Respiratory
A nurse is caring for a child with cystic fibrosis. Which intervention is the priority?
A) Administer pancreatic enzymes before meals
B) Encourage high-calorie, high-protein meals
C) Perform chest physiotherapy before meals
D) Administer oxygen at 2L via nasal cannula
C) Perform chest physiotherapy before meals
Rationale: Chest physiotherapy helps loosen thick mucus in the lungs, promoting airway clearance. It is best done before meals to prevent vomiting. While pancreatic enzymes and high-calorie meals are important, airway clearance is the priority. Oxygen therapy may be needed in severe cases but is not the first-line intervention.
A 2-month-old infant presents with severe coughing spells followed by periods of apnea. The nurse should immediately:
A) Administer a cough suppressant
B) Place the infant in a room with a HEPA filter
C) Initiate droplet precautions and prepare for oxygen support
D) Give an oral antibiotic and send the infant home
C) Initiate droplet precautions and prepare for oxygen support
Rationale: Pertussis (whooping cough) is highly contagious and requires droplet precautions. Infants are at high risk for respiratory distress and apnea, so oxygen support may be necessary. Cough suppressants are not given, as coughing helps expel mucus. HEPA filters are unnecessary. The infant should not be sent home without stabilization.
A nurse is preparing to administer digoxin to a pediatric patient with heart failure. Which assessment finding requires the nurse to hold the medication?
A) Apical heart rate of 110 bpm in an infant
B) Apical heart rate of 58 bpm in a school-aged child
C) Serum potassium level of 4.0 mEq/L
D) Mild nausea reported by the child
Correct Answer: B) Apical heart rate of 58 bpm in a school-aged child
Rationale: Digoxin should be held if the heart rate is:
A heart rate of 58 bpm in a school-aged child is too low, possibly indicating digoxin toxicity. A potassium level of 4.0 mEq/L is normal. Mild nausea can be an early sign of toxicity, but the priority is assessing the heart rate before administration.
A patient with asthma is experiencing shortness of breath, wheezing, and use of accessory muscles. Which medication should the nurse administer first?
A) Albuterol nebulizer
B) Montelukast (Singulair)
C) Fluticasone inhaler
D) Ipratropium (Atrovent)
A) Albuterol nebulizer
Rationale: Albuterol is a short-acting beta-agonist (SABA) used for acute asthma attacks. Montelukast is a leukotriene receptor antagonist for long-term asthma control. Fluticasone is a corticosteroid used for prevention, not immediate relief. Ipratropium is an anticholinergic used as an adjunct, but albuterol is the first-line treatment.
A patient with a history of deep vein thrombosis suddenly develops dyspnea, tachycardia, and chest pain. What is the nurse's priority action?
A) Obtain a stat chest X-ray
B) Check oxygen saturation and apply oxygen
C) Encourage the patient to cough and deep breathe
D) Administer an anticoagulant
B) Check oxygen saturation and apply oxygen
Rationale: The symptoms suggest a pulmonary embolism. The nurse should assess oxygenation and apply oxygen immediately to prevent hypoxia. A chest X-ray may be needed but is not the priority action. Anticoagulants are given after confirming the diagnosis. Coughing and deep breathing do not resolve a PE.
A child with congestive heart failure (CHF) is receiving furosemide (Lasix). Which assessment finding should be reported immediately to the healthcare provider?
A) Serum potassium level of 2.8 mEq/L
B) Daily weight decrease of 0.5 kg
C) Urine output of 2 mL/kg/hr
D) Blood pressure of 100/70 mmHg
Correct Answer: A) Serum potassium level of 2.8 mEq/L
Rationale: Furosemide is a loop diuretic that causes potassium loss. A potassium level <3.5 mEq/L can lead to dysrhythmias. A weight decrease shows effective fluid removal. Urine output >1 mL/kg/hr is normal. The BP is within normal limits for a child.
A nurse is caring for a pediatric patient diagnosed with bacterial pneumonia. Which of the following interventions should the nurse include in the care plan? (Select all that apply.)
A) Encourage incentive spirometry use
B) Administer antibiotics as prescribed
C) Place the child in a supine position
D) Maintain adequate hydration
E) Administer cough suppressants to reduce irritation
Correct Answers: A, B, D
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis. Antibiotics are essential for treating bacterial pneumonia. Adequate hydration helps thin secretions. The child should be positioned upright to optimize lung expansion, not supine. Cough suppressants should be avoided since coughing helps clear secretions.
A 3-year-old child with croup presents to the emergency department with inspiratory stridor, a "barking" cough, and mild retractions. Which nursing intervention is most appropriate?
A) Administer humidified oxygen and keep the child calm
B) Obtain a throat culture to confirm the diagnosis
C) Lay the child supine and prepare for intubation
D) Start IV antibiotics immediately
Correct Answer: A) Administer humidified oxygen and keep the child calm
Rationale: Croup is a viral illness that causes upper airway inflammation. Humidified oxygen helps reduce airway swelling, and keeping the child calm prevents worsening airway obstruction. A throat culture is contraindicated due to the risk of laryngospasm. Supine positioning can worsen symptoms. Antibiotics are not needed since croup is viral.
A nurse is administering propranolol to a child with tetralogy of Fallot. Which nursing considerations should the nurse follow? (Select all that apply.)
A) Monitor for bradycardia
B) Check blood pressure before administration
C) Educate the family that abrupt discontinuation can cause rebound tachycardia
D) Encourage high-sodium foods to prevent hypotension
E) Administer the medication with meals
Correct Answers: A, B, C, E
Rationale:
A nurse is assessing a child having an asthma exacerbation. Which assessment finding requires immediate intervention?
A) Audible wheezing on auscultation
B) Use of accessory muscles and nasal flaring
C) Oxygen saturation of 94%
D) Prolonged expiratory phase
B) Use of accessory muscles and nasal flaring
Rationale: Use of accessory muscles and nasal flaring indicate increased respiratory distress and possible impending respiratory failure. Wheezing and prolonged expiration are expected in asthma but do not require immediate intervention unless worsening. An oxygen saturation of 94% is within the acceptable range.
A nurse is providing care for an infant diagnosed with respiratory syncytial virus (RSV). Which nursing interventions should be included? (Select all that apply.)
A) Suction the infant’s airway frequently to remove secretions
B) Place the infant on droplet and contact precautions
C) Administer IV antibiotics to treat the virus
D) Position the infant at a 30–45 degree angle
E) Offer small, frequent feedings to prevent fatigue
Correct Answers: A, B, D, E
Rationale: RSV produces thick mucus, so frequent suctioning is necessary. RSV is highly contagious, requiring droplet and contact precautions. Infants should be positioned with head elevation to ease breathing. Small, frequent feedings help prevent respiratory fatigue. Antibiotics are not effective against RSV, as it is viral.
A child with a mechanical heart valve is prescribed warfarin (Coumadin). Which statements by the parents indicate correct understanding of warfarin therapy? (Select all that apply.)
A) "We should monitor for signs of bleeding, like bruising or nosebleeds."
B) "Our child should avoid high doses of leafy greens, like spinach and kale."
C) "We will check INR levels regularly as prescribed."
D) "Our child should take ibuprofen for pain relief when needed."
E) "We need to stop the medication before all dental procedures."
Correct Answers: A, B, C
Rationale:
A child with suspected epiglottitis is brought to the emergency department. What is the nurse’s priority action?
A) Obtain a throat culture
B) Have the child lie down to rest
C) Prepare for emergency intubation
D) Administer IV antibiotics immediately
Correct Answer: C) Prepare for emergency intubation
Rationale: Epiglottitis is a medical emergency due to the risk of airway obstruction. The priority is securing the airway, which may require intubation. A throat culture should never be done as it may trigger complete airway closure. The child should be kept upright to facilitate breathing. IV antibiotics are necessary but not the first action.
A nurse is educating the parents of a child newly diagnosed with cystic fibrosis (CF). Which statements by the parents indicate a need for further teaching? (Select all that apply.)
A) “We will encourage our child to drink plenty of fluids.”
B) “We should perform chest physiotherapy right after meals.”
C) “We will give pancreatic enzymes before meals and snacks.”
D) “We should limit our child’s physical activity to avoid overexertion.”
E) “We will watch for signs of respiratory infections.”
Correct Answers: B, D
Rationale: Chest physiotherapy should be performed before meals, not after, to prevent vomiting. Physical activity should be encouraged, as it helps improve lung function. The other statements are correct—fluids help loosen mucus, pancreatic enzymes aid digestion, and infection prevention is crucial in CF.
A child with a deep vein thrombosis (DVT) is receiving heparin therapy. The nurse notes bleeding at the IV site and a petechial rash. What is the priority action?
A) Stop the heparin infusion
B) Increase the infusion rate
C) Apply ice to the IV site
D) Prepare to administer vitamin K
Correct Answer: A) Stop the heparin infusion
Rationale: Petechiae and bleeding are signs of heparin-induced thrombocytopenia (HIT) or excessive anticoagulation. The infusion must be stopped immediately to prevent life-threatening bleeding. Protamine sulfate is the antidote, not vitamin K (which is for warfarin).