Chapter 25 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 25

Question 1

Type: MCSA

The nurse is planning postoperative care for an infant after a cleft-lip repair. Which nursing intervention is most appropriate for this infant?

1. Prone positioning

2. Suctioning with a Yankauer device

3. Supine or side-lying positioning

4. Avoidance of soft elbow restraints

Correct Answer: 3

Rationale 1: Integrity of the suture line is essential for postoperative care of cleft-lip repair. The infant should be placed in a supine or side-lying position to avoid rubbing the suture line on the bedding. The prone position should be avoided. A Yankauer suction device is made of hard plastic and, if used, could cause trauma to the suture line. Suctioning should be done with a small, soft suction catheter. Soft elbow restraints may be used to prevent the infant from touching the incisional area.

Rationale 2: Integrity of the suture line is essential for postoperative care of cleft-lip repair. The infant should be placed in a supine or side-lying position to avoid rubbing the suture line on the bedding. The prone position should be avoided. A Yankauer suction device is made of hard plastic and, if used, could cause trauma to the suture line. Suctioning should be done with a small, soft suction catheter. Soft elbow restraints may be used to prevent the infant from touching the incisional area.

Rationale 3: Integrity of the suture line is essential for postoperative care of cleft-lip repair. The infant should be placed in a supine or side-lying position to avoid rubbing the suture line on the bedding. The prone position should be avoided. A Yankauer suction device is made of hard plastic and, if used, could cause trauma to the suture line. Suctioning should be done with a small, soft suction catheter. Soft elbow restraints may be used to prevent the infant from touching the incisional area.

Rationale 4: Integrity of the suture line is essential for postoperative care of cleft-lip repair. The infant should be placed in a supine or side-lying position to avoid rubbing the suture line on the bedding. The prone position should be avoided. A Yankauer suction device is made of hard plastic and, if used, could cause trauma to the suture line. Suctioning should be done with a small, soft suction catheter. Soft elbow restraints may be used to prevent the infant from touching the incisional area.

Global Rationale: Integrity of the suture line is essential for postoperative care of cleft-lip repair. The infant should be placed in a supine or side-lying position to avoid rubbing the suture line on the bedding. The prone position should be avoided. A Yankauer suction device is made of hard plastic and, if used, could cause trauma to the suture line. Suctioning should be done with a small, soft suction catheter. Soft elbow restraints may be used to prevent the infant from touching the incisional area.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 25.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population.

Question 2

Type: MCSA

An infant is born with an esophageal atresia and tracheoesophageal fistula. Which preoperative nursing diagnosis is the priority for this infant?

1. Risk for Aspiration Related to Regurgitation

2. Acute Pain Related to Esophageal Defect

3. Ineffective Infant Feeding Pattern Related to Uncoordinated Suck and Swallow

4. Ineffective Tissue Perfusion: Gastrointestinal, Related to Decreased Circulation

Correct Answer: 1

Rationale 1: With the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea. Pain is not usually experienced preoperatively with this condition. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. Tissue perfusion is not a problem with this condition.

Rationale 2: With the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea. Pain is not usually experienced preoperatively with this condition. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. Tissue perfusion is not a problem with this condition.

Rationale 3: With the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea. Pain is not usually experienced preoperatively with this condition. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. Tissue perfusion is not a problem with this condition.

Rationale 4: With the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea. Pain is not usually experienced preoperatively with this condition. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. Tissue perfusion is not a problem with this condition.

Global Rationale: With the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea. Pain is not usually experienced preoperatively with this condition. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. Tissue perfusion is not a problem with this condition.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 25.2 Discuss the pathophysiologic processes associated with specific gastrointestinal disorders in the pediatric population.

Question 3

Type: MCSA

The nurse is evaluating an infants tolerance of feedings after a pyloromyotomy. Which finding indicates that the infant is not tolerating the feeding?

1. Need for frequent burping

2. Irritability during feeding

3. The passing of gas

4. Emesis after two feedings

Correct Answer: 4

Rationale 1: An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.

Rationale 2: An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.

Rationale 3: An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.

Rationale 4: An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.

Global Rationale: An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 25.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

Question 4

Type: MCSA

An infant born with an omphalocele defect is admitted to the intensive-care nursery. Which instruction from the nurse manager to the unlicensed assistive personnel is most appropriate?

1. Prepare a warmer.

2. Prepare a crib.

3. Prepare a feeding of formula.

4. Prepare the bilirubin light.

Correct Answer: 1

Rationale 1: Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The infant many lose heat through the viscera; a warmer is indicated to prevent hypothermia. The crib would not provide adequate maintenance of temperature control. The infant is NPO (nothing by mouth) preoperatively and may or may not need a bilirubin light before surgery.

Rationale 2: Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The infant many lose heat through the viscera; a warmer is indicated to prevent hypothermia. The crib would not provide adequate maintenance of temperature control. The infant is NPO (nothing by mouth) preoperatively and may or may not need a bilirubin light before surgery.

Rationale 3: Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The infant many lose heat through the viscera; a warmer is indicated to prevent hypothermia. The crib would not provide adequate maintenance of temperature control. The infant is NPO (nothing by mouth) preoperatively and may or may not need a bilirubin light before surgery.

Rationale 4: Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The infant many lose heat through the viscera; a warmer is indicated to prevent hypothermia. The crib would not provide adequate maintenance of temperature control. The infant is NPO (nothing by mouth) preoperatively and may or may not need a bilirubin light before surgery.

Global Rationale: Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The infant many lose heat through the viscera; a warmer is indicated to prevent hypothermia. The crib would not provide adequate maintenance of temperature control. The infant is NPO (nothing by mouth) preoperatively and may or may not need a bilirubin light before surgery.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

Question 5

Type: MCSA

The nurse is providing instruction to the parents of an infant with a colostomy. Which statement by the parents indicates appropriate understanding of the teaching session?

1. We will change the colostomy bag with each wet diaper.

2. We will use adhesive enhancers when we change the bag.

3. We will watch for skin irritation around the stoma.

4. We will expect a moderate amount of bleeding after cleansing the area around the stoma.

Correct Answer: 3

Rationale 1: Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.

Rationale 2: Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.

Rationale 3: Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.

Rationale 4: Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.

Global Rationale: Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 25.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

Question 6

Type: MCSA

A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment does the nurse ensure is prepared at the bedside?

1. Intubation setup

2. Appropriate bag and mask

3. Sterile gauze and saline

4. Soft arm restraints

Correct Answer: 1

Rationale 1: A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so the newborns respiratory status can be stabilized. A bag and mask will not be adequate to ventilate a newborn with this condition. The defect is not external, so sterile gauze and saline are not needed. Soft arm restraints are not immediately necessary.

Rationale 2: A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so the newborns respiratory status can be stabilized. A bag and mask will not be adequate to ventilate a newborn with this condition. The defect is not external, so sterile gauze and saline are not needed. Soft arm restraints are not immediately necessary.

Rationale 3: A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so the newborns respiratory status can be stabilized. A bag and mask will not be adequate to ventilate a newborn with this condition. The defect is not external, so sterile gauze and saline are not needed. Soft arm restraints are not immediately necessary.

Rationale 4: A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so the newborns respiratory status can be stabilized. A bag and mask will not be adequate to ventilate a newborn with this condition. The defect is not external, so sterile gauze and saline are not needed. Soft arm restraints are not immediately necessary.

Global Rationale: A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so the newborns respiratory status can be stabilized. A bag and mask will not be adequate to ventilate a newborn with this condition. The defect is not external, so sterile gauze and saline are not needed. Soft arm restraints are not immediately necessary.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

Question 7

Type: MCSA

The nurse is administering several medications to an infant with neurologic impairment and delay. Which medication is a proton pump inhibitor that is administered for gastroesophageal reflux?

1. Omeprazole

2. Ranitidine

3. Phenytoin

4. Glycopyrrolate

Correct Answer: 1

Rationale 1: Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.

Rationale 2: Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.

Rationale 3: Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.

Rationale 4: Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.

Global Rationale: Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.2 Discuss the pathophysiologic processes associated with specific gastrointestinal disorders in the pediatric population.

Question 8

Type: MCSA

A newborn is diagnosed with Hirschsprung disease. Which clinical manifestations found on assessment support this newborns diagnosis?

1. Acute diarrhea; dehydration

2. Failure to pass meconium; abdominal distension

3. Currant jelly; gelatinous stools; pain

4. Projectile vomiting; altered electrolytes

Correct Answer: 2

Rationale 1: Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.

Rationale 2: Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.

Rationale 3: Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.

Rationale 4: Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.

Global Rationale: Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns, the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 25.3 Identify signs and symptoms that may indicate a disorder of the gastrointestinal system.

Question 9

Type: MCSA

A child with severe gastroenteritis is admitted to a semiprivate room on the pediatric unit. The charge nurse should place this client with which roommate?

1. An infant with meningitis

2. A child with fever and neutropenia

3. Another child with gastroenteritis

4. A child recovering from an appendectomy

Correct Answer: 3

Rationale 1: Gastroenteritis may be viral or bacterial and can be infectious. It is best to cohort children with this infectious process. Good handwashing is essential to prevent the spread. An infant with meningitis, a child with fever and neutropenia, and a child recovering from an appendectomy should not be placed with another child with an infectious process.

Rationale 2: Gastroenteritis may be viral or bacterial and can be infectious. It is best to cohort children with this infectious process. Good handwashing is essential to prevent the spread. An infant with meningitis, a child with fever and neutropenia, and a child recovering from an appendectomy should not be placed with another child with an infectious process.

Rationale 3: Gastroenteritis may be viral or bacterial and can be infectious. It is best to cohort children with this infectious process. Good handwashing is essential to prevent the spread. An infant with meningitis, a child with fever and neutropenia, and a child recovering from an appendectomy should not be placed with another child with an infectious process.

Rationale 4: Gastroenteritis may be viral or bacterial and can be infectious. It is best to cohort children with this infectious process. Good handwashing is essential to prevent the spread. An infant with meningitis, a child with fever and neutropenia, and a child recovering from an appendectomy should not be placed with another child with an infectious process.

Global Rationale: Gastroenteritis may be viral or bacterial and can be infectious. It is best to cohort children with this infectious process. Good handwashing is essential to prevent the spread. An infant with meningitis, a child with fever and neutropenia, and a child recovering from an appendectomy should not be placed with another child with an infectious process.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.2 Discuss the pathophysiologic processes associated with specific gastrointestinal disorders in the pediatric population.

Question 10

Type: MCSA

The nurse is preparing to ambulate a school-age client who had an appendectomy. In addition to pharmacological pain management, the nurse can use which nonpharmacological pain-management strategy for this client?

1. A heating pad

2. A warm, moist pack

3. A pillow on the abdomen

4. An ice pack

Correct Answer: 3

Rationale 1: A pillow placed on the abdomen can be a nonpharmacological strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incisional area as they can impair the healing process of the wound.

Rationale 2: A pillow placed on the abdomen can be a nonpharmacological strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incisional area as they can impair the healing process of the wound.

Rationale 3: A pillow placed on the abdomen can be a nonpharmacological strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incisional area as they can impair the healing process of the wound.

Rationale 4: A pillow placed on the abdomen can be a nonpharmacological strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incisional area as they can impair the healing process of the wound.

Global Rationale: A pillow placed on the abdomen can be a nonpharmacological strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incisional area as they can impair the healing process of the wound.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

Question 11

Type: MCSA

A neonate is fed 20 mL of formula every three hours by orogastric lavage. At the beginning of this feeding, the nurse aspirates 15 mL of gastric residual. Which action by the nurse is the most appropriate?

1. Withhold the feeding and notify the healthcare provider.

2. Replace the residual and continue with the full feeding.

3. Replace the residual but only give 5 mL of the feeding.

4. Withhold the feeding and check the residual in three hours.

Correct Answer: 1

Rationale 1: Residual of more than half the amount of feeding indicates a feeding intolerance and could be a sign of necrotizing enterocolitis. Early detection of enterocolitis is essential, and aggressive management is required. Therefore, the healthcare provider should be notified of this finding. The amount of residual is too much to replace and continue with the feeding, and waiting for three hours to recheck the residual could delay treatment of a serious condition.

Rationale 2: Residual of more than half the amount of feeding indicates a feeding intolerance and could be a sign of necrotizing enterocolitis. Early detection of enterocolitis is essential, and aggressive management is required. Therefore, the healthcare provider should be notified of this finding. The amount of residual is too much to replace and continue with the feeding, and waiting for three hours to recheck the residual could delay treatment of a serious condition.

Rationale 3: Residual of more than half the amount of feeding indicates a feeding intolerance and could be a sign of necrotizing enterocolitis. Early detection of enterocolitis is essential, and aggressive management is required. Therefore, the healthcare provider should be notified of this finding. The amount of residual is too much to replace and continue with the feeding, and waiting for three hours to recheck the residual could delay treatment of a serious condition.

Rationale 4: Residual of more than half the amount of feeding indicates a feeding intolerance and could be a sign of necrotizing enterocolitis. Early detection of enterocolitis is essential, and aggressive management is required. Therefore, the healthcare provider should be notified of this finding. The amount of residual is too much to replace and continue with the feeding, and waiting for three hours to recheck the residual could delay treatment of a serious condition.

Global Rationale: Residual of more than half the amount of feeding indicates a feeding intolerance and could be a sign of necrotizing enterocolitis. Early detection of enterocolitis is essential, and aggressive management is required. Therefore, the healthcare provider should be notified of this finding. The amount of residual is too much to replace and continue with the feeding, and waiting for three hours to recheck the residual could delay treatment of a serious condition.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.3 Identify signs and symptoms that may indicate a disorder of the gastrointestinal system.

Question 12

Type: MCSA

A child with inflammatory bowel disease is prescribed prednisone daily. At which time is it most appropriate for the family to administer the prednisone?

1. Between meals

2. One hour before meals

3. At bedtime

4. With meals

Correct Answer: 4

Rationale 1: Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

Rationale 2: Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

Rationale 3: Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

Rationale 4: Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

Global Rationale: Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population.

Question 13

Type: MCMA

The nurse is caring for a school-age client who had an appendectomy after a ruptured appendix. Which orders does the nurse anticipate for this client?

Standard Text: Select all that apply.

1. Antibiotics

2. A clear liquid diet

3. NG tube

4. Vital signs every 4 hours

5. Frequent monitoring of bowel sounds

Correct Answer: 1,3,4,5

Rationale 1: Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.

Rationale 2: Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.

Rationale 3: Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.

Rationale 4: Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.

Rationale 5: Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.

Global Rationale: Antibiotics, an NG tube, vital signs every 4 hours, and frequent monitoring of bowel sounds are appropriate interventions following a ruptured appendix. The client is NPO until bowel sounds return.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

Question 14

Type: MCSA

A 3-day-old preterm infant is diagnosed with necrotizing enterocolitis. The nurse plans care around the frequent radiographs. How frequently should the nurse anticipate that the radiology staff will bring the portable machine to the nursery?

1. Every 6 hours

2. Every 12 hours

3. Every 24 hours

4. Every 48 hours

Correct Answer: 1

Rationale 1: Radiographs are done every 6 hours to evaluate for perforation.

Rationale 2: Radiographs are done every 6 hours to evaluate for perforation.

Rationale 3: Radiographs are done every 6 hours to evaluate for perforation.

Rationale 4: Radiographs are done every 6 hours to evaluate for perforation.

Global Rationale: Radiographs are done every 6 hours to evaluate for perforation.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

Question 15

Type: MCSA

A school-age client is recovering after abdominal surgery. The nurse is planning care for the return of bowel function. Which intervention should be included in the clients plan of care?

1. Fowlers position three times per day for 30 minutes each time

2. Assist the child in choosing a low-fat diet.

3. Commode at bedside

4. Ambulate 34 times a day.

Correct Answer: 4

Rationale 1: The best data that indicate return of bowel sounds are flatus and passage of stool. Ambulation is the primary intervention to assist with both. A Fowlers position, bedside commode, and a low-fat diet will not assist with bowel function.

Rationale 2: The best data that indicate return of bowel sounds are flatus and passage of stool. Ambulation is the primary intervention to assist with both. A Fowlers position, bedside commode, and a low-fat diet will not assist with bowel function.

Rationale 3: The best data that indicate return of bowel sounds are flatus and passage of stool. Ambulation is the primary intervention to assist with both. A Fowlers position, bedside commode, and a low-fat diet will not assist with bowel function.

Rationale 4: The best data that indicate return of bowel sounds are flatus and passage of stool. Ambulation is the primary intervention to assist with both. A Fowlers position, bedside commode, and a low-fat diet will not assist with bowel function.

Global Rationale: The best data that indicate return of bowel sounds are flatus and passage of stool. Ambulation is the primary intervention to assist with both. A Fowlers position, bedside commode, and a low-fat diet will not assist with bowel function.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

Question 16

Type: MCSA

A child experienced a lacerated spleen in a motor vehicle accident. Which is the highest-priority nursing intervention on admission to the pediatric intensive care unit (PICU) following surgery?

1. Observing for signs of hypovolemic shock

2. Maintaining IV fluids

3. Implementing strict bedrest

4. Administering blood products as ordered

Correct Answer: 1

Rationale 1: The priority nursing intervention is observing for signs of hypovolemic shock due to bleeding from the lacerated spleen. The other interventions are appropriate but not the highest priority.

Rationale 2: The priority nursing intervention is observing for signs of hypovolemic shock due to bleeding from the lacerated spleen. The other interventions are appropriate but not the highest priority.

Rationale 3: The priority nursing intervention is observing for signs of hypovolemic shock due to bleeding from the lacerated spleen. The other interventions are appropriate but not the highest priority.

Rationale 4: The priority nursing intervention is observing for signs of hypovolemic shock due to bleeding from the lacerated spleen. The other interventions are appropriate but not the highest priority.

Global Rationale: priority nursing intervention is observing for signs of hypovolemic shock due to bleeding from the lacerated spleen. The other interventions are appropriate but not the highest priority.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 25.6 Plan nursing care for the child with an injury to the gastrointestinal system.

Question 17

Type: MCMA

The nurse educator is preparing an in-service on the basic functions of the gastrointestinal (GI) system. Which statements will the nurse educator include in the in-service?

Standard Text: Select all that apply.

1. The GI system is responsible for the ingestion of fluids and nutrients.

2. The GI system is responsible for the excretion of fluids and nutrients.

3. The GI system is responsible for the metabolism of nutrients.

4. As infants grow, their stomach capacity increases, decreasing the frequency with which they need to be fed.

5. By the second year of life, digestive processes are still developing.

Correct Answer: 1,3,4

Rationale 1: The GI system is responsible for the ingestion of fluids and nutrients as well as the metabolism of nutrients. As infants grow, their stomach capacity increases, which does decrease the frequency with which they need to be fed. The GI system is responsible for the excretion of waste products. By the second year of life, digestive processes are fairly complete.

Rationale 2: The GI system is responsible for the ingestion of fluids and nutrients as well as the metabolism of nutrients. As infants grow, their stomach capacity increases, which does decrease the frequency with which they need to be fed. The GI system is responsible for the excretion of waste products. By the second year of life, digestive processes are fairly complete.

Rationale 3: The GI system is responsible for the ingestion of fluids and nutrients as well as the metabolism of nutrients. As infants grow, their stomach capacity increases, which does decrease the frequency with which they need to be fed. The GI system is responsible for the excretion of waste products. By the second year of life, digestive processes are fairly complete.

Rationale 4: The GI system is responsible for the ingestion of fluids and nutrients as well as the metabolism of nutrients. As infants grow, their stomach capacity increases, which does decrease the frequency with which they need to be fed. The GI system is responsible for the excretion of waste products. By the second year of life, digestive processes are fairly complete.

Rationale 5: The GI system is responsible for the ingestion of fluids and nutrients as well as the metabolism of nutrients. As infants grow, their stomach capacity increases, which does decrease the frequency with which they need to be fed. The GI system is responsible for the excretion of waste products. By the second year of life, digestive processes are fairly complete.

Global Rationale: The GI system is responsible for the ingestion of fluids and nutrients as well as the metabolism of nutrients. As infants grow, their stomach capacity increases, which does decrease the frequency with which they need to be fed. The GI system is responsible for the excretion of waste products. By the second year of life, digestive processes are fairly complete.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 25.1 Describe the general function of the gastrointestinal system.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 6th Ed. Test Bank

Copyright 2015 by Pearson Education, Inc.

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