Review Exam 3

Any topic

100

Multiple Choice (Priority)

A nurse is caring for a newborn with myelomeningocele. The sac is intact. Which action is the nurse’s priority?

A. Place the infant supine for bonding
B. Cover the sac with sterile dry gauze
C. Apply sterile saline-moistened dressing to the sac
D. Begin range of motion exercises

C. Apply sterile saline-moistened dressing to the sac

This is a myelomeningocele → spinal cord + meninges protruding → HIGH risk for infection and rupture

👉 Priority = PROTECT THE SAC + PREVENT INFECTION

✔️ Why C is Correct:

• Sterile saline-moistened dressing keeps the sac:
  • Moist (prevents drying/cracking → rupture)
  • Sterile (reduces infection risk → meningitis)
• This is the FIRST and MOST IMPORTANT action 

200

Multiple Choice (Airway Priority)

A 3-year-old with epiglottitis is sitting upright, drooling, and has stridor. What is the nurse’s priority action?

A. Examine the throat with a tongue blade
B. Place the child supine
C. Prepare for emergency airway management
D. Offer oral fluids

C. Prepare for emergency airway management

• Epiglottitis can suddenly block the airway

• Nurse must prepare for intubation or tracheostomy immediately

• Have:
  • Oxygen ready
  • Intubation equipment
  • Emergency team notified

300

True or False

Children have a higher risk of respiratory distress because their airways are larger than adults.

False ❌

Children have SMALLER airways → higher risk of obstruction 

400

Multiple Choice (Developmental Care)

A nurse is caring for a hospitalized school-age child. Which intervention best supports development?

A. Allow unlimited parental control
B. Encourage participation in care decisions
C. Provide strict bed rest
D. Avoid explaining procedures

B. Encourage participation in care decisions

Developmental Stage Insight (School-Age = Industry vs. Inferiority)

School-age children (≈6–12 years) want to:
👉 Feel capable, involved, and in control

✔️ Why B is Correct:

• Encouraging participation helps the child:
  • Build confidence (industry)
  • Feel included and independent
  • Reduce anxiety about hospitalization
• Examples:
  • Let them choose which arm for BP
  • Help with simple tasks (holding supplies) 

500

 SATA (Patient-Centered Care)

A toddler is hospitalized and exhibiting separation anxiety (protest stage). Which behaviors should the nurse expect?

A. Crying and screaming for parents
B. Quiet withdrawal and apathy
C. Rejecting strangers
D. Clinging to parents
E. Showing interest in toys

A. Crying and screaming for parents

C. Rejecting strangers

D. Clinging to parents

The protest stage is the FIRST stage of separation anxiety. The child is basically saying:
👉 “Where are my parents?! I don’t like this!!”

✔️ Expected Behaviors (PROTEST stage)

• A. Crying and screaming for parents ✅
  → Classic sign—loud, persistent crying
• C. Rejecting strangers ✅
  → Child resists comfort from anyone who isn’t the parent
• D. Clinging to parents ✅
  → Won’t let go when parent is present

Any topic

100

MC

A child with tonsillitis is prescribed antibiotics. What is the most important teaching?

A. Stop medication once symptoms improve
B. Take full course of antibiotics
C. Avoid fluids
D. Stay on bed rest for 2 weeks

B. Take full course of antibiotics

NCLEX Priority = Prevent complications + ensure infection is fully treated

Tonsillitis is often caused by bacterial infection (like strep), and incomplete treatment can lead to serious complications.

✔️ Why B is Correct:

• Taking the full course:
  • Ensures infection is completely eliminated
  • Prevents antibiotic resistance
  • Reduces risk of complications like:
    • Rheumatic Fever
    • Glomerulonephritis 

200

Multiple Choice (Failure to Thrive)

A nurse is caring for an infant with failure to thrive (FTT). Which intervention is most appropriate?

A. Feed only when the infant cries
B. Establish a structured feeding schedule
C. Limit calorie intake
D. Avoid daily weights

B. Establish a structured feeding schedule

NCLEX Priority = Promote consistent growth + adequate nutrition

Infants with Failure to Thrive need:
👉 Regular, predictable nutrition to support weight gain

✔️ Why B is Correct:

• A structured feeding schedule:
  • Ensures adequate caloric intake
  • Prevents missed or inconsistent feeds
  • Promotes steady weight gain
• Often includes:
  • High-calorie formula
  • Frequent small feedings 

300

Priority (Croup)

A toddler with croup suddenly becomes quiet with minimal air movement. What is the nurse’s priority interpretation?

A. Child is improving
B. Child is tired from crying
C. Airway obstruction is worsening
D. Medication is effective

C. Airway obstruction is worsening

In croup, a sudden change from:
👉 loud stridor → QUIET with minimal air movement

= VERY BAD SIGN

• “Quiet” does NOT mean better

• It means little to no air is moving

• This indicates:
  • Severe airway narrowing
  • Impending respiratory failure

400

SATA (Assessment)

Which findings are expected in a child experiencing an acute asthma attack?

A. Wheezing
B. Use of accessory muscles
C. Bradycardia
D. Chest tightness
E. Silent chest

Asthma = airway narrowing + inflammation + mucus
👉 Leads to difficulty moving air IN and OUT

✔️ Expected Findings:

• A. Wheezing ✅
  → Air moving through narrowed airways
• B. Use of accessory muscles ✅
  → Indicates increased work of breathing
• D. Chest tightness ✅
  → Classic symptom reported by child
• E. Silent chest ✅ 🚨
  → VERY severe → little/no air movement → impending respiratory failure

500

SATA (Spina Bifida Care)

Which nursing interventions are appropriate for an infant with spina bifida (pre-op)?

A. Place infant in prone position
B. Apply moist sterile dressing to sac
C. Cover sac with diaper
D. Use latex-free supplies
E. Keep sac dry

A. Place infant in prone position

B. Apply moist sterile dressing to sac

D. Use latex-free supplies

 NCLEX Priority = Protect the sac + Prevent infection

Infant with Spina Bifida (especially myelomeningocele):
👉 BIG risks: rupture + infection (meningitis)

✔️ Correct Interventions:

• A. Place infant in prone position ✅
  → Prevents pressure on the sac
• B. Apply moist sterile dressing to sac ✅
  → Keeps sac hydrated + intact + infection-free
• D. Use latex-free supplies ✅
  → High risk for latex allergy in these infants

Any topic

100

Delegation

Which task can the nurse delegate to a UAP?

A. Assess a child with stridor
B. Administer nebulized medication
C. Record intake and output
D. Teach parents about RSV

C. Record intake and output

👉 UAP = Stable patients + Non-assessment + Non-teaching + Non-medication 

Recording intake and output (I&O) is:

• Routine
• Non-invasive
• Does NOT require nursing judgment
  ✅ Perfect for UAP

200

Multiple Choice (FTT)

A nurse is caring for an infant with failure to thrive. Which finding requires immediate intervention?

A. Weight gain of 10 g/day
B. Refusal to eat during feeding
C. Parent reports irregular feeding schedule
D. Output of 6 wet diapers/day

B. Refusal to eat during feeding

In an infant with Failure to Thrive, the most urgent concern is:
👉 Not taking in enough calories RIGHT NOW 

• Refusal to eat = acute nutritional deficit

• Can quickly lead to:
  • Hypoglycemia
  • Dehydration
  • Further weight loss

• Requires immediate intervention

300

Patient Teaching (Multiple Choice)

The nurse is teaching a parent about asthma medications. Which statement indicates correct understanding?

A. “Salmeterol can be used alone for quick relief”
B. “Albuterol is used for acute attacks”
C. “Ipratropium has no side effects”
D. “Steroids are only used in emergencies”

B. “Albuterol is used for acute attacks”

Rescue vs. Controller Meds in Asthma

✔️ Why B is Correct:

• Albuterol = short-acting beta₂ agonist (SABA)
  👉 Used for:
  • Quick relief
  • Acute asthma attacks (rescue inhaler)
• Works fast to open airways (bronchodilation) 

400

SATA (Assessment)

Which findings are expected in a patient with COPD?

A. Barrel chest
B. Digital clubbing
C. Productive cough
D. Bradypnea
E. Tripod positioning

COPD (chronic bronchitis + emphysema) leads to:
👉 Air trapping + chronic hypoxia + increased work of breathing

• A. Barrel chest ✅
  → From chronic air trapping (hyperinflation)
• B. Digital clubbing ✅
  → Seen with chronic hypoxia (more common in long-standing disease)
• C. Productive cough ✅
  → Especially in chronic bronchitis
• E. Tripod positioning ✅
  → Patient leans forward to improve breathing

500

SATA (Respiratory Assessment)

A nurse is assessing a child for hypoxia. Which findings are expected?

A. Tachycardia
B. Bradycardia
C. Nasal flaring
D. Retractions
E. Lethargy

NCLEX Priority = Early signs of hypoxia first!

When a child has Hypoxia, the body tries to compensate → then decompensates if untreated.

✔️ Expected Findings:

• A. Tachycardia ✅
  → Early sign: heart speeds up to deliver more oxygen
• C. Nasal flaring ✅
  → Indicates increased work of breathing
• D. Retractions ✅
  → Chest pulling in = respiratory distress
• E. Lethargy ✅
  → Late sign = worsening hypoxia (VERY concerning)

Any topic

100

Priority (RSV)

A child with RSV bronchiolitis has increased work of breathing. What is the nurse’s priority action?

A. Administer antibiotics
B. Provide oxygen therapy
C. Encourage fluids
D. Perform chest percussion

B. Provide oxygen therapy

A child with RSV Bronchiolitis and increased work of breathing is at risk for:
👉 Hypoxia 

• Oxygen directly addresses:
  • Low oxygen levels
  • Respiratory distress

• This is the IMMEDIATE life-saving intervention

200

Multiple Choice (Tracheostomy Care)

During tracheostomy care, which action is CORRECT?

A. Cut gauze to fit around trach
B. Use clean technique at all times
C. Use sterile precut gauze
D. Remove ties before applying new ones

C. Use sterile precut gauze

Sterile precut gauze:

• Prevents lint/fibers from entering airway
• Reduces infection risk
• Specifically designed for trach care
  ✅ Safe + sterile = correct

300

Priority (Ostomy Complication)

A patient with an ostomy reports leakage around the pouch. What is the nurse’s best action?

A. Apply skin barrier paste
B. Change pouch more frequently
C. Clean area with alcohol
D. Tighten pouch clamp

A. Apply skin barrier paste

Skin barrier paste:

• Fills in uneven skin surfaces
• Creates a better seal
• Prevents leakage + irritation
  ✅ This addresses the root problem

400

SATA (Ostomy Care)

Which actions are appropriate when caring for a patient with an ostomy?

A. Cut wafer 1/16–1/8 inch larger than stoma
B. Empty pouch when completely full
C. Clean skin with warm water
D. Use moisturizing soap
E. Change appliance before meals

• A. Cut wafer 1/16–1/8 inch larger than stoma ✅
  → Prevents skin breakdown while avoiding pressure on stoma

• C. Clean skin with warm water ✅
  → Gentle cleaning protects peristomal skin

• E. Change appliance before meals ✅
  → Stoma is less active, reducing leakage risk

500

SATA (Croup Management)

A child with croup is admitted. Which interventions should the nurse implement?

A. Provide cool mist humidification
B. Administer racemic epinephrine
C. Keep child calm
D. Encourage excessive crying
E. Give antibiotics immediately

Croup = airway inflammation → reduce swelling + keep airway open

Croup (laryngotracheobronchitis) causes:
👉 Barking cough + stridor + airway narrowing

✔️ Appropriate Interventions:

• A. Provide cool mist humidification ✅
  → Helps soothe airway and reduce irritation
• B. Administer racemic epinephrine ✅
  → Causes vasoconstriction → decreases airway swelling quickly
• C. Keep child calm ✅
  → Crying worsens airway obstruction → calm = better breathing

Any topic

100

What is the nurse’s priority action before suctioning a tracheostomy patient?

A. Apply suction while inserting catheter

B. Hyperoxygenate the patient 

C. Insert catheter quickly 

D. Limit suction time to 20 seconds

B. Hyperoxygenate the patient

Hyperoxygenation before suctioning:

• Increases oxygen reserves
• Prevents oxygen desaturation
• Is the FIRST step before inserting catheter

200

Multiple Choice (Suctioning Technique)

Which action is correct during suctioning?

A. Apply continuous suction during insertion
B. Suction longer than 15 seconds
C. Apply intermittent suction while withdrawing
D. Skip oxygenation before procedure

C. Apply intermittent suction while withdrawing

• Suction is applied ONLY while withdrawing the catheter

• Use intermittent suction:
  • Reduces mucosal trauma
  • Improves secretion removal
    ✅ This is the correct and safest technique

300

SATA (Parent Teaching)

Which instructions should the nurse include when teaching parents about SIDS prevention?

A. Place infant on back to sleep
B. Use firm mattress
C. Use soft blankets for comfort
D. Avoid overheating
E. Allow co-sleeping

• A. Place infant on back to sleep ✅
  → #1 most important intervention (“Back to Sleep”)

• B. Use firm mattress ✅
  → Reduces risk of suffocation

• D. Avoid overheating ✅
  → Overbundling increases SIDS risk

400

SATA (Risk Factors)

Which factors increase the risk of SIDS?

A. Secondhand smoke exposure
B. Prone sleeping position
C. Firm mattress
D. Soft bedding
E. Overheating

• A. Secondhand smoke exposure ✅
  → Affects infant’s respiratory control

• B. Prone sleeping position ✅
  → Increases risk of airway obstruction

• D. Soft bedding ✅
  → Risk of suffocation

• E. Overheating ✅
  → Linked to increased SIDS incidence

500

SATA (Hospitalized Toddler)

A hospitalized toddler is showing regression. Which behaviors would the nurse expect?

A. Bedwetting
B. Loss of language skills
C. Increased independence
D. Clinginess
E. Thumb sucking

Hospitalization is stressful → toddlers often regress to earlier behaviors for comfort and security.

✔️ Expected Regression Behaviors:

• A. Bedwetting ✅
  → Loss of previously achieved toilet training
• B. Loss of language skills ✅
  → May use fewer words or revert to baby talk
• D. Clinginess ✅
  → Increased need for parental presence and reassurance
• E. Thumb sucking ✅
  → Self-soothing behavior from earlier developmental stage