosteroid
c) Etanercept
d) Methotrexate

Aspirin
Correct
Explanation:
The child is exhibiting signs and symptoms of aspirin toxicity. Corticosteroids would lead to signs and symptoms of Cushing syndrome as well as masking the signs of infection. Methotrexate would lead to changes in the white blood cell count, placing the child at risk for infection. Etanercept, like methotrexate, places the child at risk for infection.

A child with systemic lupus erythematosus is receiving hydroxychloroquine sulfate. Which instruction would the nurse emphasize when teaching the child and parents about this drug?

a) Importance of yearly eye examinations
b) Avoiding grapefruit juice when taking the drug
c) Giving with foods to minimize gastrointestinal upset
d) Need to gradually taper the drug dosage over time

Importance of yearly eye examinations
Correct
Explanation:
When hydroxychloroquine is given, the child should have a fundoscopic eye exam and visual field testing every year. Corticosteroids need to be tapered gradually over time. Cyclosporine A should not be taken with grapefruit juice. Nonsteroidal anti-inflammatory agents should be given with food to decrease gastrointestinal upset.

A child is in the emergency department after a bee sting and experiencing bouts of nausea and vomiting. The patient’s blood pressure is 68/40; pulse is 48. The child is hypoxic and dyspneic. Which medication should the nurse prepare to give this patient?

a) Benadryl
b) Prednisone
c) Epinephrine
d) Sudafed

Epinephrine
Correct
Explanation:
Epinephrine is the drug of choice to treat anaphylaxis.

A woman in her fourth month of pregnancy has recently learned that her sexual partner is HIV positive. She agrees to be tested for the virus but asks the nurse what early symptoms she should be looking for in herself. Which of the following should the nurse mention to the client?

a) Vaginal discharge
b) Skin rash
c) Mild, flu-like symptoms
d) Genital warts

Mild, flu-like symptoms
Correct
Explanation:
Unlike other sexually transmitted infections, HIV infection rarely begins with reproductive tract lesions. Instead, early symptoms are more subtle and often difficult to differentiate from those of other diseases or even from the symptoms of early pregnancy such as fatigue, anemia, diarrhea, and weight loss. The initial invasion of the virus may be accompanied by mild, flulike symptoms.

The nurse is reviewing the medical history of a 4-year-old child. Which of the following would the nurse identify as potentially indicative of a primary immunodeficiency? Select all that apply.

a) Pneumonia last spring; resolved with antibiotics
b) Recurrent deep abscess of the thigh
c) Oral thrush, persistent over the past 6 to 7 months
d) Infected laceration requiring IV antibiotic 2 months ago; healed
e) Acute otitis media, one episode every 3 to 4 weeks over the past year.

• Acute otitis media, one episode every 3 to 4 weeks over the past year.
• Recurrent deep abscess of the thigh
• Oral thrush, persistent over the past 6 to 7 months
Explanation:
Warning signs associated with primary immunodeficiency include eight or more episodes of acute otitis media in 1 year (one episode every 3 to 4 weeks results in at least 12 episodes in the past year), recurrent deep skin or organ abscesses, persistent oral thrush or skin candidiasis after 1 year of age. A history of infections that do not clear with IV antibiotics or two or more episodes of pneumonia in 1 year would be considered warning signs.

A child is diagnosed with a latex allergy. When developing the teaching plan for this child, the nurse would include which of the following foods to avoid? Select all that apply.

a) Bananas
b) Squash
c) Peanut butter
d) Cheese
e) Cherries
f) Pineapples

• Pineapples
• Cherries
• Bananas
Explanation:
Certain foods have shown a cross-sensitivity to latex and should be avoided. These include: pear, peach, passion fruit, plum, pineapple, kiwi, fig, grape, cherry, melon, nectarine, papaya, apple, apricot, banana, chestnut, carrot, celery, avocado, tomato, or potato.

The nurse is discussing food allergies with parents of a young child. She explains that a very effective way to determine which foods a child may be allergic to is to implement

a) A raw food diet
b) Allergy skin testing
c) A food diary
d) An elimination diet

An elimination diet
Correct
Explanation:
The food diary may identify foods the child does not tolerate well, but it lacks the objectivity of the elimination diet. Skin testing usually involves whole proteins and will not test for reactions to food breakdown products. A raw food diet does not apply to allergy identification.

The most accurate screening test for the presence of HIV antigen in young children is

a) ELISA
b) PCR
c) CD4 count
d) Western blot

PCR
Correct
Explanation:
PCR tests directly for the HIV antigen. ELISA and the Western blot test detect the presence of HIV antibodies. The CD4 count is used as a measure of disease status and progression.

A 7-year-old girl has been battling leukemia and receiving radiation therapy. She is highly susceptible to infections, and the nurse recognizes that this is because she is experiencing secondary immunodeficiency. Which of the following are factors that cause secondary immunodeficiency? (Select all that apply.)

a) Severe stress
b) Genetic deficiency of B-lymphocytes
c) Radiation therapy
d) Cancer
e) Malnutrition
f) Hypogammaglobulinemia related to an inherited X-linked recessive gene

• Cancer
• Radiation therapy
• Severe stress
• Malnutrition
Explanation:
Secondary immunodeficiency, or loss of immune system response, can occur from factors such as severe systemic infection, cancer, renal disease, radiation therapy, severe stress, malnutrition, immunosuppressive therapy, and aging. Genetic deficiency of B-lymphocytes and hypogammaglobulinemia related to an inherited X-linked recessive gene are examples of primary (congenital) immunodeficiencies, not secondary (acquired) immunodeficiencies.

The nurse is working with a pregnant client with HIV who is receiving oral zidovudine. What is the primary rationale for this intervention?

a) To treat pneumonia
b) To help prevent transmission of the disease to the fetus
c) To halt the growth of Kaposi’s sarcoma
d) To restore coagulation ability

To help prevent transmission of the disease to the fetus
Correct
Explanation:
A goal of therapy during pregnancy is to maintain the CD4 cell count at greater than 500 cells/mm3 by administering oral zidovudine which helps halt maternal/fetal transmission dramatically along with one or more protease inhibitors, such as ritonavir (Norvir) or indinavir (Crixivan), in conjunction with an NRTI. If P. carinii pneumonia develops, a woman is treated with trimethoprim with sulfamethoxazole. Kaposi’s sarcoma is normally treated with chemotherapy. Women may need a platelet transfusion close to birth to restore coagulation ability.

The nurse is explaining to a parent some of the basic aspects of the immune system and its functions. She informs them that B cells, also known as _________ cells, will attack __________ antigens.

a) killer; viral
b) humoral; viral
c) humoral; bacterial
d) killer; bacterial

humoral; bacterial
Correct
Explanation:
B cells are also called humoral cells and typically attack bacterial organisms. Another term for T cells is killer cells, and they most commonly attack viral organisms.

What advice would be most appropriate for the child with a stinging-insect allergy?

a) Arrange for allergy testing for foods with ingredients similar to those in insect venom.
b) Obtain a Medic-Alert bracelet so the presence of the allergy can be identified easily.
c) Join a peer support group to help relieve anxiety about this problem.
d) Consult a genetic counselor to reveal other susceptible family members.

Obtain a Medic-Alert bracelet so the presence of the allergy can be identified easily.
Correct
Explanation:
Stinging-insect allergy can lead to anaphylactic shock. Alerting health care personnel to the possibility of an insect sting is important.

A 6-month-old boy has been admitted to the hospital with severe bloody diarrhea. The nurse notes petechiae and eczema with signs of secondary infection. As the nurse documents the boy’s history, the parents report easy bruising and prolonged bleeding after circumcision. Based on these findings, the nurse suspects a diagnosis of which of the following?

a) von Willebrand’s disease
b) Beta-thalassemia major
c) Wiskott-Aldrich syndrome
d) Severe combined immunodeficiency

Wiskott-Aldrich syndrome
Correct
Explanation:
Severe bloody diarrhea, petechiae, bruising, eczema with secondary infection, and prolonged bleeding episodes are signs and symptoms of Wiskott-Aldrich syndrome. Beta-thalassemia major would be manifested by signs of bleeding. von Willebrand’s disease would be manifested by signs of bleeding. Severe combined immunodeficiency would be manifested by chronic diarrhea and failure to thrive, persistent thrush, and a history of severe infections beginning in infancy.

The nurse is providing family education about the administration of cyclosporine A. Which response by the family indicates a need for further teaching?

a) “We should monitor for signs of infection.”
b) “We need to adhere to the schedule for routine follow up blood work.”
c) “The medication is best absorbed with the vitamin C in citrus juices.”
d) “It is okay to take cyclosporine with dairy products.”

“The medication is best absorbed with the vitamin C in citrus juices.”
Explanation:
Cyclosporine A should not be taken with grapefruit juice but it may be administered with dairy products. While this medication is being used, the patient needs to be monitored for signs of infection and adhere to the schedule for follow up blood tests to evaluate for complications.

The nurse is teaching the parents of a 4-year-old boy with a peanut allergy about diet and possible unexpected locations of peanuts or peanut oil in food products. After describing this to the parents, which response by the mother would indicate a need for further teaching?

a) “We can’t go wrong with hamburgers and hot dogs.”
b) “We must be careful with Asian food.”
c) “We must be careful about baked goods.”
d) “Some hot-chocolate mixes have peanuts.”

“We can’t go wrong with hamburgers and hot dogs.”
Correct
Explanation:
The nurse needs to remind the mother that peanut oil might be a hidden ingredient in barbecue sauce, which is commonly used on hamburgers and hot dogs. Baked goods can be hidden sources for peanut oil and peanuts. Hot chocolate may contain peanuts or peanut oil. Asian foods may contain hidden peanuts.

When teaching about primary and secondary humoral responses, what should the nurse identify as the immunoglobin that is first to appear in the serum?

a) IgD
b) IgE
c) IgG
d) IgM

IgM
Correct
Explanation:
IgM is the first immunoglobin to appear in the serum with the primary and secondary humoral responses.

The nurse is preparing an informational brochure about risk factors for immune disorders. Which of the following disease processes can indicate a potential underlying immunologic disorder? Select all that apply.

a) Persistent oral thrush
b) Occasional rhinorrhea
c) Chronic cough
d) Illness with a high-grade fever
e) Extensive eczema

• Persistent oral thrush
• Chronic cough
• Extensive eczema
Correct
Explanation:
Occasional rhinorrhea is common and does not indicate an immune disorder. Illness with high fever is a sign of acute illness, rather than a chronic underlying disorder such as immune dysfunction.

After teaching a class of nursing students about acquired immunodeficiency, the instructor determines that the teaching was effective when the students identify which of the following as a contributing factor? Select all that apply.

a) Cancer
b) Malnutrition
c) Vitamin therapy
d) Minor localized infection
e) Immunosuppressive drugs

• Cancer
• Malnutrition
• Immunosuppressive drugs
Correct
Explanation:
Factors contributing to secondary (acquired) immunodeficiency include severe systemic infection, cancer, renal disease, radiation therapy, severe stress, malnutrition, immunosuppressive therapy, and aging.

A nurse is giving a talk to high-school students about preventing the spread of HIV. What does the nurse identify as ways in which HIV is spread? (Select all that apply.)

a) Transfusion of contaminated blood
b) Perinatally from mother to fetus
c) Sharing the same bathroom
d) Sharing contaminated needles
e) Through breastfeeding
f) Exposure to blood and body fluids through sexual contact

• Transfusion of contaminated blood
• Perinatally from mother to fetus
• Sharing contaminated needles
• Through breastfeeding
• Exposure to blood and body fluids through sexual contact
Correct
Explanation:
HIV is spread by exposure to blood and other body fluids through sexual contact, sharing of contaminated needles for injection, transfusion of contaminated blood, perinatally from mother to fetus, and through breastfeeding.

Susie is a 3-year-old with a history of neonatal transmission of HIV and recent diagnosis of AIDS, as manifested by M. tuberculosis infection. To date, Susie has been relatively healthy with few illnesses associated with high fever; she has been developing appropriately and is at the 5th percentile for height and weight. Susie is at risk for all of the following diagnoses. Prioritize the order of urgency of these diagnoses based on the scenario provided.

Altered family coping related to new presentation of significant illness
Delayed growth and development related to frequent infections
Altered comfort related to severity of new illness
Inadequate nutrition related to side effects of medication
Inadequate adherence to medication regimen related to side effects

Altered family coping related to new presentation of significant illness
Altered comfort related to severity of new illness
Inadequate adherence to medication regimen related to side effects
Inadequate nutrition related to side effects of medication
Delayed growth and development related to frequent infections
Explanation:
Because Susie has been relatively healthy since she was diagnosed with HIV, the change in her status is likely to cause changes in family coping mechanisms and dynamics that will have implications for the entire family. Next, the nurse needs to address the specific symptoms of the child. With the increased degree of illness and altered coping strategies, the child may have more difficulty with medication adherence, as well as other complications of AIDS-related illness and treatment, such as poor nutritional intake and delayed growth and development.

Which of the following nursing problems could be associated with a child with primary immunodeficiency? Select all that apply.

a) Risk for infection
b) Delayed growth and development
c) Altered skin integrity
d) Altered gastrointestinal function
e) Altered fluid and electrolytes

Risk for infection
Altered skin integrity
Delayed growth and development

The mother of a child with a possible food allergy asks the nurse for information about how to test for it. Which response by the nurse would be most appropriate?

a) “Skin testing using a patch is probably the easiest method.”
b) “The best way is to eliminate the food from the diet and then look for improvement.”
c) “We can inject an extract of the food under the skin and see if there is a reaction.”
d) “We can check the level of antibodies in the blood to confirm the allergy.”

“The best way is to eliminate the food from the diet and then look for improvement.”
Correct
Explanation:
Food allergies are best identified by eliminating a suspected food from the diet and observing whether symptoms improve. After a time of improvement, the food is reintroduced and if the child is allergic to the food, the symptoms will return. Skin testing with either a patch or intracutaneous injection is ineffective for determining food allergies. Serum antibody levels can be measured but are not specific in helping to determine food allergies.

Which of the following treatments are common to both systemic lupus erythematosus and juvenile idiopathic arthritis? Select all that apply.

a) Antipyretics
b) Corticosteroids
c) Antirheumatics
d) Nonsteroidal antiinflammatories
e) Antimalarials

• Corticosteroids
• Nonsteroidal antiinflammatories
Explanation:
Antimalarials are specific to SLE; antirheumatics are specific to JIA. Antipyretics are not typically used for either disorder.

An 8-year-old boy is suffering from allergic rhinitis. The nurse should advise his mother to avoid which of the following allergens?

a) Penicillin
b) Pollen
c) Peanuts
d) Soap

Pollen
Correct
Explanation:
The allergens that usually cause allergic rhinitis are pollens or molds rather than foods or drugs. Soap is not associated with allergic rhinitis.

Which of the following immune cells are disrupted when a child is infected with HIV? Select all that apply.

a) Platelets
b) Phagocytes
c) T cells
d) B cells
e) Erythrocytes

• T cells
• B cells
• Phagocytes
Explanation:
Platelets and erythrocytes are not affected by the HIV virus because the disease affects primarily the immune system.

To establish whether the problem is truly a milk allergy in a child who is suspected of having this condition, milk should be reintroduced every 6 to 12 months.

a) True
b) False

True
Correct
Explanation:
To establish whether the problem is truly a milk allergy, milk should be reintroduced every 6 to 12 months. If the problem is a true milk allergy, signs will recur.

A nursing student correctly identifies which of the following to be the most serious of all of the immunologic disorders?

a) allergic rhinitis
b) contact dermatitis
c) HIV
d) serum sickness

HIV
Correct
Explanation:
Of the immunologic disorders, human immunodeficiency virus (HIV) infection is the most serious, not only because it is still fatal but also because its spread has been difficult to contain.

When evaluating parents’ understanding of atopic dermatitis, which of the following statements would you want to hear them voice?

a) “Atopic dermatitis follows a streptococcal infection.”
b) “Hydrocortisone cream may lead to kidney disease.”
c) “Flare-ups of lesions are not uncommon following therapy.”
d) “Atopic dermatitis turns to asthma later in life.”

“Flare-ups of lesions are not uncommon following therapy.”
Correct
Explanation:
Atopic dermatitis may recur when the child is re-exposed to the substance to which he or she is allergic.

The nursing diagnosis you anticipate that would best apply to a child with allergic rhinitis is

a) pain related to sinus edema and headache
b) Ineffective tissue perfusion related to nosebleeds

pain related to sinus edema and headache.
Correct
Explanation:
Many children with allergic rhinitis develop sinus headaches from edema of the upper airway.

Nursing students are reviewing the events involved in humoral immunity. They demonstrate understanding of the information when they identify which of the following as occurring with complement activation? Select all that apply.

a) Smooth muscle relaxation
b) Lysis of the foreign antigen
c) Decreased vascular permeability
d) Phagocytosis
e) Chemotaxis

• Lysis of the foreign antigen
• Phagocytosis
• Chemotaxis
Correct
Explanation:
Complement activation results in increased vascular permeability, smooth muscle contraction, chemotaxis, phagocytosis, and lysis of the foreign antigen.

A nurse is providing care to a child with HIV who is prescribed therapy with a nucleoside reverse transcriptase inhibitor. Which of the following would the nurse expect to administer?

a) Nevirapine
b) Zidovudine
c) Ritonavir
d) Efavirenz

Zidovudine
Explanation:
Zidovudine is a nucleoside reverse transcriptase inhibitor. Nevirapine and efavirenz are classified as nonnucleoside reverse transcriptase inhibitors. Ritonavir is a protease inhibitor.

The nurse instructs a school-aged child who has a bee-sting allergy and his parents on proper use of the EpiPen. What is the order of steps that should be taken if the child is bit by a bee?

Remove gray safety cap.
Place EpiPen against child’s thigh, injecting solution.
Grasp the EpiPen with your fist, with black tip pointing down.
Hold syringe in place for 10 seconds.

Grasp the EpiPen with your fist, with black tip pointing down.
Remove gray safety cap.
Place EpiPen against child’s thigh, injecting solution.
Hold syringe in place for 10 seconds.
Correct
Explanation:
These are the necessary steps for injecting the EpiPen. First, make sure to hold the device correctly. Then remove the cap. Next, place the injection tip against the thigh, either directly on the skin or on the clothing. Finally, hold the syringe in place for 10 seconds to make sure the content is injected properly.

Nebulized albuterol should be available to counteract anaphylactic shock. This drug

a) facilitates breathing.
b) increases the pulse rate.
c) depresses the central nervous system.
d) counteracts hypotension.

facilitates breathing.
Explanation:
Albuterol is a bronchodilator that enlarges the lumen of the airway.

When treating allergies in a child, the nurse is aware that the classification for the drug of choice to control itching, sneezing, and rhinorrhea is which of the following?

a) Antihistamines
b) Decongestants
c) Corticosteroids
d) Antibiotics

Antihistamines
Correct
Explanation:
Antihistamines block histamine release and as a result control itching, sneezing, and rhinorrhea.

A mother, who is HIV positive, is distraught when she learns that her 6-month-old baby is also HIV positive. The child had undergone open heart surgery as a newborn and had received numerous blood transfusions. The nurse recognizes that which of the following is the most likely means of transmission of the disease to this child?

a) The mother kissing the baby on the forehead
b) Breastfeeding
c) Blood transfusion products contaminated with the virus
d) Placental spread during pregnancy

Placental spread during pregnancy
Correct
Explanation:
Although it is decreasing in incidence, transmission of HIV from mother to child by placental spread is still the most common reason for childhood HIV infection in the United States. Children with hemophilia no longer have a high incidence of the disease because blood products are now screened for the virus. HIV is not transmitted by animals or through usual casual contact, such as shaking hands or kissing, or in households, day care centers, or schools. Infection via breast milk is possible but less likely that via placental spread.

A school-aged child has a bee-sting allergy. When the child is stung by a bee during a school recess, assuming that all of the following interventions are covered by school protocol, which initial intervention by the school nurse would be most appropriate?

a) Immediately transport the child to the local hospital.
b) Apply a warm compress to the site of the bee sting.
c) Administer epinephrine immediately.
d) Notify the child’s mother.

Administer epinephrine immediately.
Correct
Explanation:
Epinephrine counteracts histamine release to decrease bronchospasm and difficulty breathing.

Place in correct order the steps in the anaphylactic response.

Vasodilation
Rapid immune response
Bronchoconstriction
Exposure to allergen
Circulatory collapse

Exposure to allergen
Rapid immune response
Vasodilation
Bronchoconstriction
Circulatory collapse
Explanation:
Anaphylaxis typically is a very rapid response to exposure to an allergen. Vasodilation leads to potential circulatory collapse. Bronchospasm occurs simultaneously with other system reactions, also contributing to the life-threatening possibility.

A 5 year old is hospitalized after an asthma attack at school. The child tells the nurse that the janitor had been cleaning in the classroom prior to the attack and that a lot of dust was in the air. The dust that likely caused the attack is known as what?

a) allergen
b) antigen
c) immunogen
d) macrophage

allergen
Correct
Explanation:
Mediating substances that are released and cause tissue injury and allergic symptoms are called allergens. An antigen is any foreign substance capable of stimulating an immune response. An antigen that can be readily destroyed by an immune response is called an immunogen. Macrophages are mature white blood cells.

A 4-year-old child is receiving monthly IgG transfusions for hypergammaglobulinemia. In assessing the child’s current health status, the nurse will ask about several aspects of care, including which of the following? Select all that apply.

a) Sleep disturbances
b) Vacation plans
c) Nutritional intake
d) Frequency of recent illnesses
e) Participation in activities

• Frequency of recent illnesses
• Nutritional intake
• Participation in activities
• Sleep disturbances
• Vacation plans
Explanation:
Evidence of frequent illness is of concern if the child is receiving IgG supplementation. The child with this disorder will have a poor appetite. The child may experience activity intolerance due to fatigue, illness, or joint pain. Sleep disturbances are common in children with immune disorders. The family will need to consider the child’s health status and risks of exposure when planning a vacation.

The nurse is caring for a child with systemic lupus erythematosus. The doctor will most likely order which test to monitor the child’s progress?

a) IgG subclasses
b) Immunoglobulin electrophoresis
c) Lymphocyte immunophenotyping T-cell quantification
d) Complement assay (C3 and C4)

Lymphocyte immunophenotyping T-cell quantification
Explanation:
Lymphocyte immunophenotyping T-cell quantification is for ongoing monitoring of progressive depletion of CD4 T lymphocytes in HIV disease. The nurse would expect the physician to order a complement assay (C3 and C4) for ongoing monitoring of systemic lupus erythematosus. IgG subclasses measures the levels of the four subclasses of IgG and is used to determine immunodeficiencies. Immunoglobulin electrophoresis is ordered for immunodeficiency and autoimmune disorders, not to monitor systemic lupus erythematosus.

A child is diagnosed with severe combined immunodeficiency syndrome. Which of the following would the nurse expect to find when reviewing the child’s history and physical examination?

a) Elevated IgE levels
b) Worsening eczema
c) Chronic diarrhea
d) Weight greater than expected for height

The nurse is caring for a 4-year-old girl with HIV. The girl is taking nucleoside analogue reverse transcriptase inhibitors (NRTI) as part of a three-drug regimen. The nurse knows to monitor for signs of a fatal hypersensitivity reaction that can occur with which of the following medications?

a) Zidovudine
b) Ritonavir
c) Abacavir
d) Lamivudine

Abacavir
Correct
Explanation:
A fatal hypersensitivity reaction may occur with abacavir. Ritonavir is a protease inhibitor, not a nucleoside analogue reverse transcriptase inhibitor. This drug is not associated with a fatal hypersensitivity reaction. This drug is not associated with a fatal hypersensitivity reaction.

The first time a child with hypersensitivity to stinging insects is stung, the reaction is usually anaphylactic shock and, if not immediately treated, death.

a) False
b) True

False
Correct
Explanation:
The first time a child is stung, the total reaction is probably only local edema at the site. The second time, generalized urticaria, pruritus, and edema may develop. The third time, symptoms may progress to wheezing and dyspnea. The next time, the reaction could be so severe that shock and death result. The progression of symptoms may be slower than this (involving 10 to 12 stings) if the stings occur far apart; if the stings are received close together (1 or 2 days apart, or even 3 weeks apart), the progression to fatal symptoms may occur as early as the second or third exposure.

A child is scheduled to undergo hyposensitization. The nurse understands that this therapy attempts to achieve which of the following?

a) An increased level of IgE
b) Blockage of histamine release
c) Reduction in allergen exposure
d) Increased concentration of IgG

Increased concentration of IgG
Correct
Explanation:
Hyposensitization works by increasing the plasma concentration of IgG antibodies. IgG acts to prevent or block IgE antibodies from coming into contact with the allergen. IgE levels are not increased. Antihistamines block the release of histamine. Environmental control helps to reduce exposure to potential allergens.

Nursing students demonstrate correct understanding when they identify which immunoglobin as occurring most frequently in plasma and the major one to be synthesized during secondary response?

a) IgA
b) IgD
c) IgM
d) IgG

IgG
Correct
Explanation:
IgG is the most frequent antibody in plasma and is the major immunoglobin to be synthesized during the secondary response.

A mother brings her 4-month-old infant to the doctor’s office due to vesicular lesions that have appeared on the child’s scalp and face. The mother says that the child will not stop scratching at the lesions and that she is concerned that he is having some kind of allergic reaction. Which of the following should the nurse recommend to the mother to help reduce pruritus in this child?

a) Have the child retested for PKU
b) Have the child undergo skin testing
c) Apply wet dressings for 15 to 20 minutes, followed by moisturizer
d) Put the child on elimination diets

Apply wet dressings for 15 to 20 minutes, followed by moisturizer
Explanation:
A major consideration in treatment of atopic dermatitis is aimed at reducing pruritus so children do not irritate lesions and cause secondary infections by scratching. Hydrating the skin by bathing or applying wet dressings (wet with tap water or Burrow’s solution) for 15 to 20 minutes, followed by application of moisturizer such as Eucerin is helpful. Skin testing is usually ineffective because, although the allergen causing infantile atopic dermatitis may be pollen, dust or a mold spore; it is often a food allergen. Elimination diets can help identify an allergen, but do not directly help reduce pruritus; in any case, a 4-month-old should not be eating solid foods. Because untreated phenylketonuria (PKU) can lead to atopic dermatitis, children with infantile atopic dermatitis need to have a repeat test for PKU to be certain this is ruled out—however, this intervention does not directly reduce pruritus, either.

The nurse is teaching the parents of a 4-year-old girl with thalassemia about sound nutritional choices. The nurse asks the mother about good snack choices to send to preschool. Which response by the mother would indicate a need for further teaching?

a) “She likes string cheese and saltine crackers.”
b) “She can bring graham crackers and peanut butter.”
c) “I can send apple slices with yogurt dip.”
d) “Yogurt and granola is a good choice.”

“She can bring graham crackers and peanut butter.”
Explanation:
Children with thalassemia should avoid foods that are high in iron. Peanut butter is high in iron and should be avoided. Yogurt, granola, string cheese, saltine crackers, and apples are appropriate choices.

A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in his care should be given priority?

a) Seeing that he ingests a protein-rich diet
b) Beginning active range-of-motion exercises
c) Maintaining a fluid intravenous line
d) Encouraging him to take deep breaths hourly

Maintaining a fluid intravenous line
Correct
Explanation:
Dehydration increases sickling of cells, so maintaining fluid balance is important.

An 8-month-old girl appears pale, irritable, and anorexic. On blood testing, the red blood cells are hypochromic and microcytic. The hemoglobin level is less than 5 g/100 mL, and the serum iron level is high. Which of the following symptoms should the nurse most expect as a result of excessive iron deposits?

a) An enlarged heart
b) An enlarged spleen
c) Enlarged lymph nodes
d) An enlarged thyroid gland

An enlarged spleen
Correct
Explanation:
The child with thalassemia major may have both an enlarged spleen and liver due to excessive iron deposits and fibrotic scarring in the liver and the spleen’s increased attempts to destroy defective RBCs.

After teaching a group of students about hemophilia, the instructor determines that the students have understood the information when they identify hemophilia A as involving a problem with which of the following?

a) Plasmin
b) Factor IX
c) Platelets
d) Factor VIII

Factor VIII
Correct
Explanation:
In hemophilia A, the problem is with factor VIII, and in hemophilia B it is factor IX. Platelets are problematic in idiopathic thrombocytopenia purpura. Plasmin is involved in the pathophysiologic events of disseminated intravascular coagulation.

The nurse is teaching an in service program to a group of nurses on the topic of children diagnosed with sickle cell anemia. The nurses in the group make the following statements. Which statement is most accurate regarding sickle cell anemia?

a) “If the trait is inherited from both parents the child will have the disease.”
b) “The trait or the disease is seen in one generation and skips the next generation.”
c) “Males are much more likely to have the disease than females.”
d) “The disease is most often seen in individuals of Asian decent.”

“If the trait is inherited from both parents the child will have the disease.”
Correct
Explanation:
When the trait is inherited from both parents (homozygous state), the child has sickle cell disease, and anemia develops. The trait does not skip generations.
The trait occurs most commonly in African Americans. Either sex can have the trait and disease.

A toddler who is beginning to walk has fallen and hit his head on the corner of a low table. The caregiver has been unable to stop the bleeding and brings the child to the pediatric clinic. The nurse is gathering data during the admission process and notes several bruises and swollen joints. A diagnosis of hemophilia is confirmed. This child most likely has a deficiency of which of the following blood factors?

a) Factor V
b) Factor VIII
c) Factor XIII
d) Factor X

Factor VIII
Correct
Explanation:
The most common types of hemophilia are factor VIII deficiency and factor IX deficiency, which are inherited as sex-linked recessive traits, with transmission to male offspring by carrier females.

The nurse is reinforcing teaching with a group of caregivers of children diagnosed with iron deficiency anemia. One of the caregivers tells the group, “I give my child ferrous sulfate.” Which of the following statements made by the caregivers is correct regarding giving ferrous sulfate?

a) “I always give the ferrous sulfate with meals.”
b) “We watch closely for any diarrhea since that usually happens when he takes ferrous sulfate.”
c) “When I give my son ferrous sulfate I know he also needs potassium supplements.”
d) “My husband gives our daughter orange juice when she takes her ferrous sulfate, so she gets Vitamin C.”

“My husband gives our daughter orange juice when she takes her ferrous sulfate, so she gets Vitamin C.”
Explanation:
When ferrous sulfate is administered, it should be given between meals with juice (preferably orange juice, because vitamin C aids in iron absorption). For best re sults, iron should not be given with meals. Ferrous sulfate can cause constipation or turn the child’s stools black

A 9-month-old boy with iron-deficiency anemia is given ferrous sulfate therapy. Which of the following assessments would best help you determine that he is actually taking it daily?

a) His reticulocyte count will have decreased.
b) He will develop diarrhea.
c) He will be less irritable than he was at his last visit.
d) His stools will appear black.

His stools will appear black.
Explanation:
A side effect of ferrous sulfate therapy is to color stools black.

In hemophilia A, the classic form, only females manifest a bleeding disorder.

a) False
b) True

False
Correct
Explanation:
The classic form of hemophilia is caused by deficiency of the coagulation component factor VIII, the antihemophilic factor, and transmitted as a sex-linked recessive trait. In the United States, the incidence is approximately 1 in 10,000 white males. A female carrier may have slightly lowered but sufficient levels of the factor VIII component so that she does not manifest a bleeding disorder. Males with the disease also have varying levels of factor VIII; their bleeding tendency varies accordingly, from mild to severe.

The nurse is assessing a child and notices pinpoint hemorrhages appearing on several different areas of the body. The hemorrhages do not blanch on pressure. The nurse documents this finding as which of the following?

a) Poikilocytosis
b) Purpura
c) Petechiae
d) Ecchymosis

Petechiae
Correct
Explanation:
Petechiae are pinpoint hemorrhages that occur anywhere on the body and do not blanch with pressure. Purpura are larger areas of hemorrhage in which blood collects under the tissues and appear purple in color. Ecchymosis refers to areas of bruising. Poikilocytosis refers to the variation in the size and shape of the red blood cells commonly found in children with thalassemia.

A nurse is reviewing the medical records of several children who have undergone lead screening. The nurse would identify the child with which lead level as requiring no further action?

a) 8 mcg/dL
b) 14 mcg/dL
c) 20 mcg/dL
d) 26 mcg/dL

8 mcg/dL
Correct
Explanation:
A blood lead level less than 10 mcg/dL requires no action. A level of 14 mcg/dL would need to be confirmed with a repeat test in 1 month along with parental education for decreased lead exposure and then a repeat test in 3 months. Levels of 20 mcg/dL and 26 mcg/dL need to be confirmed with a repeat test in 1 week along with parental education and a referral to the local health department for investigation of the home for lead reduction.

The parents of a 6-year-old male with idiopathic thrombocytopenic purpura (ITP) ask the nurse conducting an assessment of the child what causes the disease. What is the nurse’s best response?

a) “ITP is a serious bleeding disorder characterized by a decreased, absent, or dysfunctional procoagulant factor.”
b) “ITP is primarily an autoimmune disease in that the immune system attacks and destroys the body’s own platelets, for an unknown reason.”
c) “ITP is characterized by the loss of surface area on the red blood cell membrane.”
d) “ITP occurs when the body’s iron stores are depleted due to rapid physical growth, inadequate iron intake, inadequate iron absorption, or loss of blood.”

“ITP is primarily an autoimmune disease in that the immune system attacks and destroys the body’s own platelets, for an unknown reason.”
Correct
Explanation:
Idiopathic thrombocytopenic purpura (ITP) is primarily an autoimmune disease, which is an acquired, self-limiting disorder of hemostasis characterized by destruction and decreased numbers of circulating platelets. Hemophilia A and hemophilia B are distinguished by the particular procoagulant factor that is decreased, absent, or dysfunctional. Iron deficiency anemia occurs when the body’s iron stores are depleted. Hereditary spherocytosis (HS) is characterized by loss of surface area on the red blood cell membrane.

When developing the postoperative plan of care for a child with sickle cell anemia who has undergone a splenectomy, which of the following would the nurse identify as the priority?

a) Risk for delayed growth and development
b) Deficient fluid volume
c) Risk for infection
d) Impaired skin integrity

Risk for infection
Correct
Explanation:
Removal of the spleen places the child at significant risk for infection. Although the child’s skin integrity is disrupted due to the surgery, this is not the priority nursing diagnosis. Loss of fluids occurs during surgery and adequate hydration is important to prevent a sickle cell crisis, but this diagnosis is not the priority in the postoperative period. Although the child is at risk for delayed growth and development, the priority postoperatively is to prevent infection.

Complications associated with bleeding most often involve joints and muscles. Adjunct measures to control bleeding include:

a) Heat
b) Lowering extremities
c) Compression
d) Exercise

Compression
Correct
Explanation:
Complications associated with bleeding most often involve joints and muscles. Adjunct measures include rest, ice, compression, and elevation (RICE). In addition, corticosteroids such as prednisone may be used to reduce inflammation in the joint.

The parents of a child with a bleeding disorder ask the nurse about appropriate activities and sports that they should encourage the child to participate in. Which of the following would be the safest for the nurse to suggest?

a) Rugby
b) Swimming
c) Gymnastics
d) Soccer

Swimming
Correct
Explanation:
Swimming, a noncontact sport or activity, would be the safest for the nurse to recommend. Soccer and gymnastics may be appropriate; however, these are considered riskier. Rugby would not be recommended because the risks outweigh the benefits.

A child who weighs 22 pounds is to receive a blood transfusion. The nurse would expect to administer _____ of the blood transfusion in an hour?

_____ milliliters

The child weighs 22 pounds, which is equivalent to 10 kg. The recommended rate of infusion is 10 mL/kg/hour. A child who weighs 10 kg would receive 100 mL in an hour.

The child with Thalassemia may be given which of the following classifications of medications to prevent one of the complications frequently seen with the treatment of this disorder.

a) Potassium supplements
b) Factor VIII preparations
c) Iron-chelating drugs
d) Vitamin supplements

Iron-chelating drugs
Correct
Explanation:
Frequent transfusions can lead to complications and additional concerns for the child, including the possibility of iron overload. For these children, iron-chelating drugs such as deferoxamine mesylate (Desferal) may be given. Vitamin and potassium supplements would not be given to treat the iron overload. Factor VIII preparations are given to the child with hemophilia.

You are assessing children in an ambulatory clinic. Which child would be most likely to have iron-deficiency anemia?

a) A 15-year-old girl who has heavy menstrual periods
b) An 8-year-old girl who carries her lunch to school
c) A 7-month-old boy who has started table food
d) A 3-month-old boy who is totally breastfed

A 15-year-old girl who has heavy menstrual periods
Correct
Explanation:
Adolescents with heavy menstrual flows lose enough blood each month to cause iron-deficiency anemia.

The nurse is caring for a 10-year-old boy with hemophilia. He asks the nurse for suggestions about appropriate physical activities. Which activity would the nurse most likely recommend?

a) Football
b) Baseball
c) Wrestling
d) Soccer

Baseball
Correct
Explanation:
Children with hemophilia should stay active. Good physical activities would be swimming, baseball, basketball, and bicycling (with a helmet). He would still need to be careful about falls and sliding into base. Intense contact sports like football, wrestling, and soccer should be avoided.

The nurse is administering meperidine as ordered for pain management for a 10-year-old boy in sickle cell crisis. The nurse would be alert for which of the following?

a) Priapism
b) Seizures
c) Leg ulcers
d) Behavioral addiction

Seizures
Correct
Explanation:
Repeated use of meperidine for pain management during sickle cell crisis increases the risk of seizures when used in children with sickle cell anemia. Behavioral addiction is rarely a concern in the child with sickle cell anemia if the narcotic is used for the alleviation of severe pain. Priapism is a complication of sickle cell anemia unrelated to meperidine administration. Leg ulcers are a complication of sickle cell anemia unrelated to meperidine administration.

A nursing instructor describes what happens to the red blood cell after it disintegrates and how bilirubin is formed. Place the events in the order that the instructor would discuss from first to last.

Conversion to direct bilirubin
Conversion to protoporphyrin
Break down into indirect bilirubin
Degradation of heme portion
Excretion in bile

Degradation of heme portion
Conversion to protoporphyrin
Break down into indirect bilirubin
Conversion to direct bilirubin
Excretion in bile
Explanation:
As the heme portion is degraded, it is converted into protoporphyrin. Protoporphyrin is then further broken down into indirect bilirubin. Indirect bilirubin is fat soluble and cannot be excreted by the kidneys in this state. It is therefore converted by the liver enzyme glucuronyl transferase into direct bilirubin, which is water soluble. This is then excreted in bile.

The nurse preparing a patient for diagnostic testing for disseminated intravascular coagulation knows that the following is a result indicative of this disease:

a) Increased antithrombin III
b) Decreased fibrogen/fibrin degradation products
c) Increased D-dimer assay
d) Decreased fibrinopeptide A level

Increased D-dimer assay
Correct
Explanation:
Results indicative of disseminated intravascular coagulation include: increased D-dimer assay, decreased antithrombin III, increased fibrogen/fibrin degradation products, and increased fibrinopeptide A level.

The mother of Mary Jo, a 10-year-old who had a febrile reaction following a transfusion, asks the nurse: “Why did this happen to my child?” What is the nurse’s best response?

a) “The donor blood contained plasma proteins or other antigens to which Mary Joe was hypersensitive.”
b) “Too much of the blood product was transfused at too rapid a rate.”
c) “Mary Jo’s blood was not compatible with the blood product, causing red blood cell destruction.”
d) “Mary Jo’s blood has developed antibodies to leukocyte, platelet, or plasma protein antigens in the donor blood.”

“Mary Jo’s blood has developed antibodies to leukocyte, platelet, or plasma protein antigens in the donor blood.”
Correct
Explanation:
A febrile reaction is not associated with hemolysis and generally occurs when the recipient has developed antibodies to leukocyte, platelet, or plasma protein antigens in the donor blood. In a hemolytic reaction, the blood product is not compatible with the recipient’s blood. An allergic reaction is a nonhemolytic reaction that occurs when the donor blood contains plasma proteins or antigens to which the recipient is hypersensitive.

The nurse is caring for a child with leukemia. Which of the following nursing interventions would be the highest priority for this child?

a) Following guidelines for protective isolation
b) Providing age appropriate activities
c) Grouping nursing care
d) Encouraging the child to share feelings

Following guidelines for protective isolation
Explanation:
The child with leukemia is susceptible to infection, especially during chemotherapy. Infections such as meningitis, septicemia, and pneumonia are the most common causes of death. To protect the child from infectious organisms, follow standard guidelines for protective isolation. Grouping nursing care to provide rest is important, but not the highest priority. Encouraging the child to share feelings and providing age appropriate activities are important, but psychological issues are a lower priority than physical.

An 11-year-old male is diagnosed with mild hemophilia. Upon assessment, the nurse documents the following factor level for this category of hemophilia:

a) Factor level greater than 50%
b) Factor level of 1% to 5%
c) Factor level of 5% to 50%
d) Factor level less than 1%

Factor level of 5% to 50%
Correct
Explanation:
Mild hemophilia is characterized by a factor level of 5% to 50%. People with mild hemophilia experience prolonged bleeding only when injured. Thus, their condition may not be diagnosed unless they have trauma or surgery.

To prevent further sickle cell crisis, you would advise the parents of a child with sickle cell anemia to

a) prevent the child from drinking an excess amount of fluids per day.
b) notify a health care provider if the child develops an upper respiratory infection.
c) administer an iron supplement daily.
d) encourage the child to participate in school activities, such as long-distance running.

notify a health care provider if the child develops an upper respiratory infection.
Correct
Explanation:
Reduction of oxygen and dehydration lead to increased sickling of cells. Early prevention of these with respiratory illness is important.

The nurse is collecting data from the caregivers of a child brought to the clinic setting. The parents tell the nurse that the child’s skin seems to be an unusual color. The nurse notes that the child’s skin appears bronze-colored and jaundiced. This observation alerts the nurse to the likelihood that this child has which of the following disorders?

a) Sickle cell disease
b) Hemophilia
c) Kawasaki disease
d) Thalassemia

Thalassemia
Explanation:
In the child with Thalassemia the skin may appear bronze-colored or jaundiced. The child with hemophilia may have bruised areas on the skin. The skin color in children with sickle cell disease may be pale in color, and with Kawasaki disease the child may have a rash on the trunk and extremities.

The nurse is assessing a child who is experiencing an acute splenic sequestration secondary to sickle cell disease. Which of the following would be a priority?

a) Emergent transfusion
b) Antibiotic administration
c) Oxygen administration
d) Pain relief

Emergent transfusion
Explanation:
Acute splenic sequestration can rapidly progress to cardiovascular collapse and death. Prepare the child for emergent transfusion with packed red blood cells. Pain relief would be a priority for a vaso-occlusive crisis. Antibiotic administration would be a priority for a febrile child with sickle cell disease. Oxygen administration would be a priority for a child with acute chest syndrome (a vaso-occlusive crisis).

A nurse is preparing a 7-year-old girl for bone marrow aspiration. Which of the following sites should she prepare?

a) Iliac crest
b) Sternum
c) Femur
d) Anterior tibia

Iliac crest
Correct
Explanation:
Bone marrow aspiration provides samples of bone marrow so the type and quantity of cells being produced can be determined. In children, the aspiration sites used are the iliac crests or spines (rather than the sternum, which is commonly used in adults) because performing the test at these sites is usually less frightening for children; these sites also have the largest marrow compartments during childhood. In neonates, the anterior tibia can be used as an additional site.

A child with hypoplastic anemia develops hemosiderosis. The therapy for this is

a) ferrous sulfate.
b) deferoxamine.
c) aspirin.
d) prednisone.

deferoxamine.
Correct
Explanation:
Hemosiderosis is deposition of iron into tissue. A chelating agent, such as deferoxamine, removes it from tissue.

Which nursing diagnosis would be most appropriate for a child with idiopathic thrombocytopenic purpura?

a) Ineffective breathing pattern related to decreased white blood count
b) Risk for infection related to abnormal immune system
c) Ineffective tissue perfusion related to poor platelet formation
d) Risk for altered urinary elimination related to kidney impairment

Ineffective tissue perfusion related to poor platelet formation
Correct
Explanation:
Idiopathic thrombocytopenic purpura results in decreased platelets, so bleeding into tissue can occur.

After teaching the parents of a child diagnosed with pernicious anemia about the disorder and treatment, the nurse determines that the teaching was successful when the parents state which of the following?

a) “He’ll need to have those vitamin shots for the rest of his life.”
b) “He needs to eat more green leafy vegetables to cure the anemia.”
c) “He might get constipated from the supplement.”
d) “We’ll need to plan for a bone marrow transplant soon.”

“He’ll need to have those vitamin shots for the rest of his life.”
Correct
Explanation:
Monthly injections of vitamin B12 are required for life. Although diet is important, diet alone will not cure the anemia. Iron used to treat iron-deficiency anemia can lead to constipation. Bone marrow transplant is used to treat aplastic anemia.

A boy with hemophilia A is scheduled for surgery. Which of the following precautions would you institute with him?

a) Caution him not to brush his teeth before surgery.
b) Mark his chart for him to receive no analgesia.
c) Do not allow a dressing to be applied postoperatively.
d) Handle him gently when transferring him to a stretcher.

Handle him gently when transferring him to a stretcher.
Correct
Explanation:
Gentle handling can reduce bruising. Analgesia will be needed postoperatively; IM injections are contraindicated because of potential bleeding.

The child has been diagnosed with severe iron deficiency anemia. The child requires 5 mg/kg of elemental iron per day in three equally divided doses. The child weighs 47.3 pounds. How many milligrams of elemental iron should the child receive with each dose? Round to the nearest whole number.

______ mg

36
Correct
Explanation:
47.3 pounds x 1 kg/2.2 pounds = 21.5 kg 21.5 kg x 5 mg/1 kg = 107.5 mg/day 107.5 mg/3 doses = 35.8333 mg/dose Rounded to the nearest whole number = 36 mg

The nurse is preparing a child for discharge following a sickle cell crisis. The mother makes the following statements to the nurse. Which statement by the mother indicates a need for further teaching?

a) “She has been down, but playing in soccer camp will cheer her up.”
b) “I put her legs up on pillows when her knees start to hurt.”
c) “She loves popsicles, so I’ll let her have them as a snack or for dessert.”
d) “I bought the medication to give to her when she complains of pain.”

“She has been down, but playing in soccer camp will cheer her up.”
Correct
Explanation:
Following a sickle cell crisis the child should avoid extremely strenuous activities that may cause oxygen depletion. Fluids are encouraged, pain management will be needed, and the child’s legs may be elevated to relieve discomfort, so these are all statements that indicate an understanding of caring for the child who has had a sickle cell crisis.

The nurse is caring for a 3-year-old boy with suspected iron-deficiency anemia. Which test would the nurse expect to be ordered to confirm the diagnosis?

a) Serum ferritin
b) Hemoglobin electrophoresis
c) Reticulocyte count
d) Iron test

Serum ferritin
Correct
Explanation:
Serum ferritin is a measure of ferritin (the major iron storage protein) in the blood. It is the most sensitive test for determination of iron-deficiency anemia. Hemoglobin electrophoresis is indicated for sickle cell anemia and thalassemia and measures the percentage of normal and abnormal hemoglobin in the blood. Reticulocyte count measures the number of immature red blood cells (RBCs) in the blood and indicates the bone marrow’s ability to respond to anemia with production of RBCs. The iron test evaluates iron metabolism.

A 9-year-old boy will be undergoing a hematopoietic stem cell transplantation, with donor cells being provided by his 12-year-old sister. The nurse recognizes that this type of transplantation is which of the following?

a) Autologous
b) Allogenic
c) Syngeneic
d) Heterologous

Allogenic
Explanation:
Stem cell transplantation can be allogeneic, syngeneic, or autologous. Allogeneic transplantation is the transfer of stem cells from an immune-compatible (histocompatible) donor, usually a sibling, or from a national cord blood bank or national volunteer donor registry. Syngeneic transplantation (rare) involves a donor and recipient who are genetically identical (are identical twins). Autologous transplantation involves use of the child’s own stem cells removed from cord blood banked at the time of the child’s birth. Heterologous is not a type of stem cell transplantation.

The caregiver of a child with sickle cell disease asks the nurse how much fluid her child should have each day after the child goes home. In response to the caregiver’s question, the nurse would explain that for the child with sickle cell disease, it is best that the child have:

a) 1,500 to 2,000 mL of fluid per day
b) 300 to 800 mL of fluid per day
c) 1,000 to 1,200 mL of fluid per day
d) 2,500 to 3,200 mL of fluid per day

1,500 to 2,000 mL of fluid per day
Correct
Explanation:
Prevention of crises is the goal between episodes. Adequate hydration is vital; fluid intake of 1,500 to 2,000 mL daily is desirable for a child weighing 20 kg and should be increased to 3,000 mL during the crisis.

You care for a 4-year-old with sickle cell anemia. A physical finding you might expect to see in him is

a) slightly yellow sclerae.
b) increased growth of long bones.
c) enlarged mandibular growth.
d) depigmented areas on the abdomen.

slightly yellow sclerae.
Correct
Explanation:
Many children with sickle cell anemia develop mild scleral yellowing from excess bilirubin from breakdown of damaged cells.

The nurse is caring for a 2-year-old with sickle cell anemia and describing the acute and chronic manifestations of sickle cell anemia to his mother. Which statement by the mother indicates a need for further teaching?

a) “Bone infarction, dactylitis, and recurrent pain episodes are acute manifestations.”
b) “Aplastic crisis is a life-threatening acute manifestation of sickle cell anemia.”
c) “Delayed growth and development and delayed puberty are chronic manifestations.”
d) “The acute manifestations, like splenic sequestration, are most often life-threatening.”

“The acute manifestations, like splenic sequestration, are most often life-threatening.”
Explanation:
Splenic sequestration is a life-threatening acute manifestation of sickle cell anemia, but some of the chronic manifestations of the disease, such as pulmonary hypertension and restrictive lung disease, are also often life-threatening. Aplastic crisis is a life-threatening acute manifestation. Bone infarction, dactylitis, and recurrent pain episodes are acute manifestations; delayed growth and development and chronic puberty are chronic manifestations.

Individuals with hemophilia B have a deficiency in factor IX, which can cause excessive blood loss. What is another name for this clotting factor?

a) Proconvertin
b) Christmas factor
c) Antihemophilic factor
d) Stuart factor

Christmas factor
Correct
Explanation:
Factor IX is also known as plasma thromboplastin component or Christmas factor; factor X is Stuart factor; factor VIII is antihemophilic factor; and factor VII is proconvertin.

When planning care for a child with idiopathic thrombocytopenic purpura, you plan to teach her

a) to apply a soothing cream to lesions.
b) to use mainly cold water to wash.
c) not to pick or irritate her nose.
d) what foods are high in folic acid.

not to pick or irritate her nose.
Correct
Explanation:
Without adequate platelets, children bleed easily from lesions.

When assessing a child for a possible hematologic disorder, which of the following would the nurse need to keep in mind as most important?

a) Multiple body sites can be affected.
b) A child’s nutritional status is key.
c) Demographic data is of little relevance.
d) Sequelae are rare with chronic problems.

Multiple body sites can be affected.
Correct
Explanation:
The nurse needs to keep in mind that hematologic alterations can affect multiple body sites, so assessment needs to address all body systems. A child’s nutritional status may be helpful in assessing certain hematologic disorders such as iron deficiency anemia, but this information is not the most important to remember. Sequelae commonly occur with hematologic alterations, especially chronic conditions such as hemophilia or sickle cell disease. The child’s demographic data are important, because some hematologic diagnoses are more commonly associated with a certain age group, sex, race, or geographic location.

In caring for a child with sickle cell disease, the highest priority goal is which of the following?

a) The child’s fluid intake will improve.
b) The child’s skin integrity will be maintained.
c) The family caregivers’ anxiety will be reduced.
d) The family will verbalize understanding of of the disease crisis.

The child’s fluid intake will improve.
Correct
Explanation:
The highest priority goals for this child are maintaining comfort and relieving pain. The child is prone to dehydration because of the kidneys’ inability to concentrate urine, so increasing fluid intake is the next highest priority. Other goals include improving physical mobility, maintaining skin integrity, reducing the caregivers’ anxiety, and increasing the caregivers’ knowledge about the causes of crisis episodes, but these goals are not the highest priority.

In discussing the causes of iron deficiency anemia in children with a group of nurses, the following statements are made. Which of these statements is a misconception related to iron deficiency anemia?

a) “A family’s economic problems are often a cause of malnutrition.”
b) “Caregivers sometimes don’t understand the importance of iron and proper nutrition.”
c) “Milk is a perfect food, and babies should be able to have all the milk they want.”
d) “Children have a hard time getting enough iron from food during their first few years.”

“Milk is a perfect food, and babies should be able to have all the milk they want.”
Correct
Explanation:
Babies with an inordinate fondness for milk can take in an astonishing amount and, with their appetites satisfied, may show little interest in solid foods. These babies are prime candidates for iron deficiency anemia. Many children with iron deficiency anemia, however, are undernourished because of the family’s economic problems. A caregiver knowledge deficit about nutrition is often present. Because only 10 percent of dietary iron is absorbed, a diet containing 8 to 10 mg of iron is needed for good health. During the first years of life, obtaining this quantity of iron from food is often difficult for a child. If the diet is inadequate, anemia quickly results.

A nurse is preparing a teaching plan for a child with hemophilia and his parents. Which of the following would the nurse be least likely to include to manage a bleeding episode?

a) Give Factor VIII replacement
b) Apply heat to the site of bleeding
c) Apply direct pressure until the bleeding stops
d) Elevate injured extremities

Apply heat to the site of bleeding.
Correct
Explanation:
Ice or cold compresses, not heat, would be applied to the site of bleeding. Direct pressure is applied until the bleeding stops. The injured part is elevated unless elevating would contribute to further injury. Factor VIII replacement is given to replace the missing clotting factor.

Complications associated with bleeding most often involve joints and muscles. Adjunct measures to control bleeding include:

a) Heat
b) Lowering extremities
c) Exercise
d) Compression

Compression
Correct
Explanation:
Complications associated with bleeding most often involve joints and muscles. Adjunct measures include rest, ice, compression, and elevation (RICE). In addition, corticosteroids such as prednisone may be used to reduce inflammation in the joint.

A nurse is providing care for a child with disseminated intravascular coagulation (DIC). Which of the following would alert the nurse to possible neurologic compromise?

a) Widely fluctuating blood pressure
b) Equal pupillary response
c) Hematuria
d) Petechiae

Widely fluctuating blood pressure
Explanation:
A key aspect of the nurse’s role is to assess the child for signs and symptoms of impaired tissue perfusion in the various body systems that may be affected by DIC. Unstable or abnormal blood pressure such as wide fluctuations in blood pressure or unequal pupil size may suggest neurologic compromise. Hematuria would suggest renal compromise. Petechiae would be indicative of bleeding into the skin.

A 14-year-old girl who is a vegetarian has recently developed anemia. Blood smear results show large, fragile, immature erythrocytes. She claims to take an iron supplement regularly and is surprised to learn that she is anemic, as she is otherwise healthy. The nurse recognizes that which of the following is the likely cause of this type of anemia?

a) Sickle-cell disorder
b) Vitamin B12 deficiency
c) Acute blood loss
d) Iron deficiency

Vitamin B12 deficiency
Explanation:
Vitamin B12 is necessary for the maturation of RBCs. Pernicious anemia results from deficiency or inability to use the vitamin, resulting in RBCs that appear abnormally large and are immature megaloblasts (nucleated immature red cells). Thus, pernicious anemia is one of the megaloblastic anemias. In children, the cause is more often lack of ingestion of vitamin B12 rather than poor absorption. Adolescents may be deficient in vitamin B12 if they are ingesting a long-term, poorly formulated vegetarian diet as the vitamin is found primarily in foods of animal origin.

A nurse caring for an 8-year-old patient with a bleeding disorder documents the following nursing diagnosis: ineffective tissue perfusion related to intravascular thrombosis and hemorrhage. This diagnosis is most appropriate for a patient with:

a) Iron deficiency anemia
b) von Willebrand disease
c) Disseminated intravascular coagulation
d) Hemophilia

Disseminated intravascular coagulation
Correct
Explanation:
Disseminated intravascular coagulation (DIC) is an acquired coagulopathy that, paradoxically, is characterized by both thrombosis and hemorrhage. The outcome for this patient is: The child will maintain adequate tissue perfusion of all body systems affected by DIC and regain adequate laboratory values for hemostasis.

The nurse is reviewing the laboratory test results of a child with thalassemia. Which result would the nurse expect to find with the hemoglobin electrophoresis? Select all that apply.

a) Hemoglobin F
b) Hemoglobin A2
c) Hemoglobin A
d) Hemoglobin S

• Hemoglobin F
• Hemoglobin A2
Explanation:
In thalassemia, the hemoglobin electrophoresis would reveal the presence of hemoglobin F and A2 only. Hemoglobin S would be found with sickle cell disease.

A nurse is teaching the parents of a child with sickle cell disease about factors that predispose the child to a sickle cell crisis. The nurse determines that the teaching was successful when the parents identify which of the following as a factor?

a) Fluid overload
b) Respiratory distress
c) Infection
d) Pallor

Infection
Correct
Explanation:
Factors that may precipitate a sickle cell crisis include: fever, infection, dehydration, hot or humid environment, cold air or water temperature, high altitude, or excessive physical activity. Respiratory distress and pallor are general signs and symptoms of a sickle cell crisis.

The nurse is caring for a 10-year-old girl with iron toxicity. Which of the following would the nurse expect the physician to order?

a) Succimer
b) Desferal
c) Dimercaprol
d) Edentate calcium disodium

Desferal
Correct
Explanation:
Desferal is indicated for iron toxicity. It binds with iron, which is removed via the kidneys. Dimercaprol is indicated for blood lead levels greater than 45 mcg/dL. It removes lead from soft tissues and bone, allowing for its excretion via the renal system. Edentate calcium disodium is indicated for blood lead levels greater than 45 mcg/dL. The medication removes lead from soft tissues and bone, allowing for its excretion via the renal system. Succimer is indicated for blood lead levels greater than 45 mcg/dL; it removes lead from soft tissues and bone, allowing for its excretion via the renal system.

The nurse is reviewing the results of a clotting study for a healthy 6-year-old. Which of the following would the nurse document as a normal prothrombin finding?

a) 16.0 to 18.0 seconds
b) 21.0 to 35.0 seconds
c) 6.0 to 9.0 seconds
d) 11.0 to 13.0 seconds

11.0 to 13.0 seconds
Correct
Explanation:
The nurse would identify a prothrombin time of 11.0 to 13.0 seconds as normal for a healthy child. A result of 21.0 to 35.0 seconds would be the expected range for partial thromboplastin time and activated partial thromboplastin time. Findings of 6.0 to 9.0 seconds and 16.0 to 18.0 seconds are outside the normal range.

The nurse is preparing a presentation for a local parent group about nutritional measures to prevent anemia. The group of parents have children between the ages of 4 and 8 years of age. The nurse would recommend a daily iron intake of which amount?

a) 6 mg
b) 15 mg
c) 12 mg
d) 10 mg

10 mg
Explanation:
The recommended daily dietary iron intake for children 1 to 10 years of age is 10 mg. The recommended daily dietary iron intake for children 0 to 6 months of age is 6 mg. The recommended daily dietary iron intake for boys 11 to 18 years of age is 12 mg. The recommended daily dietary iron intake for girls 11 to 18 years of age is 15 mg.

A child is to receive oral iron therapy in liquid form three times a day. After teaching the parents about administering the iron, which statement indicates a need for additional teaching?

a) “Her bowel movements will probably turn very dark.”
b) “She can drink the medicine from a medicine cup.”
c) “We will have her drink water or juice with the medicine.”
d) “We’ll try to give the medicine to her in between milk servings.”

“She can drink the medicine from a medicine cup.”
Explanation:
Liquid iron can stain the teeth; therefore, the parents should give the liquid iron through a straw or syringe, placing it toward the back of the child’s mouth. Iron turns stools dark. To maximize absorption, it is best to give the iron with water or juice between meals.

When a poison has been ingested by a child, the parents should be instructed to do which of the following first?

a) Induce vomiting.
b) Call the local poison control center.
c) Administer an emetic.
d) Get to an emergency facility.

Call the local poison control center.
Correct
Explanation:
Not all poisons should be vomited. Strong acids, for example, could cause as much destruction of tissue being vomited as being swallowed. The poison control center will provide the most accurate information on the next steps for the patient.

Assessment of a child reveals a tension pneumothorax. The nurse would prepare the child for which of the following?

a) Needle thoracotomy
b) Suctioning
c) Intubation
d) Defibrillation

Needle thoracotomy
Correct
Explanation:
A needle thoracotomy is indicated for tension pneumothorax to relieve the air collected in the space. Intubation is indicated for apnea and in situations in which the airway cannot be maintained. Suctioning would be indicated for excessive airway secretions that influence airway patency. Defibrillation is used to stimulate or alter the heart’s electrical rhythm.

A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 BPM. Choose the priority intervention:

a) Administer doses defibrillator shocks in a row
b) Initiate cardiac compressions
c) Give three doses of epinephrine
d) Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR)

Initiate cardiac compressions
Correct
Explanation:
The American Heart Association (AHA) emphasizes the importance of cardiac compressions in pulseless clients with arrhythmias, making this the priority intervention in this situation. Current AHA recommendations are for defibrillation to be administered once followed by five cycles of CPR. The AHA now recommends against using multiple doses of epinephrine because they have not been shown to be helpful and may actually cause harm to the child.

A 3-year-old girl had a near-drowning incident when she fell into a wading pool. Which intervention would be of the highest priority?

a) Inserting a nasogastric tube to decompress stomach
b) Assuring the child stays still during an X-ray
c) Suctioning the upper airway to ensure airway patency
d) Covering the child with warming blankets

Suctioning the upper airway to ensure airway patency
Correct
Explanation:
Due to the potentially devastating effects of drowning-related hypoxia on a child’s brain, airway interventions must be initiated immediately. The child’s airway should be suctioned to ensure patency. Other interventions such as covering the child with blankets, inserting a nasogastric tube, and assuring that the child remains still during X-ray are interventions that are appropriate once airway patency is achieved and maintained.

The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of which of the following?

a) Underlying heart disease
b) Respiratory failure
c) Neurologic trauma
d) Lethal arrhythmia

Respiratory failure
Correct
Explanation:
Cardiopulmonary arrest in infants and children typically results from disorders that lead to respiratory failure and shock. In adults, the most common causes of cardiopulmonary arrest are lethal arrhythmias secondary to heart disease. Although neurologic trauma can lead to respiratory failure, it alone is not the most likely factor.

A 13-year-old girl suffered a serious fall while hiking with friends and injured her head. She is now being evaluated by a nurse in the emergency room. The nurse notices clear fluid flowing from the girl’s nose. The girl’s friend said that she had been suffering from pollen allergy recently. Which of the following interventions should the nurse implement to determine whether the fluid is cerebrospinal fluid (CSF) or rhinitis from an allergy?

a) Evaluate the client’s level of consciousness
b) Assess the client’s blood pressure
c) Perform a skull x-ray
d) Test the fluid with a glucose reagent strip

Test the fluid with a glucose reagent strip
Correct
Explanation:
Rhinorrhea or otorrhea (clear fluid draining from the nose or ear, respectively) may be noticeable. The fluid is cerebrospinal fluid (CSF) and is a serious finding because it means that the child’s central nervous system is open to infection. If it’s not clear if the fluid is CSF or rhinitis from an allergy, test the fluid with a glucose reagent strip. CSF will test positive for glucose, whereas the clear, watery drainage from an upper respiratory tract infection or allergy will not. The other interventions would not help determine whether the fluid was CSF or rhinitis.

Which medication is used for symptomatic bradycardia unresponsive to ventilation and oxygenation?

a) Atropine
b) Naloxone
c) Sodium bicarbonate
d) Calcium carbonate

Atropine
Correct
Explanation:
Atropine is used for symptomatic bradycardia unresponsive to ventilation and oxygenation. Sodium bicarbonate is used for metabolic acidosis. Naloxone reverses the effect of opioids. Calcium carbonate is used for documented or suspected hypocalcemia, hyperkalemia, hypermagnesemia, and calcium channel blocker overdose.
The nurse must calculate the adolescent’s cardiac output. The child’s heart rate is 76 beats per minute and the stroke volume is 75 mL. Calculate the child’s cardiac output.
5700
Explanation:
Cardiac output (CO) is equal to heart rate (HR) times ventricular stroke volume (SV). That is, CO = HR x SV 76 beats per minute x 75 mL = 5,700

A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which of the following treatments is most likely appropriate in the immediate treatment of the girl’s poisoning?

a) Intravenous rehydration
b) Administration of activated charcoal
c) Gastric lavage
d) Inducing vomiting

Administration of activated charcoal
Correct
Explanation:
Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl’s poisoning.
The child’s ability to perfuse well is poor due to inadequate circulation. The physician writes an order for the child to receive 20 mL of normal saline for each kilogram of body weight. The child will receive the normal saline as a bolus through a central intravenous line. The child weighs 78 pounds. Calculate
the amount of normal saline the nurse should administer as a bolus. Round to the nearest whole number._____ mL

709
Explanation:
78 pounds x 1 kg/2.2 pounds = 35.455 kg x 20 mL/kg = 709.1 mL. When rounded to the nearest whole number = 709 mL

A 16-year-old boy is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to which of the following?

a) Play-related injuries
b) Falls from beds
c) Automobile accidents
d) Falls from staircases

Automobile accidents
Correct
Explanation:
Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-aged children, and falling from staircases is a common injury among toddlers.

Administration of which medication reverses histamine release and hypotension that are seen in anaphylaxis?

a) Atropine
b) Epinephrine
c) Benadryl
d) Zantac

Epinephrine
Correct
Explanation:
Epinephrine reverses histamine release and hypotension due to anaphylaxis.

A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in teaching parents about how to protect a toddler from accidental poisoning?

a) Label poisonous solutions.
b) Do not leave the toddler alone.
c) Closely monitor the toddler’s activity.
d) Keep cleaning solutions locked up.

Keep cleaning solutions locked up.
Correct
Explanation:
The parents should keep cleaning solutions locked up to protect the toddler from accidental poisoning. Accidental poisonings usually occur among toddlers and commonly involve substances located in bathrooms or kitchens. Labeling poisonous substances may not help as toddlers are unable to read. Not leaving the child alone and closely monitoring the child are important, but not feasible all the time.

The effect of the bite of a rattlesnake, copperhead, or cottonmouth moccasin (all pit vipers) is the almost immediate failure of the blood coagulation system.

a) False
b) True

True

A 3-year-old boy has been brought to the doctor’s office with symptoms of anorexia and abdominal pain. A blood test reveals a lead level of 20 μg/100 mL. The child is prescribed an oral chelating agent. On discharge, the nurse should counsel the parents regarding which of the following?

a) Putting child safety locks on kitchen cabinets
b) Placing house plants out of reach of children
c) Putting medicine away where children cannot reach it
d) Removal or covering of flaking paint on the walls of the home

Removal or covering of flaking paint on the walls of the home
Correct
Explanation:
The usual sources of ingested lead are paint chips or paint dust, home-glazed pottery, or fumes from burning or swallowed batteries. A child with a blood lead level over 5 μg/dL needs to be rescreened to confirm the level and then active interventions begun to prevent further lead exposure such as removal of the child from the environment containing the lead source or removal of the source of lead from the child’s environment. Removal of the lead source is not an easy task in homes because simple repainting or wallpapering does not necessarily remove the source of peeling paint adequately. After some months, the new paint will begin to peel because of the defective paint underneath. The walls must therefore be covered by paneling or dry wall or other solid protective material. The other answers refer to safety measures to prevent other types of poisoning, such as from household cleaners, medicine, and plants.

Which finding from the history of a child with extensive burns would make you most alert to assess for respiratory complications?

a) Firemen found the child sobbing silently.
b) The child’s clothing was burned.
c) The child was trapped in a closed burning bedroom.
d) The fire was caused by burning weeds.

The child was trapped in a closed burning bedroom.
Correct
Explanation:
When a child is confined in a closed space during a fire, he or she can inhale a great deal of smoke, causing respiratory tract burns or irritation.

The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern?

a) Palpation of the head reveals a closed posterior fontanel.
b) The child is crying and looking around fearfully.
c) The child’s eyes remain closed unless she is spoken to.
d) Inspection shows a sluggish pupillary reaction.

Inspection shows a sluggish pupillary reaction.
Correct
Explanation:
A sluggish pupillary reaction may occur with increased intracranial pressure, which would be cause for concern. A closed posterior fontanel in an 11-month-old would be a normal finding. Crying and looking around are encouraging signs indicating improved neurologic status. Opening the eyes when being spoken to is an encouraging sign.

When assessing a child with a traumatic injury, which of the following would be the priority assessment?

a) Airway patency and airflow
b) Breathing effectiveness and breath sounds
c) Level of consciousness and papillary reaction
d) Pulse rate and skin color

Airway patency and airflow
Correct
Explanation:
When assessing the child with a traumatic injury, the ABCs are assessed first: assess the patency of the airway and establish the effectiveness of breathing, examining the child’s respiratory effort, breath sounds, and color; evaluate the circulation, noting pulse rate and quality and observing the color, skin temperature, and perfusion. Once this is accomplished, the nurse assesses for disability (D), rapidly assessing critical neurologic function including level of consciousness, pupillary reaction, and verbal and motor responses to auditory and painful stimuli.

A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which of the following actions should the nurse take first?

a) Provide oral analgesics as ordered.
b) Draw blood for type and cross-match.
c) Begin hyperventilation.
d) Establish a suitable IV site.

Establish a suitable IV site.
Correct
Explanation:
The goal of treating shock is to restore circulating blood volume. This requires that vascular access be obtained to administer fluids and vasoactive drugs. Hyperventilation is reserved for temporary treatment of severe intracranial pressure. Analgesics should not be administered prior to neurologic and cardiovascular examination being performed. Chelation therapy is a treatment for metallic poisoning.

A 14-year-old child is brought to the emergency department. His parents state that they think he took “too many of his pain pills.” The child had been prescribed oxycodone every 4 hours for pain secondary to a bone infection. Which agent would the nurse expect to be administered to counteract the analgesics?

1) Atropine
2) Naloxone
3) Lidocaine
4) Ketamine

Naloxone
Correct
Explanation:
Oxycodone is an opioid analgesic whose effects can be reversed by the administration of naloxone. Atropine decreases secretions and reduces the vagal effects of intubation. It also is used for sinus bradycardia, asystole, and pulseless electrical activity. Lidocaine is used to correct ventricular arrhythmias. Ketamine may be used for rapid-sequence intubation.

The nurse is caring for a 7-year-old child with suspected basilar head trauma. Which of the following interventions is most likely to be required?

a) Beginning hyperventilation of the child
b) Intubation and mechanical ventilation
c) Administering small doses of morphine
d) Providing blow-by oxygenation

Intubation and mechanical ventilation
Correct
Explanation:
A child with a basilar skull fracture may require intubation and mechanical ventilation to maintain a normal PaCO2. Morphine and other pain medications should be administered after completing primary and secondary assessments. Prophylactic hyperventilation is not indicated because it could cause vasoconstriction of cerebral arteries and ischemia. Blow-by oxygen is used when there is a history of chronic pulmonary disease.

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

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.

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

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

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.

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

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 jaw-thrust 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

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

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

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

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

Possible tissue damage from hypoxia
Explanation:
Oxygen should be administered by a non-rebreather mask until oxygenation and perfusion status is completely assessed. This will stabilize the effects of hypoxia. Reduced core temperature and resultant metabolic demands, as well as the need for epinephrine, are secondary to the ABCs (airway, breathing, and circulation).

A 10-year-old boy who was in a car wreck has been brought to the emergency room for evaluation. He appears to have suffered abdominal trauma do to his seat belt. He has tenderness in the left upper quadrant of the abdomen, especially on deep inspiration. Given these circumstances, the nurse should suspect injury to which of the following organs?

a) Pancreas
b) Spleen
c) Liver
d) Stomach

Spleen
Correct
Explanation:
In children, the spleen is the most frequently injured organ when there is abdominal trauma, because it is usually palpable under the lower left rib. Frequent causes of injury are inappropriately applied seat belts in automobiles, handlebar injuries in bicycle accidents, or skateboard or snowboard accidents. The child will have tenderness in the left upper quadrant, of the abdomen, especially on deep inspiration, when the diaphragm moves down and touches the spleen.

The child’s physician requests that the nurse should notify her if the child’s urine output is less than 1 mL/kg of body weight each hour. The child weighs 56 pounds. Calculate the minimum amount of urine output the child should produce each hour. Round to the nearest whole number.

_____ mL/hour

25
Correct
Explanation:
56 pounds x 1 kg/2.2 pounds = 25.455 kg of body weight. 25.455 kg x 1 mL/kg = 25.455 mL/hour The child must produce 25 mL/hour

A young patient in the intensive care unit is in a coma after a severe head injury. The primary nurse is teaching a nursing student how to assess the patient’s level of consciousness by using a coma scale. This scale is referred to as which of the following?

a) Apgar scale
b) Visual analogue scale
c) Glasgow scale
d) Wong-Baker FACES scale

Glasgow scale
Correct
Explanation:
The Glasgow Coma Scale is used to grade coma according to level of consciousness. The Apgar score is assigned immediately after delivery to determine how the infant tolerated the birth. Wong-Baker FACES and the visual analogue scales are used to rate pain.

The condition of an 11-year-old boy who is on mechanical ventilation begins to deteriorate. Which of the following would the nurse do next?

a) Confirm that the ventilator is working properly.
b) Examine the child for signs of pneumothorax.
c) Suction the tube to remove a mucus plug.
d) Check to see if the tracheal tube is displaced.

Check to see if the tracheal tube is displaced.
Explanation:
Use the mnemonic DOPE for troubleshooting when the status of a child who is intubated deteriorates. This means checking for displacement and disconnections first. Checking the ventilator, suctioning for obstruction, and examining for signs of pneumothorax would come later.

The nurse has administered IV adenosine as ordered to a child with supraventricular tachycardia. Which action would the nurse do next?

a) Monitor for ventricular arrhythmias.
b) Set up a continuous infusion for administration of adenosine.
c) Administer a rapid generous saline flush.
d) Give five positive-pressure ventilations.

Administer a rapid generous saline flush.
Correct
Explanation:
Administration of IV adenosine should be followed immediately by a rapid generous saline flush. Adenosine is given rapidly over 1 to 2 seconds and repeated every 1 to 2 minutes to a maximum dose of 0.3 mg/kg. Five positive-pressure ventilations are given after atropine, which is diluted with 3 to 5 mL of normal saline, is given via the tracheal route. After giving adenosine, the nurse would monitor for shortness of breath, dyspnea, and a worsening of asthma. Monitoring for ventricular arrhythmias is necessary when giving dobutamine, dopamine, and epinephrine.

After assessing a child’s airway, breathing, and circulation (ABCs), which of the following would the nurse do next?

a) Remove the child’s clothing.
b) Obtain a full set of vital signs.
c) Assess level of consciousness.
d) Provide pain management.

Assess level of consciousness.
Correct
Explanation:
Once the ABCs are completed, the nurse’s next step is to assess the child’s level of consciousness or disability. This would be followed by removing the child’s clothing and diaper (exposure) to assess for underlying signs of illness or injury. Next, full vital signs are taken while facilitating the family presence, followed by giving comfort by managing pain and providing emotional support. The acronym ABCDEFG is a useful reminder of the order of assessment: airway, breathing, circulation, disability, exposure, full vital signs and facilitating family, and giving comfort.

The nurse is preparing to insert an oropharyngeal airway. Which action would be most appropriate to determine the proper size?

a) Measuring from the tip of the nose to earlobe to middle of xiphoid process
b) Measuring distance from end of nose to tragus of ear
c) Placing the airway next to the cheek with tip pointing down
d) Inspecting the child’s fifth digit to estimate the diameter

Placing the airway next to the cheek with tip pointing down
Explanation:
The nurse determines the correct size by placing it next to the child’s cheek with the tip pointing down. An airway that is too large will extend past the angle of the child’s mandible and can obstruct the glottic opening when inserted. Measuring the distance from the end of the nose to the tragus of the ear is appropriate for a nasopharyngeal airway. Looking at the child’s fifth digit reflects the approximate diameter of the nasopharyngeal airway. Measuring from the tip of the nose to the earlobe to the middle area between the xiphoid process and umbilicus is used to determine the length of a nasogastric tube.

The nurse is attempting to establish peripheral vascular access in child requiring pediatric advanced life support. The decision to use the intraosseous route would be made if the nurse were unsuccessful after how many attempts within 90 seconds?

a) Two
b) Four
c) Three
d) Five

Three
Explanation:
No more than three attempts should be made within 90 seconds to obtain peripheral vascular access.

A home care nurse provides health education to parents regarding the care of their toddler. Which of the following precautions should the nurse suggest the parents take to protect the toddler from drowning?

1) Teach the toddler water is bad
2) Tell the toddler to stay away from the pool
3) Avoid unattended baths for the toddler.

Avoid unattended baths for the toddler.
Correct
Explanation:
The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool or teaching them that water is dangerous is insufficient to ensure safety.

The nurse is examining a 10-month-old girl who has fallen from the back porch. Which assessment will directly follow evaluation of the “ABCs?”

a) Palpating the abdomen for soreness
b) Palpating the anterior fontanel
c) Auscultating for bowel sounds
d) Observing skin color and perfusion

Palpating the anterior fontanel
Correct
Explanation:
Once the ABCs have been evaluated, the nurse will move on to “D” and assess for disability by palpating the anterior fontanel for signs of increased intracranial pressure. Observing skin color and perfusion is part of evaluating circulation. Palpating the abdomen for soreness and auscultating for bowel sounds would be part of the full-body examination that follows assessing for disability.

A 7-year-old boy is brought to the emergency room by his parents following an accident in which he was struck in the back of the head with a baseball bat. The nurse is assessing him. Which of the following would indicate increased intracranial pressure in this child?

a) Decrease in pulse and temperature and increase in respiratory rate and pulse pressure
b) Decrease in temperature and pulse pressure and increase in pulse and respiratory rate
c) Decrease in pulse and pulse pressure and increase in temperature and respiratory rate
d) Decrease in pulse and respiratory rate and increase in temperature and pulse pressure

Decrease in pulse and respiratory rate and increase in temperature and pulse pressure
Explanation:
All children with head trauma require a neurologic assessment as soon as they are seen and again at frequent intervals to detect signs and symptoms of increased intracranial pressure (ICP) as increasing pressure puts stress on the respiratory, cardiac, and temperature centers, causing dysfunction in these areas. The mark of increased pressure is a decrease in pulse and respiratory rate and an increase in temperature and pulse pressure (the distance between the diastolic and systolic pressure). The child’s pupils also become slow or unable to react immediately. Level of consciousness and motor ability both also decrease.

A 7-year-old girl is in the intensive care unit following a bicycle accident. Which of the following would be most helpful in providing support to the girl’s parents?

a) Giving them brief explanations of procedures
b) Encouraging them to read to their daughter
c) Describing the treatment plan for their daughter
d) Providing honest answers in a reassuring manner

Providing honest answers in a reassuring manner
Correct
Explanation:
Providing honest answers to the parents’ questions and concerns in a reassuring manner will provide the most support. Procedures and treatment plans should be explained in terms they can understand and repeated patiently, if need be. Encouraging the parents to read to their daughter will involve them in their child’s care and help normalize the situation for the child.

A nurse is preparing discharge teaching for a client being discharged with her newborn baby. What is the highest priority item that must be included in the teaching plan?

a) Keep all pots and pans in lower cabinets.
b) Give warm bottles of formula to the baby.
c) Lock all cabinets that contain cleaning supplies.
d) Restrain the baby in a car seat.

Restrain the baby in a car seat.
Correct
Explanation:
The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets and giving warm bottles of formula to the baby are secondary teachings.

The child needs a tracheal tube placed. The child is 8 years old. Calculate the size of the tracheal tube that should be used for this child.

_____ mm

6
Correct
Explanation:
The following formula should be used to calculate the correct tracheal tube size for a child: Divide the child’s age by 4 and add 4 = size in millimeters (8 years old/4) + 4 = 6 mm

The nurse is examining a 10-year-old boy with tachypnea and increased work of breathing. Which finding is a late sign that the child is in shock?

a) Significantly decreased skin elasticity
b) Delayed capillary refill with cool extremities
c) Blood pressure slightly less than normal
d) Equally strong central and distal pulses

Significantly decreased skin elasticity
Explanation:
Decrease skin turgor is a late sign of shock. Blood pressure is not a reliable method of evaluating for shock in children because they tend to maintain normal or slightly below normal blood pressure in compensated shock. Equal central and distal pulses are not a sign of shock. Delayed capillary refill with cool extremities are signs of shock that occur earlier than changes in skin turgor.

When developing the plan of care for a 10-month-old infant in septic shock, which of the following would the nurse most likely include?

a) Administering intravenous saline as ordered
b) Administering intravenous dopamine as ordered
c) Giving blood if saline provides inadequate response
d) Inserting a urinary catheter for monitoring urinary output

Administering intravenous dopamine as ordered
Explanation:
Although isotonic intravenous solutions such as saline, blood transfusion, and urinary catheter insertion are important for any child with shock, children experiencing septic shock often require larger volumes of fluid as a result of the increased capillary permeability. Thus, fluid alone may not improve the status of a child with septic shock, necessitating the use of vasoactive medications such as dopamine. Saline is the first choice for restoring fluid volume, but this child will most likely need vasoactive medications. Children in shock from trauma may require blood transfusions to restore volume. Once fluids are given, a urinary catheter will be placed to monitor urine output.

A 14-year-old girl arrives at the hospital in a comatose state. Her father, who found her comatose in her room, tells you that she has an opiate addiction. Which of the following would confirm that the coma was caused by opiate intoxication?

a) Both pupils are pinpoints
b) Both pupils are dilated
c) One pupil dilated and the other normal
d) One pupil dilated and the other deviated downward

Both pupils are pinpoints
Correct
Explanation:
Observe the child’s eyes for signs of dilated pupils from increased ICP. If both pupils are dilated, irreversible brainstem damage is suggested, although such a finding may also be present with poisoning with an atropine-like drug. Pinpoint pupils suggest barbiturate or opiate intoxication. One pupil dilated or the eye deviated downward or laterally more than the other suggests third cranial nerve compression or a tentorial tear (laceration of the membrane between the cerebellum and cerebrum) with herniation of the temporal lobe into the torn membrane.

A 3-year-old child has sustained injuries from a fall. Once the airway is secured, which of the following interventions would be next?

a) Stabilize the cervical spine.
b) Set up antecubital IV access.
c) Administer 100% oxygen.
d) Check mouth for debris.

Stabilize the cervical spine.
Correct
Explanation:
If head or spine injuries are suspected, then after the airway is opened, the cervical spine must be stabilized to prevent damage. Checking the mouth for debris is part of securing an airway. Administering oxygen and IV access occur after the C-spine is stabilized.

A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 BPM. Choose the priority intervention:

a) Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR)
b) Initiate cardiac compressions
c) Administer doses defibrillator shocks in a row
d) Give three doses of epinephrine

Initiate cardiac compressions
Explanation:
The American Heart Association (AHA) emphasizes the importance of cardiac compressions in pulseless clients with arrhythmias, making this the priority intervention in this situation. Current AHA recommendations are for defibrillation to be administered once followed by five cycles of CPR. The AHA now recommends against using multiple doses of epinephrine because they have not been shown to be helpful and may actually cause harm to the child.

The nurse is caring for a 4-year-old boy who is receiving mechanical ventilation. Which is the priority intervention when moving this child?

a) Monitoring the pulse oximeter for oxygen saturation
b) Checking the CO2 monitor for a yellow display
c) Watching for disconnections in the breathing circuit
d) Auscultating the lungs for equal air entry

Checking the CO2 monitor for a yellow display
Explanation:
Exhaled CO2 monitoring is recommended when a child has been intubated. It provides quick, visual assurance that the tracheal tube remains in place and that the child is being adequately ventilated. When moving the child, maintaining tube placement would be crucial. The other interventions would also be appropriate but not as essential as monitoring the child’s exhaled CO2 level. Unlike the other interventions, exhaled CO2 monitoring can provide an early sign of a problem.

The parents of a 7-month-old boy with a broken arm agree on how the accident happened. Which account would lead the nurse to suspect child abuse?

a) “He was climbing out of his crib and fell.”
b) “The gate was open and he fell down three steps.”
c) “Mom turned and he fell from changing table.”
d) “He fell out of a shopping cart in the store.”

“He was climbing out of his crib and fell.”
Explanation:
The nurse would be suspicious of a 7-month-old climbing out of his crib, since it is not consistent with his developmental stage. Other areas of concern are if the parents have different accounts of the accident and if the injury is not consistent with the type of accident.

The nurse has been monitoring the child’s vital signs. The child is 7 years old. Calculate the child’s minimum acceptable systolic blood pressure.

____

84

Use the following formula (according to Pediatric Advance d Life Support (PALS): 70 + (2 times the age in years) Hence, the minimal systolic BP of a 7-year-old is 70 = (2 x 7) = 84.

The nurse is assessing the respiratory status and lungs of a 6-year-old child. Which of the following would the nurse report immediately?

a) High-pitched breath sounds over the trachea
b) Minimal air movement through the lungs
c) Low-pitched bronchial sounds over the periphery
d) Resonance over the lungs on percussion

Minimal air movement through the lungs
Explanation:
Minimal or no air movement requires immediate intervention because this child’s status is severely compromised. Breath sounds over the trachea typically are high pitched. Breath sounds over the peripheral lung fields are lower pitched. Normally percussion over air-filled lungs reveals resonant sounds.

Fever increases the basal metabolic rate resulting in:

a) Bradypnea
b) Bradycardia
c) Tachypnea
d) Decreased oxygen demand

Tachypnea
Correct
Explanation:
Fever increases the basal metabolic rate, resulting in tachycardia, tachypnea, and increased oxygen demand.

An unconscious client is brought to the emergency department after ingesting too much prescribed medication. Which of the following is the highest priority nursing intervention?

a) Establish a patent airway.
b) Establish IV access.
c) Call family members.
d) Administer antacids.

Establish a patent airway.
Correct
Explanation:
Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function. This is a priority over communication with the family, establishing IV access or administering other medications.

The nurse is caring for a 2-year-old who has been rushed to the clinic immediately after swallowing an unknown number of acetaminophen tablets. Which of the following is the priority intervention?

a) Perform a gastric lavage.
b) Administer N-acetylcysteine.
c) Initiate chelation therapy.
d) Start IV fluid replacement.

Perform a gastric lavage.
Explanation:
If the child ingested the pills within the last 60 minutes, a gastric lavage and administration of activated charcoal would be the preferred treatment. If the acetaminophen is in the bloodstream, N-acetylcysteine may be administered. Chelation therapy is meant for metal poisoning. IV fluid replacement is used to treat hypovolemic shock.

A 4-year-old girl is brought to the emergency room following ingestion of large amounts of acetaminophen (Tylenol). Which of the following interventions does the nurse expect?

a) Stimulation of vomiting
b) Assessing for consciousness
c) Performing hands-only CPR
d) Administration of acetylcysteine

Administration of acetylcysteine
Correct
Explanation:
In the emergency department, activated charcoal or acetylcysteine, a mucolytic agent and also the specific antidote for acetaminophen poisoning, will be administered. Acetylcysteine prevents hepatotoxicity by binding with the breakdown product of acetaminophen so that it will not bind to liver cells. Unfortunately, acetylcysteine has an offensive odor and taste. Administering it in a small amount of a carbonated beverage can help the child to swallow it.

While working in the emergency room, you receive a call that a 3-year-old child sustained extensive burns in a house fire. Assuming all of the following actions are included in the standing burn-care protocol, which would be your first nursing action?

a) Insert an NG tube to empty the stomach.
b) Ask the child to drink a glass of milk.
c) Give a tetanus toxoid injection.
d) Obtain a weight.

Obtain a weight.
Correct
Explanation:
Obtaining a weight provides a base for calculating the fluid that will need to be replaced. NG placement and/or drinking milk are not actions to take at this point. Tetanus can be given later and is not critical to active management.

A 9-year-old boy nearly drowned when he fell through the ice while skating on a pond. The child is exhibiting bradycardia. Which of the following would the nurse expect to implement to resolve the child’s bradycardia?

a) Administering epinephrine as ordered
b) Using a convective air warming blanket
c) Providing 100% oxygen via face mask
d) Giving intravenous isotonic fluids

Using a convective air warming blanket
Explanation:
Bradycardia may be resolved by addressing the underlying condition—in this case by relieving hypothermia with a convective air warming blanket. Providing 100% oxygen and then administering epinephrine are primary and secondary treatments for arrhythmias. Giving fluids is an intervention for collapsed rhythms and hypovolemic shock.

A 5-year-old girl is breathing spontaneously but is unable to maintain an airway. Which of the following would be the priority?

a) Placing a towel under her shoulders
b) Inserting an oropharyngeal airway
c) Assisting with tracheal tube insertion
d) Positioning her using head tilt/chin lift

Inserting an oropharyngeal airway
Correct
Explanation:
Inserting an oropharyngeal airway will help ensure that the child maintains a patent airway. Placing a towel under the shoulders would be helpful for opening the airway if this child were an infant. A tracheal tube would not be appropriate since the child is breathing spontaneously and able to maintain her ventilatory effort. Repositioning her using the head tilt/chin lift won’t help if she can’t maintain an airway independently.

A child is to undergo synchronized cardioversion. The child weighs 44 lbs. The nurse would expect how many joules to be delivered?

a) 10 to 20 joules
b) 5 to 10 joules
c) 2 to 4 joules
d) 30 to 40 joules

10 to 20 joules
Explanation:
Energy for cardioversion is delivered at 0.5 to 1 joule/kg. The child weighs 44 lbs or 20 kg. Therefore, the child would receive 10 to 20 joules.

The concept of health promotion consists of efforts to prevent rather than to cure disease or disability. This description best describes: a. tertiary prevention b. secondary prevention c. primary prevention d. morbidity prevention c Standards for well child care and …

Which is considered a normal physiologic change during pregnancy? a. ECG T-wave changes b. Increased cardiac output c. Increased bleeding time d. Decreased renal perfusion increased cardiac output Which of the following exercises should be taught to a pregnant woman …

A client’s fasting blood sugar (FBS) is 63 mg/dL (3.5 mmol/L) at 0700. The client is alert and oriented. What should the nurse do first? a) Give the prescribed dose of insulin. b) Give one ampule of 50% dextrose via …

A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse’s most plausible conclusion based on this assessment finding? The patient’s insulin levels are inadequate. Ketones in …

David from ajethno:

Hi there, would you like to get such a paper? How about receiving a customized one? Check it out https://goo.gl/chNgQy