Chapter 18 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 18

Question 1

Type: MCSA

A nurse is taking care of four different pediatric clients. The client with the greatest risk for dehydration is the:

1. 15-year-old working out in a weight room for an hour before football practice.

2. 10-year-old playing baseball outdoors in 85 degree heat.

3. 5-year-old refusing to eat because of a virus.

4. A newborn under a radiant warmer for an hour after the first bath.

Correct Answer: 2

Rationale 1: A condition that increases the risk of insensible fluid loss places the child at risk for dehydration. Any of these situations can place the child at risk for dehydration but the child at greatest risk is the child playing baseball in direct heat, which will increase utilization of extracellular fluids more rapidly than the other situations.

Rationale 2: A condition that increases the risk of insensible fluid loss places the child at risk for dehydration. Any of these situations can place the child at risk for dehydration but the child at greatest risk is the child playing baseball in direct heat, which will increase utilization of extracellular fluids more rapidly than the other situations.

Rationale 3: A condition that increases the risk of insensible fluid loss places the child at risk for dehydration. Any of these situations can place the child at risk for dehydration but the child at greatest risk is the child playing baseball in direct heat, which will increase utilization of extracellular fluids more rapidly than the other situations.

Rationale 4: A condition that increases the risk of insensible fluid loss places the child at risk for dehydration. Any of these situations can place the child at risk for dehydration but the child at greatest risk is the child playing baseball in direct heat, which will increase utilization of extracellular fluids more rapidly than the other situations.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 03. Recognize threats to fluid and electrolyte balance in children.

Question 2

Type: MCSA

The nurse is assessing an infant brought to the clinic because of diarrhea. The infant is alert but has dry mucous membranes. Which other sign indicates the infant is still in the early or mild stage of dehydration?

1. Tachycardia.

2. Bradycardia.

3. Increased blood pressure.

4. Decreased blood pressure.

Correct Answer: 1

Rationale 1: Tachycardia is a sign that indicates mild dehydration. Bradycardia and increased blood pressure are not signs of dehydration. Decreased blood pressure is not a sign of mild dehydration. Decreased blood pressure indicates moderate to severe dehydration.

Rationale 2: Tachycardia is a sign that indicates mild dehydration. Bradycardia and increased blood pressure are not signs of dehydration. Decreased blood pressure is not a sign of mild dehydration. Decreased blood pressure indicates moderate to severe dehydration.

Rationale 3: Tachycardia is a sign that indicates mild dehydration. Bradycardia and increased blood pressure are not signs of dehydration. Decreased blood pressure is not a sign of mild dehydration. Decreased blood pressure indicates moderate to severe dehydration.

Rationale 4: Tachycardia is a sign that indicates mild dehydration. Bradycardia and increased blood pressure are not signs of dehydration. Decreased blood pressure is not a sign of mild dehydration. Decreased blood pressure indicates moderate to severe dehydration.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 04. Analyze assessment findings to recognize fluid and electrolyte problems and acid-base imbalance in children.

Question 3

Type: MCSA

A 1-month-old infant is admitted to the emergency room with severe diarrhea. Which of the following assessments suggest the infant is severely dehydrated?

1. Skin moist and flushed; mucous membranes dry.

2. Low specific gravity of urine; skin color pale.

3. Fontanels depressed; capillary refill greater than three seconds.

4. High specific gravity of urine; moist mucous membranes.

Correct Answer: 3

Rationale 1: Two signs of severe dehydration are depressed fontanels and capillary refill time greater than three seconds. Moist, flushed skin; moist mucous membranes; and low specific gravity of urine are not signs of dehydration. Dry mucous membranes and pale skin color are signs of mild dehydration, not severe.

Rationale 2: Two signs of severe dehydration are depressed fontanels and capillary refill time greater than three seconds. Moist, flushed skin; moist mucous membranes; and low specific gravity of urine are not signs of dehydration. Dry mucous membranes and pale skin color are signs of mild dehydration, not severe.

Rationale 3: Two signs of severe dehydration are depressed fontanels and capillary refill time greater than three seconds. Moist, flushed skin; moist mucous membranes; and low specific gravity of urine are not signs of dehydration. Dry mucous membranes and pale skin color are signs of mild dehydration, not severe.

Rationale 4: Two signs of severe dehydration are depressed fontanels and capillary refill time greater than three seconds. Moist, flushed skin; moist mucous membranes; and low specific gravity of urine are not signs of dehydration. Dry mucous membranes and pale skin color are signs of mild dehydration, not severe.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 04. Analyze assessment findings to recognize fluid and electrolyte problems and acid-base imbalance in children.

Question 4

Type: MCSA

The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid should the nurse anticipate the doctor to order initially to replace fluids?

1. D5W.

2. 0.9 percent Normal Saline (NS).

3. Albumin.

4. D5 0.2 percent () Normal Saline.

Correct Answer: 2

Rationale 1: 0.9 percent Normal Saline (NS) maintains Na and chloride at present levels. D5W can lower sodium levels so would not be used to initially replace fluids in severe isotonic dehydration. Albumin is used to restore plasma proteins. D5 0.2 percent () Normal Saline would not be used initially but later, as maintenance fluids.

Rationale 2: 0.9 percent Normal Saline (NS) maintains Na and chloride at present levels. D5W can lower sodium levels so would not be used to initially replace fluids in severe isotonic dehydration. Albumin is used to restore plasma proteins. D5 0.2 percent () Normal Saline would not be used initially but later, as maintenance fluids.

Rationale 3: 0.9 percent Normal Saline (NS) maintains Na and chloride at present levels. D5W can lower sodium levels so would not be used to initially replace fluids in severe isotonic dehydration. Albumin is used to restore plasma proteins. D5 0.2 percent () Normal Saline would not be used initially but later, as maintenance fluids.

Rationale 4: 0.9 percent Normal Saline (NS) maintains Na and chloride at present levels. D5W can lower sodium levels so would not be used to initially replace fluids in severe isotonic dehydration. Albumin is used to restore plasma proteins. D5 0.2 percent () Normal Saline would not be used initially but later, as maintenance fluids.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Plan appropriate interventions for children experiencing fluid and electrolyte problems and acid-base imbalance.

Question 5

Type: MCSA

Parents of an infant with slow weight gain ask the nurse if they can feed their baby a highly concentrated formula. An appropriate response given by the nurse would be

1. A higher-concentrated formula could lead to dehydration because of high sodium content; lets discuss other strategies.

2. An undiluted formula concentrate could be given to help the child gain weight; lets look at brands.

3. Evaporated milk could be given to the infant instead of the current formula youre using.

4. A higher-concentrated formula could be given for daytime feedings; lets work on a schedule.

Correct Answer: 1

Rationale 1: Parents and caregivers of bottle-fed babies should be taught never to give undiluted formula concentrate or evaporated milk due to the high sodium content.

Rationale 2: Parents and caregivers of bottle-fed babies should be taught never to give undiluted formula concentrate or evaporated milk due to the high sodium content.

Rationale 3: Parents and caregivers of bottle-fed babies should be taught never to give undiluted formula concentrate or evaporated milk due to the high sodium content.

Rationale 4: Parents and caregivers of bottle-fed babies should be taught never to give undiluted formula concentrate or evaporated milk due to the high sodium content.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 03. Recognize threats to fluid and electrolyte balance in children.

Question 6

Type: MCSA

The nurse has just finished a parent-teaching session on preventing heat-related illnesses for children who exercise. Which statement by a parent indicates understanding of preventive techniques taught?

1. Hydration should occur at the end of an exercise session.

2. Water is the drink of choice to replenish fluids.

3. Wearing dark clothing during exercise is recommended.

4. During activity, stop for fluids every 1520 minutes.

Correct Answer: 4

Rationale 1: During activity, stopping for fluids every 1520 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light clothing is best to wear during exercise activities; wearing of dark colors can increase sweating.

Rationale 2: During activity, stopping for fluids every 1520 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light clothing is best to wear during exercise activities; wearing of dark colors can increase sweating.

Rationale 3: During activity, stopping for fluids every 1520 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light clothing is best to wear during exercise activities; wearing of dark colors can increase sweating.

Rationale 4: During activity, stopping for fluids every 1520 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light clothing is best to wear during exercise activities; wearing of dark colors can increase sweating.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 05. Plan appropriate interventions for children experiencing fluid and electrolyte problems and acid-base imbalance.

Question 7

Type: FIB

A child is being treated for dehydration with intravenous fluids. The child currently weighs 13 kg and is estimated to have lost 7 percent of his normal body weight. The nurse is double-checking the IV rate the physician has ordered. The formula the physician used was for maintenance fluids: 1000 mL for 10 kg of body weight plus 50 cc for every kg over 10 for 24 hours. Replacement fluid is the percentage of lost body weight 10 per kg of body weight. According to the calculation for maintenance plus replacement fluid, this childs hourly IV rate for 24 hours should be ____.

Standard Text:

Correct Answer: 86

Rationale : Maintenance need for 13 kg is 1000 + (50 3), or 1150 mL/24 hours. Add to this the replacement-fluid loss = 7 (percent of total body weight lost) 10 = 70 mL/kg/24 hours (70 13 = 910). 1150 + 910 = 2060 for 24 hours. 2060/24 = 86 cc per hour.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Plan appropriate interventions for children experiencing fluid and electrolyte problems and acid-base imbalance.

Question 8

Type: MCSA

In the morning, a nurse receives a report on four pediatric clients who have some form of fluid-volume excess. The nurse should first check the child with

1. Periorbital edema, normal respiratory rate.

2. Tachypnea and pulmonary congestion.

3. Dependent and sacral edema, regular pulse.

4. Hepatomegaly, normal respiratory rate.

Correct Answer: 2

Rationale 1: A child with respiratory distress should be the first client the nurse checks after receiving report. The child with periorbital edema and normal respiratory rate, the child with dependent and sacral edema and regular pulse, and the child with hepatomegaly and normal respiratory rate are all more stable than the child with tachypnea and pulmonary congestion.

Rationale 2: A child with respiratory distress should be the first client the nurse checks after receiving report. The child with periorbital edema and normal respiratory rate, the child with dependent and sacral edema and regular pulse, and the child with hepatomegaly and normal respiratory rate are all more stable than the child with tachypnea and pulmonary congestion.

Rationale 3: A child with respiratory distress should be the first client the nurse checks after receiving report. The child with periorbital edema and normal respiratory rate, the child with dependent and sacral edema and regular pulse, and the child with hepatomegaly and normal respiratory rate are all more stable than the child with tachypnea and pulmonary congestion.

Rationale 4: A child with respiratory distress should be the first client the nurse checks after receiving report. The child with periorbital edema and normal respiratory rate, the child with dependent and sacral edema and regular pulse, and the child with hepatomegaly and normal respiratory rate are all more stable than the child with tachypnea and pulmonary congestion.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 03. Recognize threats to fluid and electrolyte balance in children.

Question 9

Type: MCSA

The nurse is caring for a child on bed rest who has severe edema in a left lower leg due to blocked lymphatic drainage. A priority nursing diagnosis would be

1. Risk for Imbalanced Nutrition: Less Than Body Requirements.

2. Risk for Impaired Skin Integrity.

3. Risk for Altered Body Image.

4. Risk for Activity Intolerance.

Correct Answer: 2

Rationale 1: The highest priority problem is skin integrity. Nutrition, body image, and activity intolerance would not take priority over the integrity of the skin for this scenario.

Rationale 2: The highest priority problem is skin integrity. Nutrition, body image, and activity intolerance would not take priority over the integrity of the skin for this scenario.

Rationale 3: The highest priority problem is skin integrity. Nutrition, body image, and activity intolerance would not take priority over the integrity of the skin for this scenario.

Rationale 4: The highest priority problem is skin integrity. Nutrition, body image, and activity intolerance would not take priority over the integrity of the skin for this scenario.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 04. Analyze assessment findings to recognize fluid and electrolyte problems and acid-base imbalance in children.

Question 10

Type: MCSA

A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a new RN on the pediatric unit, cautions the new nurse to be especially alert for what condition in the child?

1. Seizures.

2. Bradycardia.

3. Respiratory distress.

4. Hyperthermia.

Correct Answer: 1

Rationale 1: A child with hyponatremia is at risk for seizures. Bradycardia, respiratory distress, and hyperthermia are not risks of hyponatremia.

Rationale 2: A child with hyponatremia is at risk for seizures. Bradycardia, respiratory distress, and hyperthermia are not risks of hyponatremia.

Rationale 3: A child with hyponatremia is at risk for seizures. Bradycardia, respiratory distress, and hyperthermia are not risks of hyponatremia.

Rationale 4: A child with hyponatremia is at risk for seizures. Bradycardia, respiratory distress, and hyperthermia are not risks of hyponatremia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 04. Analyze assessment findings to recognize fluid and electrolyte problems and acid-base imbalance in children.

Question 11

Type: MCSA

A nurse is planning care for a child with hyperkalemia. The nurse explains to the parents that an adverse outcome of hyperkalemia is

1. Seizures.

2. Bradycardia.

3. Respiratory distress.

4. Hyperthermia.

Correct Answer: 2

Rationale 1: A child with hyperkalemia is at risk for cardiac issues. Seizures, respiratory distress, and hyperthermia are not risks of hyperkalemia.

Rationale 2: A child with hyperkalemia is at risk for cardiac issues. Seizures, respiratory distress, and hyperthermia are not risks of hyperkalemia.

Rationale 3: A child with hyperkalemia is at risk for cardiac issues. Seizures, respiratory distress, and hyperthermia are not risks of hyperkalemia.

Rationale 4: A child with hyperkalemia is at risk for cardiac issues. Seizures, respiratory distress, and hyperthermia are not risks of hyperkalemia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 02. Identify regulatory mechanisms for fluid and electrolyte balance.

Question 12

Type: MCSA

A 6-year-old child is hypokalemic. The nurse is helping the child complete her menu. The nurse would encourage this child to select

1. A hamburger with french fries.

2. Pizza with a fruit plate.

3. Chicken strips with chips.

4. A fajita with rice.

Correct Answer: 2

Rationale 1: Pizza with the fruit plate should be encouraged because fruit (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination.

Rationale 2: Pizza with the fruit plate should be encouraged because fruit (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination.

Rationale 3: Pizza with the fruit plate should be encouraged because fruit (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination.

Rationale 4: Pizza with the fruit plate should be encouraged because fruit (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Plan appropriate interventions for children experiencing fluid and electrolyte problems and acid-base imbalance.

Question 13

Type: MCSA

A child is admitted to the hospital for hypercalcemia and is placed on diuretic therapy. Which diuretic would the nurse expect to give?

1. Hydrochlorothiazide (Aquazide).

2. Spironolactone (Aldactone).

3. Furosemide (Lasix).

4. Mannitol (Osmitrol).

Correct Answer: 3

Rationale 1: Furosemide (Lasix) is the diuretic used to aid in excretion of calcium. Thiazide diuretics (hydrochlorothiazide) decrease calcium excretion and should not be given to the hypercalcemic client. Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema and is not routinely used to aid in excretion of calcium. Spironolactone (Aldactone) is a potassium-sparing diuretic and would not be effective for excretion of calcium.

Rationale 2: Furosemide (Lasix) is the diuretic used to aid in excretion of calcium. Thiazide diuretics (hydrochlorothiazide) decrease calcium excretion and should not be given to the hypercalcemic client. Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema and is not routinely used to aid in excretion of calcium. Spironolactone (Aldactone) is a potassium-sparing diuretic and would not be effective for excretion of calcium.

Rationale 3: Furosemide (Lasix) is the diuretic used to aid in excretion of calcium. Thiazide diuretics (hydrochlorothiazide) decrease calcium excretion and should not be given to the hypercalcemic client. Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema and is not routinely used to aid in excretion of calcium. Spironolactone (Aldactone) is a potassium-sparing diuretic and would not be effective for excretion of calcium.

Rationale 4: Furosemide (Lasix) is the diuretic used to aid in excretion of calcium. Thiazide diuretics (hydrochlorothiazide) decrease calcium excretion and should not be given to the hypercalcemic client. Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema and is not routinely used to aid in excretion of calcium. Spironolactone (Aldactone) is a potassium-sparing diuretic and would not be effective for excretion of calcium.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 05. Plan appropriate interventions for children experiencing fluid and electrolyte problems and acid-base imbalance.

Question 14

Type: MCSA

A child with croup has an increased pCO2, a decreased pH, and a normal HCO3 blood-gas value. The nurse interprets this as uncompensated

1. Respiratory acidosis.

2. Respiratory alkalosis.

3. Metabolic acidosis.

4. Metabolic alkalosis.

Correct Answer: 1

Rationale 1: If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased pCO2 and normal HCO3; uncompensated metabolic acidosis has a decreased pH, normal pCO2 and normal HCO3; and uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.

Rationale 2: If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased pCO2 and normal HCO3; uncompensated metabolic acidosis has a decreased pH, normal pCO2 and normal HCO3; and uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.

Rationale 3: If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased pCO2 and normal HCO3; uncompensated metabolic acidosis has a decreased pH, normal pCO2 and normal HCO3; and uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.

Rationale 4: If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased pCO2 and normal HCO3; uncompensated metabolic acidosis has a decreased pH, normal pCO2 and normal HCO3; and uncompensated metabolic alkalosis has an increased pH, normal pCO2, and increased HCO3.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 04. Analyze assessment findings to recognize fluid and electrolyte problems and acid-base imbalance in children.

Question 15

Type: FIB

The nurse is completing the intake and output record for a child admitted for fluid volume deficit. The child has had the following intake and output during the shift:

Intake:

4 oz of Pedialyte

of an 8-oz cup of clear orange Jell-O

2 graham crackers

200 cc of D 5 sodium chloride IV

Output:

345 cc of urine

50 cc of loose stool

The nurse documents the clients intake as ____ milliliters.

Standard Text:

Correct Answer: 440

Rationale : Pedialyte, Jell-O and IV fluid would be calculated for intake. The child has had 240 cc orally and 200 cc intravenously for a total of 440.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Plan appropriate interventions for children experiencing fluid and electrolyte problems and acid-base imbalance.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 5th Ed. Test Bank

Copyright 2012 by Pearson Education, Inc.

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