Pediatric Nursing Exam 1 Practice Questions with Accurate Answers 2024, Exams of Nursing

Download Pediatric Nursing Exam 1 Practice Questions with Accurate Answers 2024 and more Exams Nursing in PDF only on Docsity! Pediatric Nursing Exam 1 Practice Questions with Accurate Answers 2024 The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first? Introduce him- or her. Make the family comfortable. Give assurance of privacy. Explain the purpose of the interview. - Correct Answers ANS: A The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurse's role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality. Which is considered a block to effective communication? Using silence Using clichés Directing the focus Defining the problem - Correct Answers ANS: B Using stereotyped comments or clichés can block effective communication. After the nurse uses such trite phrases, parents often do not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximum freedom of expression. By using open-ended questions and guiding questions, the nurse can obtain the necessary information and maintain a relationship with the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention. Which is the single most important factor to consider when communicating with children? Presence of the child's parent Child's physical condition Child's developmental level Child's nonverbal behaviors - Correct Answers ANS: C The nurse must be aware of the child's developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Nonverbal behaviors vary in importance based on the child's developmental level and physical condition. Although the child's physical condition is a consideration, developmental level is much more important. The presence of parents is important when communicating with young children but may be detrimental when speaking with adolescents. Because children younger than 5 years are egocentric, the nurse should do which when communicating with them? Focus communication on the child. Use easy analogies when possible. Explain experiences of others to the child. Assure the child that communication is private - Correct Answers ANS: A Because children of this age are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel. With children who are egocentric, analogies, experiences, and assurances that communication is private will not be effective because the child is not capable of understanding. The nurse's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle? A. The child may think the equipment is alive. b. Explaining the equipment will only increase the child's fear. c. One brief explanation will be enough to reduce the child's fear. d. The child is too young to understand what the equipment does. - Correct Answers ANS: A Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined? Request a detailed listing of symptoms. Ask the adolescent, "Why did you come here today?" Interview the parent away from the adolescent to determine the chief complaint. Use what the adolescent says to determine, in correct medical terminology, what the problem is. - Correct Answers ANS: B The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. Requesting a detailed list of symptoms makes it difficult to determine the chief complaint. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. The nurse is interviewing the mother of an infant. The mother reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading? History Present illness Chief complaint Review of systems - Correct Answers ANS: A The history refers to information that relates to previous aspects of the child's health, not to the current problem. The difficult delivery and prematurity are important parts of the infant's history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It should not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include squeal such as pulmonary dysfunction. Where in the health history does a record of immunizations belong? History Present illness Review of systems Physical assessment - Correct Answers ANS: A The history contains information relating to all previous aspects of the child's health status. The immunizations are appropriately included in the history. The present illness, review of systems, and physical assessment are not appropriate places to record the immunization status. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active? Ask her, "Are you sexually active?" Ask her, "Are you having sex with anyone?" Ask her, "Are you having sex with a boyfriend?" Ask both the girl and her parent if she is sexually active. - Correct Answers ANS: B Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information for the nurse to provide necessary care. The word "anyone" is preferred to using gender-specific terms such as "boyfriend" or "girlfriend." Using gender-neutral terms is inclusive and conveys acceptance to the adolescent. Questioning about sexual activity should occur when the adolescent is alone. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which? Lacking in protein Indicating they live in poverty Providing sufficient amino acids Needing enrichment with meat and milk - Correct Answers ANS: C A diet that contains vegetables, legumes, and starches may provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. Combinations of foods contain the essential amino acids necessary for growth. Many cultures use diets that contain this combination of foods. It is not indicative of poverty. A dietary assessment should be done, but many vegetarian diets are sufficient for growth. Which parameter correlates best with measurements of total muscle mass? Height Weight Skinfold thickness Upper arm circumference - Correct Answers ANS: D Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the body's major protein reserve and is considered an index of the body's protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the body's fat content. The nurse is preparing to perform a physical assessment on a 10-year- old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which? Appropriate because of child's age Appropriate, but the mother may be uncomfortable Inappropriate because of child's age Inappropriate because child is same sex as mother - Correct Answers ANS: A It is appropriate to give older school-age children the option of having the parent present or not. During the examination, the nurse should respect the child's need for privacy. Children who are 10 years old are minors, and parents are responsible for health care decisions. The mother of a 10-year-old child would not be uncomfortable. The child should help determine who is present during the examination. With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight? 10th percentile 75th percentile 85th percentile 95th percentile - Correct Answers ANS: C Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children who are greater than or equal to the 95th percentile are considered overweight. Children whose BMI is between the 10th and 75th percentiles are within normal limits. Which explains the importance of detecting strabismus in young children? Color vision deficit may result. Amblyopia, a type of blindness, may result. Epicanthi folds may develop in the affected eye. Corneal light reflexes may fall symmetrically within each pupil. - Correct Answers ANS: B By the age of 3 to 4 months, infants are able to fixate on one visual field with both eyes simultaneously. In strabismus, or cross-eye, one eye deviates from the point of fixation. If misalignment is constant, the weak eye becomes "lazy," and the brain eventually suppresses the image produced from that eye. If strabismus is not detected and corrected by age 4 to 6 years, blindness from disuse, known as amblyopia, may occur. Color vision is not the only concern. Epicanthi folds are not related to amblyopia. In children with strabismus, the corneal light reflex will not be symmetric for each eye. Which is the most frequently used test for measuring visual acuity? Snelling letter chart Ishihara vision test Allen picture card test Denver eye screening test - Correct Answers ANS: A The Snelling letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. The Ishihara Vision Test is used for color vision. The Allen picture card test and Denver eye screening test involve single cards for children ages 2 years and older who are unable to use the Snelling letter chart. The nurse is testing an infant's visual acuity. By which age should the infant be able to fix on and follow a target? 1 month 1 to 2 months 3 to 4 months 6 months - Correct Answers ANS: C Visual fixation and ability to follow a target should be present by ages 3 to 4 months. One to 2 months is too young for this developmental milestone. If an infant is not able to fix and follow by 6 months, further ophthalmologic evaluation is needed. During an orthoscopic examination on an infant, in which direction is the pinna pulled? Up and back Up and forward Down and back Down and forward - Correct Answers ANS: C In infants and toddlers, the ear canal is curved upward. To visualize the ear canal, it is necessary to pull the pinna down and back to the 6 to 9 o'clock range to straighten the canal. In children older than age 3 years and adults, the canal curves downward and forward. The pinna is pulled up and back to the 10 o'clock position. Up and forward and down and forward are positions that do not facilitate visualization of the ear canal. What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child? Rinse test Weber test Pure tone audiometry Eliciting the startle reflex - Correct Answers ANS: C Pure tone audiometry uses an audiometer that produces sounds at different volumes and pitches in the child's ears. The child is asked to respond in some way when the tone is heard in the earphone. The Rinse and Weber tests measure bone conduction of sound. Eliciting the startle reflex may be useful in infants. What is the appropriate placement of a tongue blade for assessment of the mouth and throat? On the lower jaw Side of the tongue Against the soft palate Center back area of the tongue - Correct Answers ANS: B The side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. On the lower jaw and against the soft palate are not appropriate places for the tongue blade. Placement in the center back area of the tongue elicits the gag reflex. When assessing a preschooler's chest, what should the nurse expect? Respiratory movements to be chiefly thoracic Anteroposterior diameter to be equal to the transverse diameter Retraction of the muscles between the ribs on respiratory movement Movement of the chest wall to be symmetric bilaterally and coordinated with breathing - Correct Answers ANS: D Movement of the chest wall should be symmetric bilaterally and coordinated with breathing. In children younger than 6 or 7 years, respiratory movement is principally abdominal or diaphragmatic. The anteroposterior diameter is equal to the transverse diameter during infancy. As the child grows, the chest increases in the transverse direction, so that the anteroposterior diameter is less than the lateral diameter. Retractions of the muscles between the ribs on respiratory movement are indicative of respiratory distress. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as? Suggestive of chronic pulmonary disease Suggestive of impending respiratory failure An abnormal finding warranting investigation A normal finding in infants younger than 1 year of age - Correct Answers ANS: C Absent or diminished breath sounds are always an abnormal finding. Fluid, air, or solid masses in the pleural space all interfere with the conduction of breath sounds. Further data are necessary for diagnosis of chronic pulmonary disease or impending respiratory failure. Diminished breath sounds in certain segments of the lungs can alert the nurse to pulmonary areas that may benefit from chest physiotherapy. Further evaluation is needed in all age groups. Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium? Vesicular Bronchial Adventitious Bronchovesicular - Correct Answers ANS: A This is the definition of vesicular breath sounds. They are heard over the entire surface of the lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually heard over the chest. These sounds occur Carry on some communication in English with the interpreter about the family's needs. - Correct Answers ANS: C When using an interpreter, the nurse should communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions. Questions should be posed one at a time to elicit only one answer at a time. Medical jargon should be avoided whenever possible. The nurse should avoid discussing the family's needs with the interpreter in English because some family members may understand some English. Which action should the nurse implement when taking an axillary temperature? Take the temperature through one layer of clothing. Add a degree to the result when recording the temperature. Place the tip of the thermometer under the arm in the center of the axilla. Hold the child's arm away from the body while taking the temperature. - Correct Answers ANS: C The thermometer tip should be placed under the arm in the center of the axilla and kept close to the skin, not clothing. The temperature should not be taken through any clothing. The child's arm should be pressed firmly against the side, not held away from the body. The temperature should be recorded without a degree added and designated as being taken by the axillary method. The nurse is aware that skin turgor best estimates what? Perfusion Adequate hydration Amount of body fat Amount of anemia - Correct Answers ANS: B Skin turgor is one of the best estimates of adequate hydration and nutrition. It does not indicate amount of body fat and is not a test for anemia. The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences? The parent feels inferior to the nurse. The parent is showing respect for the nurse. The parent is embarrassed to seek health care. The parent feels responsible for her child's illness. - Correct Answers ANS: B In some ethnic groups, eye contact is avoided. In the Vietnamese culture, an individual may not look directly into the nurse's eyes as a sign of respect. The nurse providing culturally competent care would recognize that the other answers listed are not why the parent avoids eye contact with the nurse. The nurse is performing an orthoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.) Ashen gray areas A well-defined light reflex A small, round, concave spot near the center of the drum The tympanic membrane is a nontransparent grayish color A whitish line extending from the umbo upward to the margin of the membrane - Correct Answers ANS: B, C, E Normal findings include the light reflex and bony landmarks. The light reflex is a fairly well-defined, cone-shaped reflection that normally points away from the face. The bony landmarks of the eardrum are formed by the umbo, or tip of the malleus. It appears as a small, round, opaque, concave spot near the center of the eardrum. The manubrium (long process or handle) of the malleus appears to be a whitish line extending from the umbo upward to the margin of the membrane. The tympanic membrane should be light pearly pink or gray and translucent, not nontransparent. Ashen gray areas indicate signs of scarring from a previous perforation. The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.) Wheezes Crackles Vesicular Bronchial Bronchovesicular - Correct Answers ANS: C, D, E Normal breath sounds are classified as vesicular, bronchovesicular, or bronchial. Wheezes or crackles are abnormal or adventitious sounds The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.) Lightly brush the palate with a cotton swab. Perform the examination in front of a mirror. Let the child examine someone else's mouth first. Have the child breathe deeply and hold his or her breath. Use a tongue blade to help the child open his or her mouth. - Correct Answers ANS: A, B, C, D To encourage a child to open the mouth for examination, the nurse can lightly brush the palate with a cotton swab, perform the examination in front of a mirror, let the child examine someone else's mouth first, and have the child breathe deeply and hold his or her breath. A tongue blade may elicit the gag reflex and should not be used. Which are effective auscultation techniques? (Select all that apply.) Ask the child to breathe shallowly. Apply light pressure on the chest piece. Use a symmetric and orderly approach. Place the stethoscope over one layer of clothing. Warm the stethoscope before placing it on the skin. - Correct Answers ANS: C, E Effective auscultation techniques include using a symmetric approach and warming the stethoscope before placing it on the skin. Breath sounds are best heard if the child inspires deeply, not shallowly. Firm, not light, pressure should be used on the chest piece. The stethoscope should be placed on the skin, not over clothing The nurse is assessing heart sounds on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.) S4 heart sound S3 heart sound Grade II murmur S1 louder at the apex of the heart S2 louder than S1 in the aortic area - Correct Answers ANS: A, C, E S4 is rarely heard as a normal heart sound; it usually indicates the need for further cardiac evaluation. A grade II murmur is not normal; it is slightly louder than grade I and is audible in all positions. S3 is normally heard in some children. Normally, S1 is louder at the apex of the heart in the mitral and tricuspid area, and S2 is louder near the base of the heart in the pulmonic and aortic area. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure. - Correct Answers ANS: C School-age children can understand that blood can be replaced. Explain the procedure to him using correct scientific and medical terminology. The venipuncture will be uncomfortable. It is inappropriate to tell him it will not hurt. Even though the nurse considers it a simple procedure, the boy is concerned. Telling him not to worry will not allay his fears. A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond? Holding your child is unsafe. Holding may help your child relax. Hospital policy prohibits this interaction. Holding your child is unnecessary given the child's age. - Correct Answers ANS: B The mother's preference for assisting, observing, or waiting outside the room should be assessed, as well as the child's preference for parental presence. The child's choice should be respected. This will most likely help the child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care. A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do? Give him a large cup with ice so it tastes better. Restrict him to his room until he drinks the GoLYTELY. Use little cups and make a game to reward him for each cup he drinks. Tell him that if he does not finish drinking by a set time, the practitioner will be angry. - Correct Answers ANS: C One liter of GoLYTELY is difficult for many children to drink. By using small cups, the child will find the amount less overwhelming. Then a game can be made in which some type of reward (sticker, reading another page of a book) is given for each cup. A large cup of ice would make it more difficult because the child would see it as too much and ice adds additional fluid to be consumed. Negative reinforcement may work if the child wishes to be out of his room. A practitioner may or may not be angry if he does not finish drinking by a set time; this is a threat that may or may not be true. If the child is having difficulty drinking, this would most likely not be effective. A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention? Administering preoperative antibiotic Verifying that the child and procedure are correct Ensuring that the toddler has been NPO since midnight Informing the parents where they can wait during the procedure - Correct Answers ANS: B The most important intervention is to ensure that the correct child is going to the operating room for the identified procedure. It is the nurse's responsibility to verify identification of the child and what procedure is to be done. If an antibiotic is ordered, administering it is important, but correct identification is a priority. Clear liquids can be given up to 2 hours before surgery. If the child was NPO (taking nothing by mouth) since midnight, intravenous fluids should be administered. Parents should be encouraged to accompany the child to the preoperative area. Many institutions allow parents to be present during induction. A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the child's heart rate is 20 beats/min less than it was preoperatively. What should be the nurse's next action? Follow the orders and check in 2 hours. Ask the parents if this is the child's usual heart rate. Recheck the pulse and blood pressure in 15 minutes. Notify the surgeon that the child is probably going into shock. - Correct Answers ANS: C In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child to see if his condition mirrors a drop in heart rate. The assessment and vital signs should be redone in 15 minutes to determine whether the child's condition is stable. When a disparity in vital signs or other assessment data is observed, the nurse should reassess sooner. Most parents will not know their child's heart rate. It is important to determine how the child is recovering from surgery. The nurse should collect additional information before notifying the surgeon. This includes blood pressure, respiratory rate, and pain status. A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen? Establish a contract with her, including rewards. Suggest time-outs when she forgets her medicine. Discuss with her mother the damaging effects of her rescuing the child. Ask the child to bring her medicine containers to each appointment so they can be counted. - Correct Answers ANS: A Many factors can contribute to the child's not taking the medication. The nurse should resolve those issues such as unpleasant side effects, difficulty taking medicine, and time constraints before school. If these factors do not contribute to the issue, then behavioral contracting is usually an effective method to shape behaviors in children. Time-outs provide negative reinforcement. If part of a contract, negative consequences can work, but they need to be structured. Discussing with her mother the damaging effects of her rescuing the child is not the most appropriate action to encourage compliance. For a school-age child, parents should refrain from nagging and rescuing the child. This child is old enough to partially assume responsibility for her own care. If the child brings her medicine containers to each appointment so they can be counted, this will help determine if the medications are being taken, but it will not provide information about whether the child is taking them by herself. A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include? Massaging reddened bony prominences Teaching the parents to turn the child every 4 hours Ensuring that nutritional intake meets requirements Minimizing use of extra linens, which can irritate the child's skin - Correct Answers ANS: C Children who are hospitalized and NPO (taking nothing by mouth) for several days are at risk for nutritional deficiencies and skin breakdown. If NPO status is prolonged, parenteral nutrition should be considered. Massaging bony prominences can cause deep tissue damage. This Place the syringe and needle in a rigid, puncture-resistant container in an area outside of the patient's room. - Correct Answers ANS: B All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant, tamper-proof container located near the site of use. Consequently, these containers should be installed in the patient's room. Needles and syringes are disposed of uncapped and unbroken. A used needle should not be transported to an area distant from use for disposal. A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus aurous (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on what precautions? Droplet Contact Airborne Standard - Correct Answers ANS: B MRSA is an increasingly significant source of hospital-acquired infections. This organism meets the criteria of being epidemiologically important and can be transmitted by direct contact. Gowns and gloves should be worn when exposed to potentially contagious materials, and meticulous hand washing is required. S. aurous is not an organism that is spread through airborne or droplet mechanisms. Additional precautions, beyond Standard Precautions, are needed to prevent spread of this organism. An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can be removed. What nurse's response is best? "Restraints need to be kept on all the time." "That is fine as long as you are with him." "That is fine if we have his parents' consent." "The restraints can be off only when the nursing staff is present." - Correct Answers ANS: B The restraints are necessary to protect the IV site. If the child has appropriate supervision, restraints are not necessary. The nurse should remove the restraints whenever possible. When parents or staff members are present, the restraints can be removed and the IV site protected. Parental permission is not needed for restraint removal. A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing traumatic care? Use an 18-gauge needle if possible. Show the child the equipment to be used before the procedure. If not successful after four attempts, have another nurse try. Restrain the child completely. - Correct Answers ANS: B To provide traumatic care the child should be able to see the equipment to be used before the procedure begins. Use the smallest gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Restrain the child only as needed to perform the procedure safely; use therapeutic hugging. A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what should the nurse do? Set up a tray with equipment the same size as for adults. Apply EMLA to the puncture site 15 minutes before the procedure. Prepare the child for conscious sedation being used for the procedure. Reassure the parents that the test is simple, painless, and risk free. - Correct Answers ANS: C Because of the urgency of the child's condition, conscious sedation should be used for the procedure. Pediatric spinal trays have smaller needles than do adult trays. EMLA should be applied approximately 60 minutes before the procedure; the emergency nature of the spinal tap precludes its use. A spinal tap is not a simple procedure and does have associated risks; analgesia will be given for the pain. Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests? Apply a urine collection bag to the perineal area. Tape a small medicine cup inside of the diaper. Aspirate urine from cotton balls inside the diaper with a syringe without a needle. Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper. - Correct Answers ANS: C To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. Diapers with superabsorbent gels absorb the urine; if these are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the child's skin. It is not feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from the cup. A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hologram, and electrolytes. What is the appropriate procedure to implement for this blood sample? Perform a new venipuncture to obtain the blood sample. Interrupt the IV fluid and withdraw the blood sample needed. Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed. Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample. - Correct Answers ANS: C The blood specimen obtained must reflect the appropriate hem dilution of the blood and electrolyte concentration. The nurse needs to withdraw the amount of fluid that is in the device and discard it. The next sample will come from the child's circulating blood. With a central venous device, the trauma of a separate venipuncture can be avoided. The blood sample will be diluted with either the IV fluid being administered or the saline. The nurse has just collected blood by venipuncture in the antecubital fossa. What should the nurse do next? Keep the child's arm extended while applying a Band-Aid to the site. Keep the child's arm extended and apply pressure to the site for a few minutes. Apply a Band-Aid to the site and keep the arm flexed for 10 minutes. Carefully under the eyelid while it is gently pulled upward - Correct Answers ANS: C The lower eyelid is pulled down, forming a small conjunctiva sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball. The lacrimal duct is not the appropriate placement for the eye medication. It will drain into the nasopharynx, and the child will taste the drug. What is the best method to verify the placement of a nasogastric tube before each use? Radiologic confirmation Auscultation of injected air Aspiration of stomach contents Verification of tape placement on tube - Correct Answers ANS: C Visual inspection and pH check of stomach contents is a reliable method of determining placement before each use. Radiologic examination should be obtained after initial placement but would be too cumbersome to do before each use. Auscultation is an unreliable method to confirm tube placement because of the similarity of sounds produced by air in the bronchus, esophagus, or pleural space. Verification of tape placement on the tube can be inaccurate if the tube has moved within the tape or become dislodged from the stomach Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G-tube). What is essential information for the parents to receive? Verify placement before each feeding. Use a syringe with a plunger to give the infant bolus feedings. Position the infant on the right side during and after the feeding. Beefy red tissue around the G-tube site must be reported to the practitioner. - Correct Answers ANS: C Positioning on the right side during and after feedings helps minimize the risk of aspiration. It is not necessary to verify placement before each feeing. G-tubes are inserted into the stomach and sutured in place. If the tube is through the skin, it is in the stomach. Feedings should be given by gravity flow. The plunger may be used to initiate the feeding, but then the formula should be allowed to flow. Beefy red tissue around the G- tube site is normal granulation tissue that is expected. What is a priority intervention for an infant with a temporary colostomy for Hirsch sprung disease? Teaching how to irrigate the colostomy Protecting the skin around the colostomy Discussing the implications of a colostomy during puberty Using simple, straightforward language to prepare the child - Correct Answers ANS: B Protection of the periosteal skin is a major priority. Well-fitting appliances and skin protectants are used. Teaching how to irrigate a colostomy is not necessary because colostomies are not irrigated in infants. The colostomy is usually reversed within 6 months to 1 year. The parents, not the infant, need to be prepared for the surgery. A 1-month-old infant is admitted to the hospital. The infant's mother is 17 years old and single and lives with her parents. Who signs the informed consent for the 1-month-old infant? The infant's mother The maternal grandparents of the infant The paternal grandparents of the infant Both the infant's mother and the maternal grandparents - Correct Answers ANS: A An emancipated minor is one who is legally under the age of majority but is recognized as having the legal capacity of an adult under circumstances prescribed by state law, such as pregnancy, marriage, high school graduation, independent living, or military service. A preschool child needs a dressing change. To prepare the child, what strategy should the nurse implement? Explain the procedure using medical terminology. Plan a 30-minute teaching session. Give choices when possible but avoid delay. Allow time after the procedure for questions and discussion. - Correct Answers ANS: C Involving children helps to gain their cooperation. Permitting choices gives them some measure of control. The other options would not be appropriate for a preschool child. The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures based on developmental characteristics. What guideline is accurate? Inform toddlers about an upcoming procedure 2 hours before the procedure is to be performed. Inform school-age children about an upcoming procedure immediately before the procedure is scheduled to occur. Discourage parent presence during procedures on infants and toddlers. Use simple diagrams of anatomy and physiology to explain a procedure to a school-age child. - Correct Answers ANS: D To assist the school-age child in meeting Erickson's developmental stage of industry, using simple diagrams of anatomy and physiology to explain a procedure is the accurate guideline. Toddlers should be told about a procedure right before the procedure. School-age children should know about the procedure in advance, not right before, and parents should be present for procedures for infants and toddlers. A laboratory technician is performing a blood draw on a toddler. The toddler is holding still but crying loudly. The nurse should take which action? Have the lab technician stop the procedure until the child stops crying. Do nothing. It's Okay for a child to cry during a painful procedure. Tell the child to stop crying; it's only a small prick. Tell the child to stop crying because the procedure is almost over. - Correct Answers ANS: B The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. It is natural for children to strike out in frustration or to try to avoid stress-provoking situations. The child needs to know that it is all right to cry. At which age should a nurse keep teaching time short (5 minutes)? Infant Toddler Preschool School age - Correct Answers ANS: B Toddlers have limited time concept, and teaching time should be kept short (5-10 minutes). The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate? Take all the tape off, assess the site, and redress. - Correct Answers ANS: C To appropriately check the intravenous (IV) site, the nurse should look at the site and palpate the area. The other options would not be adequate assessments of the site. The nurse is caring for a 12-year-old child who is on fall precautions secondary to seizures. What interventions should be included in the child's care plan? (Select all that apply.) Place a call light and desired items within reach. Keep the bed in the highest position with the two side rails up. Turn off the lights and television at night. Keep personal belongings and clutter contained in one area of the floor. Have the child wear an appropriate-size gown and nonskid footwear. - Correct Answers ANS: A, E Prevention of falls requires alterations in the environment, including keeping call light and desired items within reach and having the child wear appropriate-size gowns and nonskid footwear. The bed should be in the lowest position possible with all the side rails up; at least a dim light should be left on at night; and personal belongings and clutter should not be on the floor—they should be in a cabinet. What methods should the nurse use to measure compliance to a treatment plan? (Select all that apply.) Pill counts Chemical assays Direct observation Third-party reporting Monitoring therapeutic response - Correct Answers ANS: A, B, C, E Assessment of compliance must include direct measurement techniques. Pill counts, chemical assays, direct observation, and monitoring therapeutic response are direct measurement techniques. Third-party reporting would not always be available and would not be a method to measure compliance. What interventions should the nurse implement to prevent a pressure ulcer in a critically ill child? (Select all that apply.) Nutrition consults Using skin moisturizers Turning the child every 2 hours Using plastic disposable underpass Using draw sheets to minimize shear - Correct Answers ANS: A, B, C, and E Interventions found to prevent pressure ulcers in critically ill children include nutrition consults, using skin moisturizers, turning the child every 2 hours, and using draw sheets to minimize shear. Dry weave underpass, not underpass with plastic, should be used to reduce moisture. The nurse is preparing to obtain a nasal washing from a child. What equipment should the nurse gather for the procedure? (Select all that apply.) Sterile water A sterile swab Syringe with tubing Sterile normal saline Tracheal suction catheter - Correct Answers ANS: C, D Nasal washings may be obtained to identify viral pathogens and guide therapy in some respiratory conditions. The child is placed supine, and 1 to 3 ml of sterile normal saline is instilled with a sterile syringe (without a needle) into one nostril. The contents are aspirated with a syringe with 5 cm (2 inches) of 18- to 20-gauge tubing. The saline is quickly instilled and then aspirated to recover the nasal specimen. A tracheal suction catheter would not trap the mucus. Normal saline is used, not sterile water. A sterile swab is used for a throat culture, not for nasal washings. The clinic nurse is teaching parents about when to call the office immediately for a child with a fever. What should the nurse include in the teaching session? (Select all that apply.) The child has a stiff neck. The fever is over 40.6° C (105° F). The child is younger than 2 months. The fever has lasted for more than 3 days. The fever went away for more than 24 hours and then returned. - Correct Answers ANS: A, B, C Parents should call the office immediately if a child has a fever over 40.6° C (105° F), the child is younger than 2 months, or the child has a stiff neck. Parents are to call within 24 hours if the fever went away for more than 24 hours and then returned or the fever has lasted for more than 3 days. What strategies should the nurse implement to assist in feeding a sick child? (Select all that apply.) Serve large portions. Make mealtimes pleasant. Avoid foods that are highly seasoned. Provide finger foods for young children. Ensure a variety of foods, textures, and colors. - Correct Answers ANS: B, C, D, E To assist in feeding a sick child mealtimes should be pleasant; highly seasoned foods should be avoided; finger foods should be provided for young children; and a variety of foods, textures, and colors should be ensured. Small portions, not large, should be served. What disease processes require contact isolation? (Select all that apply.) Rotavirus Hepatitis A Streptococcal pharyngitis Mycoplasma pneumonia Respiratory syncytial virus - Correct Answers ANS: A, B, E In addition to Standard Precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include rotavirus, hepatitis A, and respiratory syncytial virus. Streptococcal pharyngitis and mycoplasma pneumonia require droplet precautions. What disease processes require airborne precautions? (Select all that apply.) Measles Varicella Pertussis Meningitis Tuberculosis - Correct Answers ANS: A, B, E In addition to Standard Precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, Family-centered care avoids expecting families to be part of the decision-making process. - Correct Answers c. Family-centered care recognizes that the family is the constant in a child's life. You are seeing a 10 year old boy with an ACE score of 6 (Adverse Childhood Experiences ACE's). Which of the following is NOT a risk factor for him in adulthood? Thyroid Disease Addiction Obesity Depression - Correct Answers a. Thyroid Disease The nurse is caring postoperatively for an 8-year-old child with multiple fractures and other trauma resulting from a motor vehicle injury. The child is experiencing severe pain. Which of the following is an important consideration in managing the child's pain? Give only an opioid analgesic at this time Increase the dosage of analgesic until the child is adequately sedated. Plan a preventative schedule of pain medication around the clock and include chosen forms of distraction. Give the child a clock and explain when he or she can have pain medications - Correct Answers c. Plan a preventative schedule of pain medication around the clock and include chosen forms of distraction. A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate? Request these favorite foods for him. Identify healthier food choices for him that he might like. Explain that he needs fruits and vegetables. Reward him with ice cream at the end of every meal that he eats. - Correct Answers a. Request these favorite foods for him. What is a key indicator of developmental health in an infant? length weight vital signs head circumference - Correct Answers d. head circumference A child who leads a sedentary lifestyle and is only outdoors when he has outdoor recess at school is at a higher risk for all of the following EXCEPT? Autism Anxiety Metabolic Syndrome Obesity - Correct Answers a. Autism A nurse is about to administer the ASQ developmental screening questionnaire (Ages & Stages Questionnaire) to a toddler during a routine pediatric visit. The parent asks "What is the ASQ?" How do you respond to this question? 'It's a simple intelligence test for young children." "It tells us what your child is doing at a particular age." "It's a test we give to measure a child's growth." "It's an excellent way to see if parents know what their toddlers can do." - Correct Answers b. "It tells us what your child is doing at a particular age." The nurse is assessing a newborn after a vaginal delivery. Which of the following findings is CONCERNING when observed in a newborn?. uneven head shape (molding) respirations are irregular between 30-60 bums (+) moor reflex heart rate is 80 beats pm - Correct Answers d. heart rate is 80 beats pm (normal HR for newborn is 100-205 when awake, 90-160 when at sleep) Which of the following statements is FALSE regarding infants at birth? Infants move more air in and out of their lungs compared to adults. Infants have limited alveolar surface for gas exchange relative to her height and weight. Infant’s immune system is immature and therefor they should not receive immunizations until they are 2 months old. The trachea is shorter and smaller in diameter putting infants at higher risk for tracheal obstruction. - Correct Answers c. Infants immune system is immature and therefor they should not receive immunizations until they are 2 months old. Which of the following would be helpful word to substitute for the word "shot" when working with a 4-year-old? Poke Bee sting Injection Medication under the skin - Correct Answers a. Poke The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex? Grasp Babinski Perez Dance or step - Correct Answers b. Babinski What advice would you give a parent regarding media use for their 11 year old child? Limit time spent on the device outside of school work to 3-4 hours daily. Parents should role model healthy habits and media use and limit their own use to 2 hours daily. Know what your child is watching & playing on their devices at all times. Children and adolescents need monitoring. B & C - Correct Answers d. B & C Which data should be included in a health history? Physical assessment Review of systems Growth measurements Record of vital signs - Correct Answers b. Review of systems The nurse needs to take the blood pressure of a pre-school boy (3 years old) for the first time. Which action would be best in gaining his cooperation? Take his blood pressure even though the parent has stepped out of the room. Tell him that this procedure will help him get well faster. required, which can be painful, and continuous monitoring cannot be done without an arterial line. Pulse oximetry can be either intermittent or continuous. It is important to make certain that sensory connectors and oximetry are compatible because incompatible wiring can cause which condition? Hyperthermia Electrocution Pressure necrosis Burns under sensors - Correct Answers ANS: D Incompatible wiring can generate considerable heat at the tip of the sensor, resulting in partial- and full-thickness burns. Heat may be generated at the site of the sensor, but it will not result in generalized hyperthermia. Electrocution is not a possibility with oximetry. Pressure necrosis can occur from improperly applied sensors but not from incompatible wiring. What test should the nurse do as a precautionary measure before doing an arterial puncture to obtain an arterial blood sample? Allen test Smith test Venipuncture Cold compress - Correct Answers ANS: A The Allen test determines the adequacy of collateral circulation in the extremity distal to the proposed puncture site. If the child does not have satisfactory circulation when the proposed artery is occluded, that extremity is not used. The Smith test, venipuncture, and a cold compress are not done before arterial blood gas sampling. Arterial blood gases have just been drawn on a child. What should the nurse do next? Take the sample to the laboratory immediately. Pack the sample in ice and take it to the laboratory immediately. Place the sample in a brown bag until it can be taken to laboratory. Refrigerate the sample until it can be taken to the laboratory. - Correct Answers ANS: B Arterial blood gases require careful handling for accurate results. Immediately after obtaining the specimen, the nurse packs it in ice to reduce cellular metabolism and takes it to the laboratory. The continuous administration of mist, or aerosolized water, for the treatment of inflammatory conditions of the airways is a common practice that functions in which manner? Has no proven benefit Decreases the viscosity of mucus Decreases bronchoconstriction Reduces the inflammation of the lower airways - Correct Answers ANS: A Aerosol therapy or mist therapy with water is not a treatment of choice for inflammatory airway conditions. Some questionable benefit may occur in mild viral croup. The parent and child may experience a reduction in anxiety in a cool, humid environment. Upper airway secretions may be moistened; however, inhaled mist does not affect the viscosity of mucus. Humidity may worsen bronchospasm. Aerosolized medications are able to reduce inflammation of the lower airways, but water does not have this effect. When bronchial (postural) drainage is generally performed? Before meals and at bedtime Right before all aerosol therapy Immediately on arising and at bedtime Thirty minutes after meals and at bedtime - Correct Answers ANS: A The therapy should be done at bedtime and before meals or 1 to 1 1/2 hours after meals to avoid stomach upset. Postural drainage is most effective when it is performed after other respiratory therapy interventions, including bronchodilator and nebulizer treatments. Immediately on arising and at bedtime are appropriate times, but postural drainage is usually carried out at least three times each day. Thirty minutes after meals may induce vomiting. What nursing consideration is most important in the care of a child on a mechanical ventilator? Humidification is not necessary. Respiratory assessment is done by the ventilator. Positioning the child for comfort and optimum ventilation is necessary. Support and reassurance are not as important because the child is unconscious. - Correct Answers ANS: C The ventilator will do the work of breathing, but the nurse must position the child with attention to achieving optimum gas exchange. The reason for mechanical ventilation and the child's comfort are part of the assessment. Mechanical ventilation is usually achieved by intubation or tracheostomy. These routes bypass the humidification that occurs in the upper airway. The ventilator provides some information about the work of breathing, but patient assessment must be done by the nurse. Support and reassurance are always important for both the child and family. Opioids and anxiolytics are often used to decrease the child's anxiety. Careful assessment is indicated. What intervention is necessary when weaning a child from the ventilator? Light sedation before scheduled estuation No suctioning before scheduled estuation Cool mist begun immediately after estuation Vigorous chest physiotherapy and suctioning performed immediately after estuation - Correct Answers ANS: C A cool mist or noninvasive oxygen therapy is initiated immediately after estuation. Steroids may be administered to minimize any laryngeal edema. Analgesics may be given, but sedation is not usually indicated. The child is suctioned just before estuation to ensure that the airway is clear. Chest physiotherapy and suctioning are performed before estuation. The nurse must suction a 6-month-old infant with a tracheostomy. What intervention should be included? Encourage the child to cough to raise the secretions before suctioning. Perform each pass of the suction catheter for no longer than 5 seconds. Allow the child to rest after every five times the suction catheter is passed. Select a catheter with a diameter three quarters of the diameter of the tracheostomy tube. - Correct Answers ANS: B Suctioning should require no longer than 5 seconds per pass. Otherwise, the airway may be occluded for too long. An infant would be unable to cooperate with instructions to cough up secretions. The child is allowed to rest for 30 to 60 seconds after each aspiration to allow oxygen tension to return to normal. Then the process is repeated until Epinephrine is considered one of the most useful drugs in treating cardiac arrest. As an adrenergic agent, it acts on both - and -receptors in the heart. Epinephrine is rapidly cleared from the bloodstream. Beryllium is no longer used in pediatric cardiac arrest management. Lidocaine is used for ventricular arrhythmias only. Naloxone is useful only to reverse effects of opioids. Effective cardiopulmonary resuscitation (CPR) on a 5-year-old child should include what technique? Provide one breath to every five chest compressions. Provide two breaths to every 30 chest compressions. Reassess the child every 10 minutes while CPR continues. Evaluate the child after 50 cycles of compression and ventilation. - Correct Answers ANS: B Two breaths to 15 compressions is the standard for infants and children when two rescuers are present. One breath to every five chest compressions is not the appropriate ratio for CPR in this age group. Reassessment of the child should take place after 20 cycles or 1 minute. A series of sub diaphragmatic abdominal thrusts (the Heimlich maneuver) is recommended for airway obstruction in children older than which age? 1 year 4 years 8 years 12 years - Correct Answers ANS: A A series of sub diaphragmatic abdominal thrusts (the Heimlich maneuver) is recommended for airway obstruction in children older than 1 year. For children younger than 1 year, back blows and chest thrusts are administered. The mother of a toddler yells to the nurse, "Help! He is choking to death on his food!" The nurse determines that lifesaving measures are necessary based on which finding? Gagging Coughing Pulse over 100 beats/min Inability to speak - Correct Answers ANS: D The inability to speak is indicative of a foreign body airway obstruction of the larynx. Abdominal thrusts are needed for treatment of the choking child. Gagging, not obstruction, indicates irritation at the back of the throat. Coughing does not indicate a complete airway obstruction. Tachycardia may be present for many reasons. The nurse is caring for a 4-year-old child who is receiving 2 L of oxygen per nasal cannula. What disadvantage should the nurse consider when planning care for the child? The child may need to have high humidity administered with the oxygen. The child may not be able to eat and drink comfortably. A nasal cannula may cause an accumulation of moisture on the face. A nasal cannula may cause abdominal distention. - Correct Answers ANS: D All oxygen delivery systems have advantages and disadvantages. One disadvantage of a nasal cannula is possible abdominal distention and discomfort, which could lead to vomiting. The advantages include that the child is able to eat and drink more comfortably, there is no need for a high humidity environment, and there is no accumulation of moisture causing skin irritation. A 5-month-old infant is in respiratory distress. What should the nurse expect to find? Nasal flaring Bradycardia Abdominal breathing Capillary refill of 2 seconds - Correct Answers ANS: A Nasal flaring is a sign of respiratory distress and a significant finding in an infant. The enlargement of the nostrils helps reduce nasal resistance and maintains airway patency. Nasal flaring may be intermittent or continuous and should be described as minimum or marked. The infant would have tachycardia, not Bradycardia, in respiratory distress. Abdominal breathing and a capillary refill are normal findings in an infant. A child is in uncompensated respiratory acidosis. What should the nurse expect the arterial blood gas to be? O2, 95; CO2, 45; pH, 7.40 O2, 88; CO2, 55; pH, 7.30 O2, 88; CO2, 35; pH, 7.28 O2, 92; CO2, 54; pH, 7.35 - Correct Answers ANS: B Respiratory acidosis results from diminished or inadequate pulmonary ventilation that causes an elevation in plasma Pco2 and thus an increased concentration of dissolved carbonic acid, which leads to elevated carbonic acid and hydrogen ion concentration. This tends to lower the ph. CO2 of 55 is elevated (normal CO2 is 35-45), and a pH of 7.30 is low (normal pH is 7.35-7.45). A child is in uncompensated respiratory alkalosis. What should the nurse expect the arterial blood gas to be? CO2, 30; pH, 7.50 CO2, 55; pH, 7.30 CO2, 35; pH, 7.28 CO2, 54; pH, 7.35 - Correct Answers ANS: A Laboratory findings in respiratory alkalosis include reduced PCO2 (35? 9?mm?9?Hg) and elevated plasma pH (>7.45). A child is in uncompensated metabolic alkalosis. What should the nurse expect the arterial blood gas to be? HCO3, 24; pH, 7.35 HCO3, 28; pH, 7.50 HCO3, 20; pH, -7.30 HCO3, 26; pH, 7.40 - Correct Answers ANS: B Metabolic alkalosis results in an elevated plasma pH (normal pH is 7.35- 7.45) that occurs when there is an excess of bicarbonate (normal HCO3 is 22-26). A child is in uncompensated metabolic acidosis. What should the nurse expect the arterial blood gas to be? HCO3, 24; pH, 7.35 HCO3, 28; pH, 7.50 HCO3, 20; pH, 7.30 HCO3, 26; pH, 7.40 - Correct Answers ANS: C Laboratory findings of uncompensated metabolic acidosis include lowered plasma pH (<7.35) and diminished plasma bicarbonate concentration (normal HCO3 is 22-26). A nurse is calculating the correlation of Pao2 with Sao2 according to the ox hemoglobin dissociation curve. What parameter should indicate that the Pao2 is less than 50 to 60 mm Hg? The nurse is analyzing an arterial blood gas of pH, 7.50; PCO2, 50; and HCO3, 29. What result should the nurse document for this blood gas? Fully compensated metabolic alkalosis Partially compensated metabolic alkalosis Fully compensated respiratory alkalosis Partially compensated respiratory alkalosis - Correct Answers ANS: B When the fundamental acid-base ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acid-base pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In metabolic alkalosis, the pH is high (?7?7.45), and the HCO3 is high (?7?26). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the PCO2 is high (?7?45), indicating an attempt at compensation. The nurse is analyzing an arterial blood gas of pH, 7.29; PCO2, 30; and HCO3, 20. What result should the nurse document for this blood gas? Fully compensated respiratory acidosis Partially compensated respiratory acidosis Fully compensated metabolic acidosis Partially compensated metabolic acidosis - Correct Answers ANS: D When the fundamental acid-base ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acid-base pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In metabolic acidosis, the pH is low (?6?7.35), and the HCO3 is low (?6?22). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the PCO2 is low (? 6?35), indicating an attempt at compensation. The nurse is analyzing an arterial blood gas of pH, 7.50; PCO2, 30; and HCO3, 20. What result should the nurse document for this blood gas? Fully compensated metabolic alkalosis Partially compensated metabolic alkalosis Fully compensated respiratory alkalosis Partially compensated respiratory alkalosis - Correct Answers ANS: D When the fundamental acid-base ratio is altered for any reason, the body attempts to correct the deviation. In a simple disturbance, a single primary factor affects one component of the acid-base pair and is usually accompanied by a compensatory or secondary change in the component that is not primarily affected. In respiratory alkalosis, the pH is high (?7?7.45), and the PCO2 is low (?6?35). When the pH is restored to normal, the disturbance is described as compensated. It is partially compensated because the pH remains abnormal, but the HCO3 is low (?6?22), indicating an attempt at compensation. What conditions can produce hyperventilation? (Select all that apply.) Hysteria Narcotics Atelectasis Salicylate intoxication Mechanical ventilation - Correct Answers ANS: A, D, E Hysteria, salicylate intoxication, and mechanical ventilation can produce hyperventilation. Narcotics and atelectasis produce inadequate gas exchange, not hyperventilation. What condition or disease decreases lung compliance? (Select all that apply.) Asthma Atelectasis Pneumothorax Pulmonary edema Lobar emphysema - Correct Answers ANS: B, C, D Atelectasis, pneumothorax, and pulmonary edema decrease lung compliance. Asthma and lobar emphysema increase lung compliance. The nurse is caring for an intubated child on mechanical ventilation. What interventions should the nurse implement to prevent ventilator- assisted pneumonia (VAP)? (Select all that apply.) Routine oral hygiene Appropriate hand hygiene Limit or pharyngeal suctioning of secretions Elevating the head of the bed 30 to 45 degrees Wearing gloves to handle respiratory secretions - Correct Answers ANS: A, B, D, and E Critically ill children on mechanical ventilation are at risk for acquisition of VAP. To prevent VAP, recommendations for nurses working with mechanically ventilated patients include appropriate hand hygiene measures; wearing gloves to handle respiratory secretions or contaminated objects; elevating the head of the bed 30 to 45 degrees; and routine oral hygiene, which includes or pharyngeal suctioning of secretions. The nurse recognizes that oxygen mist tents are rarely used for a child with respiratory distress. What are reasons for not using an oxygen mist tent? (Select all that apply.) Poor access to the child Cool and wet tent environment Oxygen levels fall when tent is entered Child may not tolerate it around the crib/bed Lower oxygen concentrations cannot be achieved - Correct Answers ANS: A, B, C, D The disadvantages of using a mist tent include poor access to the child, a cool and wet tent environment, oxygen levels fall when the tent is entered, and the child may not tolerate it around the crib or bed. Lower oxygen concentrations can be achieved in the tent and is an advantage. The nurse is participating in a code blue on a 12-year-old child in a full respiratory arrest. The child weighs 110 lb. The health care provider has ordered an initial dose of epinephrine hydrochloride (1:10,000) given intravenously. Calculate the correct initial dose of epinephrine in mg. - Correct Answers 110 lb./2.2 kg = 50 kg Initial dose of 1:10,000 epinephrine is 0.01 mg/kg 0.01 mg 50 = *0.5 mg* The nurse is calculating the amount of expected urinary output for a 24- hour period on an intubated young child who weighs 22 lb. The nurse recognizes the formula to be used is 2 ml/kg/hr. What is the expected 24-hour urinary output for this child in milliliters? - Correct Answers 22/2.2 = 10 kg 10 × 2 × 24 = *480 ml* The nurse is calculating the amount of expected urinary output for a 24- hour period on an intubated young child who weighs 33 lb. The nurse Which of the following statements about inhaled corticosteroids is FALSE? They are used to treat inflammation. They impair growth. They can cause oral thrush so patients are educated to rinse their mouth after use. Are used to treat acute asthma exacerbations. - Correct Answers D The nurse is caring for an infant admitted to the hospital with a respiratory syncytial virus infection. Which of the following assessment findings would be most concerning? Heart rate 130 beats per minute. Respiratory rate 79 breaths per minute. Infant is breastfeeding. Respiratory rate 32 breaths per minute. - Correct Answers B A patient with cystic fibrosis should take the opportunity while in the hospital to meet with other children with cystic fibrosis so they can support each other. True or False? - Correct Answers False An 8 month old infant is admitted with possible pertussis, the nurse should particularly assess the: living conditions of the infant. labor and delivery history of the mother. immunization status of the infant alcohol and drug intake of the mother. - Correct Answers C Which of the following children is in the greatest need of emergency medical treatment? A 3-year-old who has a barky cough, is afebrile, and presenting with stridor this morning. An infant with wheezing, tachypnea, tachycardia, and a high fever. An 7-year-old who has abrupt onset of mild subcostal retractions, a low grade fever, and a barky cough. A 13-year-old with a high fever, stridor but no retractions, and purulent secretions. - Correct Answers B Vaccines have led to a significant decrease in the number of INFANTS diagnosed with pneumonia. Which of the following vaccines does NOT decrease risk of pneumonia in INFANTS? Meningococcal (Encarta) Hemophilic Influenza (HIB) Pneumococcus (Prevnar) None of the above. - Correct Answers A The nurse caring for an infant admitted to the hospital with probable RSV would expect: The patient is placed in a single room or is co-hosted with another child with RSV. The patient is on standard precautions. The patient is on standard, contact and droplet precautions. Both A & C - Correct Answers D You are instructing the parents of a premature infant . What are the signs and symptoms of respiratory distress and when should they call their primary care provider? You would include all of the following in your education EXCEPT: Refusal to breast feed. Respiratory rate of 40. Fever over 101.5. Wheezing and substernal retractions. - Correct Answers B What substance is released from the posterior pituitary gland and promotes water retention in the renal system? Renin Aldosterone Angiotensin Antidiuretic hormone (ADH) - Correct Answers Antidiuretic hormone (ADH) ADH is released in response to increased osmolality and decreased volume of intravascular fluid; it promotes water retention in the renal system by increasing the permeability of renal tubules to water. Renin release is stimulated by diminished blood flow to the kidneys. Aldosterone is secreted by the adrenal cortex. It enhances sodium reabsorption in renal tubules, promoting osmotic reabsorption of water. Renin reacts with a plasma globulin to generate angiotensin, which is a powerful vasoconstrictor. Angiotensin also stimulates the release of aldosterone. Nurses should be alert for increased fluid requirements in which circumstance? Fever Mechanical ventilation Congestive heart failure Increased intracranial pressure - Correct Answers Fever Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. The mechanically ventilated child has decreased fluid requirements. Congestive heart failure is a case of fluid overload in children. Increased intracranial pressure does not lead to increased fluid requirements in children. What factor predisposes an infant to fluid imbalances? Decreased surface area Lower metabolic rate Immature kidney functioning Decreased daily exchange of extracellular fluid - Correct Answers Immature kidney functioning The infant's kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration. What is the required number of milliliters of fluid needed per day for a 14-kg child? 800 1000 1200 1400 - Correct Answers 1200 Moderate dehydration is defined as a fluid loss of between 50 and 90 ml/kg. Mild dehydration is defined as a fluid loss of less than 50 ml/kg. Weight loss up to 5% is considered mild dehydration. Weight loss over 15% is severe dehydration. Physiologically, the child compensates for fluid volume losses by which mechanism? Inhibition of aldosterone secretion Hem concentration to reduce cardiac workload Fluid shift from interstitial space to intravascular space Vasodilation of peripheral arterioles to increase perfusion - Correct Answers Fluid shift from interstitial space to intravascular space Compensatory mechanisms attempt to maintain fluid volume. Initially, interstitial fluid moves into the intravascular compartment to maintain blood volume. Aldosterone is released to promote sodium retention and conserve water in the kidneys. Hem concentration results from the fluid volume loss. With less circulating volume, tachycardia results. Vasoconstriction of peripheral arterioles occurs to help maintain blood pressure. Ongoing fluid losses can overwhelm the child's ability to compensate, resulting in shock. What early clinical sign precedes shock? Tachycardia Slow respirations Warm, flushed skin Decreased blood pressure - Correct Answers Tachycardia Shock is preceded by tachycardia and signs of poor tissue perfusion and decreased pulse oximetry values. Respirations are increased as the child attempts to compensate. As a result of the poor peripheral circulation, the child has skin that is cool and mottled with decreased capillary refilling after blanching. In children, lowered blood pressure is a late sign and may accompany the onset of cardiovascular collapse. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant? Weight loss and decreased heart rate Capillary refill of less than 2 seconds and no tears Increased skin elasticity and sunken anterior fontanel Dry mucous membranes and generally ill appearance - Correct Answers Dry mucous membranes and generally ill appearance A good predictor of a fluid deficit of at least 5% is any two four factors: capillary refill of more than 2 seconds, absent tears, dry mucous membranes, and ill general appearance. Weight loss is associated with fluid deficit, but the degree needs to be quantified. Heart rate is usually elevated. Skin elasticity is decreased, not increased. The anterior fontanel is depressed. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication? Oliguria Weight loss Irritability and seizures Muscle weakness and cardiac dysrhythmias - Correct Answers Irritability and seizures Irritability, somnolence, headache, vomiting, diarrhea, and generalized seizures are manifestations of water intoxication. Urinary output is increased as the child attempts to maintain fluid balance. Weight gain is usually associated with water intoxication. Muscle weakness and cardiac dysrhythmias are not associated with water intoxication. What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as over excitability, nervousness, and titan? Metabolic acidosis Respiratory alkalosis Metabolic and respiratory acidosis Metabolic and respiratory alkalosis - Correct Answers Metabolic and respiratory alkalosis The major symptoms and signs of alkalosis include nervous system stimulation and excitement, including over excitability, nervousness, tingling sensations, and titan that may progress to seizures. Acidosis (both metabolic and respiratory) has clinical signs of depression of the central nervous system, such as lethargy, diminished mental capacity, delirium, stupor, and coma. Respiratory alkalosis has the same symptoms and signs as metabolic alkalosis. What is an approximate method of estimating output for a child who is not toilet trained? Have parents estimate output. Weigh diapers after each void. Place a urine collection device on the child. Have the child sit on a potty chair 30 minutes after eating. - Correct Answers Weigh diapers after each void Weighing diapers will provide an estimate of urinary output. Each 1 g of weight is equivalent to 1 ml of urine. Having parents estimate output would be inaccurate. It is difficult to estimate how much fluid is in a diaper. The urine collection device would irritate the child's skin. It would be difficult for a toddler who is not toilet trained to sit on a potty chair 30 minutes after eating. The nurse is selecting a site to begin an intravenous infusion on a 2- year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins? Gently tap over the site. Apply a cold compress to the site. Raise the extremity above the level of the body. Use a rubber band as a tourniquet for 5 minutes - Correct Answers Gently tap over the site Gently tapping the site can sometimes cause the veins to be more visible. This is done before the skin is prepared. Warm compresses (not cold) may be useful. The extremity is held in a dependent position. A tourniquet may be helpful, but if too tight, it could cause the vein to burst when punctured. Five minutes is too long. When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action? Change the insertion site every 24 hours. Check the insertion site frequently for signs of infiltration. Use a macro dropper to facilitate reaching the prescribed flow rate. The nurse is teaching a parent of a 10-year-old child who will be discharged with a venous access device (VAD). What statement by the parent indicates a correct understanding of the teaching? "I should have my child wear a protective vest when my child wants to participate in contact sports." "I should apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed." "I can expect my child to have feelings of general malaise for 1 week after the VAD is inserted." "I should give my child a sponge bath for the first 2 weeks after the VAD is inserted; then I can allow my child to take a bath." - Correct Answers "I should apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed." The parents of a child with a VAD should be taught to apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed. The child should not participate in contact sports, even with a protective vest, to prevent the VAD from becoming dislodged. General malaise is a sign of an infection, not an expected finding after insertion of the VAD. The child can shower or take a bath after insertion of the VAD; the child does not need a sponge bath for any length of time. What condition is often associated with severe diarrhea? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis - Correct Answers Metabolic Acidosis Metabolic acidosis results from the increased absorption of short-chain fatty acids produced in the colon. There is an increase in lactic acid from tissue hypoxia secondary to hypovolemia. Bicarbonate is lost through the stool. Ketosis results from fat metabolism when glycogen stores are depleted. Metabolic alkalosis and respiratory alkalosis do not occur from severe diarrhea. What type of diarrhea is associated with an inflammation of the mucosa and sub mucosa in the ileum and colon caused by infectious agents? Osmotic Secretory Cytotoxic Dysenteric - Correct Answers Dysenteric Dysenteric diarrhea is associated with an inflammation of the mucosa and sub mucosa in the ileum and colon caused by infectious agents such as Campylobacter, Salmonella, or Sheila organisms. Edema, mucosal bleeding, and leukocyte infiltration occur. Osmotic diarrhea occurs when the intestine cannot absorb nutrients or electrolytes. It is commonly seen in malabsorption syndromes such as lactose intolerance. Secretory diarrhea is usually a result of bacterial enterotoxins that stimulate fluid and electrolyte secretion from the mucosal crypt cells, the principal secretory cells of the small intestine. Cytotoxic diarrhea is characterized by the viral destruction of the villi of the small intestine. This results in a smaller intestinal surface area, with a decreased capacity for fluid and electrolyte absorption. What organism is a parasite that causes acute diarrhea? Sheila organisms Salmonella organisms Giardia labia Escherichia coli - Correct Answers Giardia labia G. labia are a parasite that represents 10% of no dysenteric illness in the United States. Sheila, Salmonella, and E. coli are bacterial pathogens A school-age child with diarrhea has been rehydrated. The nurse is discussing the child's diet with the family. What food or beverage should be tolerated best? Clear fluids Carbonated drinks Applesauce and milk Easily digested foods - Correct Answers Easily digested foods Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear fluids (e.g., fruit juices and gelatin) and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. In some children, lactose intolerance will develop with diarrhea, and cow's milk should be avoided in the recovery stage. A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solutions (ORS). The child's mother calls the clinic nurse because he is also occasionally vomiting. The nurse should recommend which intervention? Bring the child to the hospital for intravenous fluids. Alternate giving ORS and carbonated drinks. Continue to give ORS frequently in small amounts. Keep child NPO (nothing by mouth) for 8 hours and resume ORS if vomiting has subsided - Correct Answers Continue to give ORS frequently in small amounts. Children who are vomiting should be given ORS at frequent intervals and in small amounts. Intravenous fluids are not indicated for mild dehydration. Carbonated beverages are high in carbohydrates and are not recommended for the treatment of diarrhea and vomiting. The child is not kept NPO because this would cause additional fluid losses. A 7-year-old child with acute diarrhea has been rehydrated with oral rehydration solution (ORS). The nurse should recommend that the child's diet be advanced to what kind of diet? Regular diet Clear liquids High carbohydrate diet BRAT (bananas, rice, applesauce, and toast or tea) diet - Correct Answers Regular diet It is appropriate to advance to a regular diet after ORS has been used to rehydrate the child. Clear liquids are not appropriate for hydration or afterward. A high carbohydrate diet may contribute to loose stools because of the low electrolyte content and high osmolality. The BRAT diet has little nutritional value and is high in carbohydrates. What is the most frequent cause of hypovolemic shock in children? Sepsis The initial physiologic response to a burn injury is a dramatic change in circulation. A precipitous drop in cardiac output precedes any change in circulating blood or plasma volumes. A circulating myocardial depressant factor associated with severe burn injury is thought to be the cause. Metabolic acidosis usually occurs secondary to the disruption of the body's buffering action resulting from fluid shifting to extravascular space. There is a greatly accelerated metabolic rate in burn patients, supported by protein and lipid breakdown. With the loss of circulating volume, there is decreased renal blood flow and depressed glomerular filtration. A child is admitted with extensive burns. The nurse notes burns on the child's lips and singed nasal hairs. The nurse should suspect what condition in the child? A chemical burn A hot-water scald An electrical burn An inhalation injury - Correct Answers An inhalation injury Evidence of an inhalation injury includes burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestations may be delayed for up to 24 hours. Chemical burns, electrical burns, and burns associated with hot-water scalds would not produce singed nasal hair. What is the most immediate threat to life in children with thermal injuries? Shock Anemia Local infection Systemic sepsis - Correct Answers Shock The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis is the primary complication. After the acute stage and during the healing process, what is the primary complication from burn injury? Shock Asphyxia Infection Renal shutdown - Correct Answers Infection During the healing phase, local infection or sepsis is the primary complication. Respiratory problems, primarily airway compromise, and shock are the primary complications during the acute stage of burn injury. Renal shutdown is not a complication of the burn injury but may be a result of the profound shock. What sign is one of the first to indicate overwhelming sepsis in a child with burn injuries? Seizures Bradycardia Disorientation Decreased blood pressure - Correct Answers Disorientation Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are not initial manifestations of overwhelming sepsis. A toddler sustains a minor burn on the hand from hot coffee. What is the first action in treating this burn? Apply burn ointment. Put ice on the burned area. Cover the hand with gauze dressing. Hold the hand under cool running water. - Correct Answers Hold the hand under cool running water In minor burns, the best method to stop the burning process is to hold the burned area under cool running water. Ointments are not applied to a new burn; the ointment will contribute to the burning. Ice is not recommended. Gauze dressings do not stop the burning process. What finding is the most reliable guide to the adequacy of fluid replacement for a small child with burns? Absence of thirst Falling hematocrit Increased seepage from burn wound Urinary output of 1 to 2 ml/kg of body weight/hr - Correct Answers Urinary output of 1 to 2 ml/kg of body weight/hr Replacement fluid therapy is delivered to provide a urinary output of 30 ml/hr in older children or 1 to 2 ml/kg of body weight/hr for children weighing less than 30 kg (66 lb.). Thirst is the result of a complex set of interactions and is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling hematocrit would be indicative of hem dilution. This may reflect fluid shifts and may not accurately represent fluid replacement therapy. Increased seepage from a burn wound would be indicative of increased output, not adequate hydration. What is the purpose of a high-protein diet for a child with major burns? Promote growth Improve appetite Minimize protein breakdown Diminish risk of stress-induced hyperglycemia - Correct Answers Minimize protein breakdown Initially after major burns, there is a hypo metabolic phase, which lasts for 2 or 3 days. A hyper metabolic phase follows, characterized by increased body temperature, oxygen and glucose consumption, carbon dioxide production, glycogenolysis, proteolysis, and lipolysis. This response continues for up to 9 months. A diet high in protein and calories is necessary. Healing, not growth, is the primary consideration. Many children have poor appetites, and supplementation is necessary. Hypoglycemia, not hyperglycemia, can occur from the stress of burn injury because the liver glycogen stores are rapidly depleted. Fentanyl and midazolam (Versed) are given before debridement of a child's burn wounds. What is the purpose of using these medications? Facilitate healing Provide pain relief Minimize risk of infection Decrease amount of debridement needed - Correct Answers Provide pain relief Partial-thickness burns require debridement of devitalized tissue to promote healing. The procedure is painful and requires analgesia and sedation before the procedure. Fentanyl and midazolam provide blood supply to the scar is immediately increased; therefore, periods without pressure should be brief to avoid nourishment of the hypertrophic tissue. Moisturizing agents are used with massage to help stretch tissue and prevent contractures. Compression garments, not loose-fitting garments, are indicated. Range of motion exercises are done to minimize contractures. Prevention of burn injury is important anticipatory guidance. In the infant and toddler period, which mode is the most common cause of burn? Matches Electrical cords Hot liquids in the kitchen Microwave-heated foods - Correct Answers Hot liquids in the kitchen Infants and toddlers are most commonly injured by hot liquids in the kitchen and bathroom. This often occurs as a result of inadequate supervision of this curious and energetic age group. Matches and lighters are seen as toys by young children and should be kept out of reach. Older toddlers and preschool children are at risk of chewing on electrical cords and placing objects in outlets. Microwave-heated fluids and foods can become superheated, resulting in oral burns. The nurse is teaching a group of female adolescents about toxic shock syndrome and the use of tampons. What statement by a participant indicates a need for additional teaching? "I can alternate using a tampon and a sanitary napkin." "I should wash my hands before inserting a tampon." "I can use a super absorbent tampon for more than 6 hours." "I should call my health care provider if I suddenly develop a rash that looks like sunburn." - Correct Answers "I can use a superabsorbent tampon for more than 6 hours." Teaching female adolescents about the association between toxic shock syndrome and the use of tampons is important. The teaching should include not using superabsorbent tampons; not leaving the tampon in for longer than 4 to 6 hours; alternating the use of tampons with sanitary napkins; washing hands before inserting a tampon to decrease the chance of introducing pathogens; and informing a health care provider if a sudden high fever, vomiting, muscle pain, dizziness, or a rash that looks like a sunburn appears. The nurse is caring for an 18-month-old child with rotavirus. What clinical manifestations should the nurse expect to observe? Severe abdominal cramping and bloody diarrhea Mild fever and vomiting followed by onset of watery stools Colicky abdominal pain and vomiting High fever, diarrhea, and lethargy - Correct Answers Mild fever and vomiting followed by onset of watery stools Rotavirus is one of the most common pathogens that cause gastroenteritis in children younger than the age of 2 years. Clinical manifestations include mild to moderate fever and vomiting followed by the onset of watery stools. The fever and vomiting usually abate in 1 or 2 days, but the diarrhea persists for 5 to 7 days. Severe abdominal cramping and bloody diarrhea are seen with Escherichia coli infection; colicky abdominal pain and vomiting are seen with salmonella infection; and high fever, diarrhea, and lethargy are seen with infection by Salmonella tophi. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.) Tachypnea Oliguria Confusion Pale extremities Hypotension Thread pulse - Correct Answers A. Tachypnea B. Oliguria C. Confusion D. Pale extremities As shock progresses, perfusion in the microcirculation becomes marginal despite compensatory adjustments, and the signs are more obvious. Signs include tachypnea, oliguria, confusion, and pale extremities, as well as decreased skin turgor and poor capillary filling. Hypotension and a thread pulse are clinical manifestations of irreversible shock. In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.) Oliguria renal failure Increased intracranial pressure Mechanical ventilation Compensated hypotension Tetralogy of Fallout Type 1 diabetes mellitus - Correct Answers A. Oliguria renal failure B. Increased intracranial pressure C. Mechanical ventilation The nurse should recognize that conditions such as oliguria renal failure, increased intracranial pressure, and mechanical ventilation can cause an increase or a decrease in fluid requirements. Conditions such as hypotension, tetralogy of Fallout, and diabetes mellitus (type 1) do not cause an alteration in fluid requirements. What clinical manifestations should be observed in a 2-year-old child with hypotonic dehydration? (Select all that apply.) Thick, doughy feel to the skin Slightly moist mucous membranes Absent tears Very rapid pulse Hyperirritability - Correct Answers B. Slightly moist mucous membranes C. Absent tears D. Very rapid pulse Clinical manifestations of hypotonic dehydration include slightly moist mucous membranes, absent tears, and a very rapid pulse. A thick, doughy feel to the skin and hyperirritability are signs of hypertonic dehydration. The nurse is caring for a child with hypokalemia. The nurse evaluates the child for which signs and symptoms of hypokalemia? (Select all that apply.)