The Child with Respiratory Health Problems 203
Managing Care Quality and Safety Answers, Rationales, and Test
61. A charge nurse is making assignments for
a group of children on a pediatric unit. The nurse
should avoid assigning the same nurse to care for
a 2-year-old with respiratory syncytial virus
(RSV) and:
■ 1. An 18-month-old with RSV.
■ 2. A 9-year-old 8 hours post-appendectomy.
■ 3. A 1-year-old with a heart defect.
■ 4. A 6-year-old with sickle cell crisis.
62. The nurse is preparing to administer the last
dose of ceftriaxone (Rocephin) before discharge to a
1-year-old but finds the I.V. has occluded. The nurse
should:
■ 1. Restart the I.V.
■ 2. Administer the medication intramuscularly.
■ 3. Arrange for early discharge.
■ 4. Contact the prescriber to request an order
change.
63. A nurse administers ranitidine (Zantac)
instead of cetirizine (Zyrtec) to an 8-year-old with
asthma. The client has suffered no adverse effects.
The nurse tells the charge nurse of the incident but
fears disciplinary action from reporting the error.
The charge nurse should tell the nurse:
■ 1. “If you do not report the error, I will have to.”
■ 2. “Reporting the error helps to identify system
problems to improve client safety.”
■ 3. “Notify the client’s physician to see if she
wants this reported.”
■ 4. “This is not a serious mistake so reporting it
will not affect your position.”
64. A 12-year-old with cystic fibrosis is being
treated in the hospital for pneumonia. The physi-
cian is calling in a telephone order for ampicillin.
The nurse should do which of the following? Select
all that apply.
■ 1. Ask the unit clerk to listen on the speaker
phone with the nurse and write down the
order.
■ 2. Ask the physician to come to the hospital and
write the order on the chart.
■ 3. Repeat the order to the physician.
■ 4. Ask the physician to confirm that the order is
correct as understood by the nurse.
■ 5. Ask the nursing supervisor to cosign the tele-
phone order as transcribed by the nurse.
Billings_Part 2_Chap 2_Test 2.indd 203
Taking Strategies
The answers and rationales for each question follow
below, along with keys ( ) to the client need
(CN) and cognitive level (CL) for each question. Use
these keys to further develop your test-taking skills.
For additional information about test-taking skills
and strategies for answering questions, refer to pages
10–21, and pages 25–26 in Part 1 of this book.
The Client with Tonsillitis
1. 4. If the child does not stick out his tongue so
the nurse can visualize the throat, it is appropriate
to use a tongue blade. Having the child participate
by holding the tongue blade while the nurse guides
it to facilitate visualization of the throat is appropri-
ate technique. It is not useful to remove the tongue
blade or have the child hold it because the nurse
will need to use the tongue blade to depress the
tongue. It is preferable to engage the child’s coopera-
tion before asking the parent to restrain the child.
CN: Physiological adaptation; CL: Analyze
2. 4. When preparing a child for a procedure the
nurse should use neutral words, focus on sensory
experiences, and emphasize the positive aspects at
the end. Being reunited with parents and having an
ice pop would be considered pleasurable events.
Children this age fear bodily harm. To reduced anxi-
ety, the nurse should use the word “fixed” instead
of “removed” to describe what is being done to the
tonsils. Using the terms “put to sleep” and “I.V.”
may be threatening. Additionally, directing a play
experience to focus on I.V. insertion may be counter-
productive as the child may have little recollection
of this aspect of the procedure.
CN: Psychosocial adaptation;
CL: Synthesize
3. 2. The most appropriate outcome for a nurs-
ing diagnosis of Risk for perioperative-positioning
injury related to the surgical procedure would be
that the child remains NPO for the designated period
of time before surgery, thereby minimizing the risk
of aspiration during the surgery. Ability to tell about
the surgery and demonstrating an understanding of
the procedure are appropriate outcomes for a nursing
diagnosis of Deficient knowledge. Knowing that the
parents will not leave is associated with a nursing
diagnosis of Anxiety or Fear related to separation
from support systems or an unfamiliar environment.
CN: Reduction of risk potential;
CL: Synthesize
8/7/2010 9:58:50 AM
 204 The Nursing Care of Children
4. 1. After a tonsillectomy and adenoidectomy,
drooling bright red blood is considered an early
sign of hemorrhage. Often, because of discomfort
in the throat, children tend to avoid swallowing;
instead, they drool. Frequent swallowing would also
be an indication of hemorrhage because the child
attempts to clear the airway of blood by swallowing.
Secretions may be slightly blood-tinged because of
a small amount of oozing after surgery. However,
bright red secretions indicate bleeding. A pulse rate
of 95 bpm is within the normal range for a 5-year-
old child, as is a blood pressure of 95/56 mm Hg.
A small amount of blood that is partially digested,
and therefore dark brown, is often present in post-
operative emesis.
CN: Reduction of risk potential;
CL: Analyze
5. 3. For the first few days after a tonsillectomy
and adenoidectomy, liquids and soft foods are best
tolerated by the child while the throat is sore. Chil-
dren typically do not chew their food thoroughly,
and solid foods are to be avoided because they are
difficult to swallow. Although meat loaf would be
considered a soft food, uncooked carrots would not
be. Pork is frequently difficult to chew. Foods that
have sharp edges, such as potato chips, are con-
traindicated because they are hard to chew and may
cause more throat discomfort.
CN: Basic care and comfort; CL: Evaluate
6. 3. The risk of hemorrhage from a tonsillec-
tomy is greatest when the tissue begins sloughing
and the scabs fall off. This typically happens
7 to 10 days after a tonsillectomy.
CN: Safety and infection control;
CL: Apply
The Client with Otitis Media
7. 2. When a person is taking amoxicillin as
well as an oral contraceptive it renders the contra-
ceptive less effective. Because pregnancy can occur
in such a situation, the nurse should advise the cli-
ent to use additional means of birth control during
the time she is taking the antibiotic. There are no
risks associated with the concurrent use of amoxicil-
lin and antacids, vitamins, or food.
CN: Psychosocial adaptation; CL: Apply
8. 4. Treatment of otitis media involves antibi-
otic therapy for 10 days and then a follow-up check
of the ears by the health care provider. If the infec-
tion is not cleared, the health care provider will
restart the client on another antibiotic. The bulging
tympanic membrane and continued pain suggest
that an infection remains. A decongestant may help
Billings_Part 2_Chap 2_Test 2.indd 204
to drain the eustachian tubes, but it would not clear
the infection. Repeating the same antibiotic that
didn’t clear the infection during the first course of
treatment would probably not be helpful if taken for
another 10 days. Myringotomy tubes are not indi-
cated with just one ear infection.
CN: Health promotion and maintenance;
CL: Synthesize
9. 1. Toddlers should be approached slowly,
because they are wary of strangers and need time
to get used to someone they do not know. The best
approach is to ignore them initially and to focus on
talking to the parents. The child will likely resist
being held by a stranger, so the nurse should not
pick up or hold the child until the child indicates a
readiness to be approached or the mother indicates
that it is okay.
CN: Health promotion and maintenance;
CL: Synthesize
10. 1. Placing ear plugs in the ears will prevent
contaminated bathwater from entering the middle
ear through the tympanostomy tube and causing
an infection. Blowing the nose forcibly during a
cold causes organisms to ascend through the eusta-
chian tube, possibly leading to otitis media. It is not
necessary to administer antibiotics continuously to
a child with a tympanostomy tube. Antibiotics are
appropriate only when an ear infection is present.
Drainage from the ear may be a sign of middle ear
infection and should be reported to the health care
provider.
CN: Reduction of risk potential;
CL: Create
The Client with Foreign
Body Aspiration
11. 4. Crackers, because they crumble and eas-
ily dissolve, are not commonly aspirated. Because
children commonly eat popcorn hulls or pieces that
have not popped, popcorn can be easily aspirated.
Toddlers frequently do not chew their food well,
making raw vegetables a commonly aspirated food.
Round candy is often difficult to chew and comes in
large pieces, making it easily aspirated.
CN: Health promotion and maintenance;
CL: Evaluate
12. 1. Young children have specific reactions to
separation and hospitalization. In the protest stage,
the toddler physically and verbally attacks anyone
who attempts to provide care. Here, the child is
fussing and crying and visibly pushes the nurse
away. In the despair stage, the toddler becomes
withdrawn and obviously depressed (e.g., not
8/7/2010 9:58:51 AM

engaging in play activities and sleeping more than
usual). Regression is a return to a developmentally
earlier phase because of stress or crisis (e.g., a tod-
dler who could feed himself before this event is not
doing so now). Denial or detachment occurs if the
toddler’s stay in the hospital without the parent is
prolonged because the toddler settles in to the hos-
pital life and denies the parents’ existence (e.g., not
reacting when the parents come to visit).
CN: Psychosocial adaptation;
CL: Analyze
13. 4. The three cardinal signs indicating that a
child is truly choking and requires immediate life-
saving interventions include inability to speak, blue
color (cyanosis), and collapse. Vomiting does not
occur while a child is unable to breathe. Once the
object is dislodged, however, vomiting may occur.
Gasping, a sudden intake of air, indicates that the
child is still able to inhale. When a child is choking,
air is not being exchanged, so gagging will not occur.
CN: Reduction of risk potential;
CL: Evaluate
The Client with Asthma
14. 3. Intercostal retractions indicate an increase
in respiratory effort, which is a sign of respiratory
distress. During an asthma attack, secretions are
thick, the cough is tight, and respiration is difficult
(and shortness of breath may occur). If mucous
secretions are copious but thin, the client can
expectorate them, which indicates an improvement
in the condition. If the cough is productive it means
the bronchospasms and the inflammation have been
resolved to the extent that the mucus can be expec-
torated. A respiratory rate of 20 breaths/minute
would be considered normal and no intervention
would be needed.
CN: Physiological adaptation;
CL: Analyze
15. 3. The therapeutic level of theophylline is
10 to 20 mcg/m. A toxic level of theophylline
can cause vomiting, irritability, headache, and
tachycardia. Oral rehydration may be helpful if the
vomiting had created enough of a fluid volume deficit
to elevate the heart rate, but this is unlikely since the
client has an I.V. Allergic reactions to ampicillin usu-
ally include rash, urticaria, respiratory distress, and
hypotension, not tachycardia and vomiting. Although
the child’s heart rate could indicate hypoxia, none of
the other signs indicate a need for oxygen.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
Billings_Part 2_Chap 2_Test 2.indd 205
The Child with Respiratory Health Problems 205
16. 2. Swimming is appropriate for this child
because it requires controlled breathing, assists
in maintaining cardiac health, enhances skeletal
muscle strength, and promotes ventilation and
perfusion. Stop-and-start activities, such as soccer,
track, and gymnastics, commonly trigger symptoms
in asthmatic clients.
CN: Health promotion and maintenance;
CL: Synthesize
17. 3. The child who is experiencing an asthma
attack typically demonstrates wheezing on expira-
tion initially. This results from air moving through
narrowed airways secondary to bronchoconstriction.
The child’s expiratory phase is normally longer than
the inspiratory phase. Expiration is passive as the
diaphragm relaxes. During an asthma attack, secre-
tions are thick and are not usually expelled until
the bronchioles are more relaxed. At the beginning
of an asthma attack the cough will be tight but not
productive. Fever is not always present unless there
is an infection that may have triggered the attack.
CN: Physiological adaptation;
CL: Analyze
18. 1, 2, 4, 6. Coughing, especially at night and
in the absence of an infection, is a common symp-
tom of asthma. Early signs of respiratory distress
include restlessness, tachypnea, tachycardia, and
diaphoresis. Other signs also include hypertension,
nasal flaring, grunting, wheezing, and intercostal
retractions. A heart rate of 95 bpm is normal for a
toddler. Malaise typically does not indicate respira-
tory distress.
CN: Physiological adaptation;
CL: Analyze
19. 2. The peak flow of 180 L/minute is in the
yellow zone, or 50% to 80% of the child’s personal
best. This means that the child’s asthma is not well
controlled, thereby necessitating the use of a short-
acting beta2-agonist medication to relieve the bron-
chospasm. A peak flow reading greater than 80% of
the child’s personal best (in this case, 220 L/minute
or better) would indicate that the child’s asthma
is in the green zone or under good control. A peak
flow reading in the red zone, or less than 50% of the
child’s personal best (135 L/minute or less), would
require notification of the health care provider or a
trip to the emergency department. Cromolyn sodium
(Intal) is not used for short-term treatment of acute
bronchospasm. It is used as part of a long-term
therapy regimen to help desensitize mast cells and
thereby help to prevent symptoms.
CN: Reduction of risk potential;
CL: Evaluate
8/7/2010 9:58:52 AM
 206 The Nursing Care of Children
20. 3. Complaints of chest pain in children and
adolescents are rarely cardiac. With a history of
asthma, the most likely cause of the chest pain is
related to the asthma. Therefore, the nurse should
check the adolescent’s peak flow reading to evalu-
ate the status of the air flow. Calling the adolescent’s
parent would be appropriate, but this would be
done after the nurse obtains the peak flow reading
and additional assessment data. Having the adoles-
cent lie down may be an option, but more data need
to be collected to help establish a possible cause.
Because the adolescent has not experienced any
asthma problems for a long time, it would be inap-
propriate for the nurse to administer a short-acting
bronchodilator at this time.
CN: Reduction of risk potential;
CL: Synthesize
21. 3. Because persistent coughing may indicate
an asthma attack and a 7-year-old child would be
able to provide only minimal history information, it
would be important to obtain information from the
parent. Although determining the child’s heart rate
is an important part of the assessment, it would be
done after the history is obtained. More information
needs to be obtained before giving the child a nebu-
lizer treatment. Although it may be necessary for the
parent to come and pick up the child, a thorough
assessment including history information should be
obtained first.
CN: Reduction of risk potential;
CL: Synthesize
22. 1. To help reduce allergic triggers in the
home, the nurse should recommend that the humid-
ity level be kept between 50% and 60%. Doing so
keeps the air moist and comfortable for breathing.
When air is dry, the risk for respiratory infections
increase. Too high a level of humidity increases
the risk for mold growth. Typically, the child with
asthma should sleep in the top bunk bed to mini-
mize the risk of exposure to dust mites. The risk
of exposure to dust mites increases when the child
sleeps in the bottom bunk bed because dust mites
fall from the top bed, settling in the bottom bed.
Scented sprays should be avoided because they
may trigger an asthmatic episode. Ideally, carpet-
ing should be avoided in the home if the child has
asthma. However, if it is present, carpeting in the
child’s room should be vacuumed often, possibly
daily, to remove dust mites and dust particles.
CN: Reduction of risk potential;
CL: Create
23. 3. Positive adjustment to a chronic condition
requires placing the child’s illness in its proper
perspective. Children with asthma need to be
treated as normally as possible within the scope of
Billings_Part 2_Chap 2_Test 2.indd 206
the limitations imposed by the illness. They also
need to learn how to manage exacerbations and then
resume as normal a life as possible. Trying to keep
the child happy at all costs is inappropriate and
can lead to the child’s never learning how to accept
responsibility for behavior and get along with oth-
ers. Although minimizing the child’s risk for expo-
sure to infections is important, the child needs to be
with his or her peers to ensure appropriate growth
and development. Children with a chronic illness
need to be involved in their care so that they can
learn to manage it. Some parents tend to overprotect
their child with a chronic illness. This overprotec-
tiveness may cause a child to have an exaggerated
feeling of importance or later, as an adolescent, to
rebel against the overprotectiveness and the parents.
CN: Psychosocial adaptation;
CL: Evaluate
24. 4. Physical activities are beneficial to asth-
matic children, physically and psychosocially. Most
children with asthma can engage in school and
sports activities that are geared to the child’s condi-
tion and within the limits imposed by the disease.
The coach and other team members need to be
aware of the child’s condition and know what to do
in case an attack occurs. Those children who have
exercise-induced asthma usually use a short-acting
bronchodilator before exercising.
CN: Health promotion and maintenance;
CL: Apply
The Client with Cystic Fibrosis and
Bronchopneumonia
25. 2. The child must take the pancreatic enzyme
supplement with meals and snacks to help absorb
nutrients so he can grow and develop normally. In
cystic fibrosis, the normally liquid mucus is tena-
cious and blocks three digestive enzymes from
entering the duodenum and digesting essential
nutrients. Without the supplemental pancreatic
enzyme, the child will have voluminous, foul, fatty
stools due to the undigested nutrients and may
experience developmental delays due to malnutri-
tion. Dehydration is not a problem related to cystic
fibrosis. The pancreatic enzymes have no effect on
the viscosity of the tenacious mucus. Diarrhea is
not caused by failing to take the pancreatic enzyme
supplement.
CN: Pharmacological and parenteral
therapies; CL: Apply
26. 3. Clients with cystic fibrosis commonly
die from respiratory problems. The mucus in the
lungs is tenacious and difficult to expel, leading to
lung infections and interference with oxygen and
8/7/2010 9:58:52 AM

carbon dioxide exchange. The client will likely need
supplemental oxygen and respiratory treatments to
maintain adequate gas exchange, as identified by
the oximeter reading. The child will be on bed rest
due to respiratory distress. However, although blood
gases will probably be ordered, the oximeter read-
ings will be used to determine oxygen deficit and
are, therefore, more of a priority. A diet high in calo-
ries, proteins, and vitamins with pancreatic granules
added to all foods ingested will increase nutrient
absorption, and help the malnutrition; however, this
intervention is not the priority at this time. Insert-
ing an I.V. to administer antibiotics is important,
and can be done after ensuring adequate respiratory
function.
CN: Physiological adaptation;
CL: Synthesize
27. 2. Fried scallops are high in fat, and fats are
difficult for a client with cystic fibrosis to digest;
scallops are also not commonly preferred by most
children. Clients with cystic fibrosis commonly lack
calories and protein because their bodies do not
absorb nutrients. Nutrients are not absorbed because
tenacious mucus blocks key digestive enzymes from
entering the digestive system. Thus, a diet rich in
proteins and carbohydrates is essential for these
clients. Roasted chicken and an egg omelet are high
in protein and help with growth and development.
The milk shake is high in carbohydrate and protein.
CN: Health promotion and maintenance;
CL: Apply
28. 1. Monitoring intake and output is the most
important nursing action when administering an
aminoglycoside, such as gentamicin, because a
decrease in output is an early sign of renal dam-
age. Daily weight monitoring is not indicated when
the client is receiving an aminoglycoside. Con-
stipation and bleeding are not adverse effects of
aminoglycosides.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
29. 2. Postural drainage, which aids in mobi-
lizing the thick, tenacious secretions commonly
associated with CF, is usually performed before
meals to avoid the possibility of vomiting or regur-
gitating food. Although the child with CF needs
frequent rest periods, this is not an important factor
in scheduling postural drainage. However, the nurse
would not want to interrupt the child’s rest period
to perform the treatment. Inhalation treatments
are usually given before postural drainage to help
loosen secretions.
CN: Reduction of risk potential;
CL: Apply
Billings_Part 2_Chap 2_Test 2.indd 207
The Child with Respiratory Health Problems 207
30. 4. CF affects the exocrine glands. Mucus is
thick and tenacious, sticking to the walls of the
pancreatic and bile ducts and eventually caus-
ing obstruction. Because of the difficulty with
digestion and absorption, a high-calorie, high-
protein, high-carbohydrate, moderate-fat diet is
indicated.
CN: Physiological adaptation; CL: Apply
31. 2. In children with CF, poor digestion and
absorption of foods, especially fats, results in fre-
quent bowel movements that are bulky, large,
and foul-smelling. The stools also contain
abnormally large quantities of fat, which is called
steatorrhea. An adolescent experiencing good
control of the disease would describe soft stools
with little odor. Stool described as loose with
bits of food indicates diarrhea. Stool described
as hard with streaks of blood may indicate
constipation.
CN: Physiological adaptation;
CL: Analyze
32. 2. The child’s favorite doll would be a
good choice of toys. The doll provides support
and is familiar to the child. Although a 3-year-
old may enjoy puzzles, a 100-piece jigsaw puzzle
is too complicated for an ill 3-year-old child. In
view of the child’s lung pathology, a fuzzy stuffed
animal would not be advised because of its poten-
tial as a reservoir for dust and bacteria, possibly
predisposing the child to additional respira-
tory problems. Scissors, paper, and paste are not
appropriate for a 3-year-old unless the child is
supervised closely.
CN: Health promotion and maintenance;
CL: Create
33. 1. CF is characterized by a dysfunction in
the body’s mucus-producing exocrine glands. The
mucus secretions are thick and sticky rather than
thin and slippery. The mucus obstructs the bronchi,
bronchioles, and pancreatic ducts. Mucus plugs in
the pancreatic ducts can prevent pancreatic diges-
tive enzymes from reaching the small intestine,
resulting in poor digestion and poor absorption of
various food nutrients. Fibrous cysts do not form
in various organs. Cystic fibrosis is an autosomal
recessive inherited disorder and does not involve
any reaction to the formation of antibodies against
streptococcus.
CN: Physiological adaptation;
CL: Evaluate
34. 1. After treatment, the client outcome
would be that respiratory status would be within
normal limits, as evidenced by a respiratory rate
and rhythm within expected range. Absence of
8/7/2010 9:58:53 AM
 208 The Nursing Care of Children
chills and fever, although related to an underlying
problem causing the respiratory problem (e.g., the
infection), do not specifically relate to the respira-
tory problem of ineffective airway clearance. The
child’s ability to engage in age-related activities
may provide some evidence of improved respira-
tory status. However, this outcome criterion is
more directly related to a nursing diagnosis of
Activity intolerance. Although the child’s abil-
ity to tolerate his or her usual diet may indirectly
relate to respiratory function, this outcome is more
specifically related to a nursing diagnosis of Imbal-
anced nutrition: Less than body requirements,
which may or may not be related to the child’s
respiratory status.
CN: Physiological adaptation;
CL: Evaluate
35. 1. Swimming would be the most appropri-
ate suggestion because it coordinates breathing and
movement of all muscle groups and can be done on
an individual basis or as a team sport. Because track
events, baseball, and javelin throwing usually are
performed outdoors, the child would be breathing
in large amounts of dust and dirt, which would be
irritating to her mucous membranes and pulmo-
nary system. The strenuous activity and increased
energy expenditure associated with track events, in
conjunction with the dust and possible heat, would
play a role in placing the child at risk for an upper
respiratory tract infection and compromising her
respiratory function.
CN: Health promotion and maintenance;
CL: Synthesize
The Client with Sudden Infant
Death Syndrome
36. 1, 3, 4. Exposure to environmental tobacco
increases the risk for SIDS. Sleeping on the back and
breast-feeding both decrease the risk of SIDS. The
side-lying position is not recommended for sleep. It
is recommended that babies be dressed in sleepers
and that cribs are free of blankets, pillows, bumper
pads, and stuffed animals. Co-bedding with parents
is not recommended as parents may roll on the
child.
CN: Safety and infection control;
CL: Create
37. 1. The highest incidence of SIDS occurs in
infants between ages 2 and 4 months. About 90%
of SIDS occurs before the age of 6 months. Apnea
lasting longer than 20 seconds has also been
Billings_Part 2_Chap 2_Test 2.indd 208
associated with a higher incidence of SIDS. SIDS
occurs with higher frequency in families where
a child in the family has already died of SIDS,
but the age of the parents has not been shown to
contribute to SIDS. A respiratory infection such as
pneumonia has not been shown to cause a higher
incidence of SIDS.
CN: Health promotion and maintenance;
CL: Analyze
38. 3. Because this is an especially disturbing
and upsetting time for the parents, they must be
approached in a sensitive manner. Asking what the
infant looked like when found allows the parents to
verbalize what they saw and felt, thereby helping
to minimize their feelings of guilt without implying
any blame, neglect, wrongdoing, or abuse. Asking if
the child was wrapped in a blanket or lying on his
stomach, or when the parents last checked on the
infant, implies that the parents did something wrong
or failed in their care of the infant, thus blaming
them for the event.
CN: Physiological adaptation;
CL: Analyze
39. 4. The community health nurse should visit
as soon after the death as possible, because the
parents may need help to deal with the sudden,
unexpected death of their infant. Parents often have
a great deal of guilt in these situations and need to
express their feelings to someone who can provide
counseling.
CN: Psychosocial adaptation;
CL: Synthesize
40. 1. The goal of the second home visit is to
help the parents express their feelings more openly.
Many parents are reluctant to express their grief
and need help. The goal of the first visit is to help
the parents understand the disease and what hap-
pened. The first visit also provides time to help
the parents understand that they are not to blame.
Although it is important to assess the impact of
SIDS on siblings, this is not the primary goal for the
second visit. However, the nurse must be flexible in
case problems involving this area arise. Typically,
parents are unable to deal with decisions such
as having other children during the second visit
because they are grieving for the child that they
lost. This topic may be discussed later in the course
of care.
CN: Psychosocial adaptation;
CL: Synthesize
8/7/2010 9:58:54 AM

The Client Who Requires
Immediate Care and
Cardiopulmonary Resuscitation
41.
2. Assess the airway.
1. Administer activated charcoal.
3. Reassure the mother.
6. Perform a physical exam.
5. Obtain a history of the incident.
4. Check serum acetaminophen levels.
Immediate care of the child who has ingested acet-
aminophen is to ensure airway, breathing, and circu-
lation. Next, the nurse should administer activated
charcoal. Acetylcysteine (Mucomyst) may also be
used as an antidote. When the child is stable, the
nurse should reassure the mother. Next, the nurse
should perform a physical exam to assess the child
for other health problems, and then obtain fur-
ther information about how the child obtained the
aspirin. The serum acetaminophen level should be
obtained 4 hours after ingestion.
CN: Safety and infection control;
CL: Synthesize
42. 1. When breathlessness is determined, the
priority nursing action is to clear the airway. This
action alone may reestablish spontaneous respira-
tion. If the client does not begin breathing, mouth-
to-mouth resuscitation is initiated. Oxygen therapy
would not be initiated at this time, because the child
is not breathing. Also, administering oxygen therapy
would interfere with providing mouth-to-mouth
resuscitation. Chest compressions are begun only
after the client is determined to be pulseless.
CN: Physiological adaptation;
CL: Synthesize
43. 1. Rescue breaths should be delivered slowly
at a volume that makes the chest rise and fall. For a
5-year-old child, the rate is 10 breaths per minute. If
the nurse is also administering chest compressions,
the rate is 2 breaths for every 15 compressions.
CN: Physiological adaptation; CL: Apply
44. 3. CPR is done on children for heart rate
of less 60 with signs of poor perfusion. Rescu-
ers should use a 15:2 compression to ventilation
ratio for 2-rescuer CPR for a child. Breaths without
Billings_Part 2_Chap 2_Test 2.indd 209
The Child with Respiratory Health Problems 209
compressions are indicated only for respiratory
arrests where the heart rate remains above 60. The
AED/defibrillator should be used as soon as it is
ready, but rescuers should not discontinue compres-
sions until the device is ready for use. The ratio for
2-person CPR in adults is 30:2.
CN: Physiological adaptation;
CL: Synthesize
45. 3. To maintain the best perfusion, it is
recommended that compressions be given at a rate
of 100 per minute in a 30 compression to 2 breath
ratio for one rescuer CPR. Children still are more
likely to have had a respiratory arrest than a cardiac
arrest and are more likely to respond to opening the
airway and rescue breaths. Therefore, it is recom-
mended that unless the collapse was witnessed, a
sole rescuer should attempt 5 cycles of CPR before
leaving to call for help. Using 2-3 fingers for chest
compressions is recommended for infant CPR only.
Abdominal thrusts are no longer recommended for
unconscious victims.
CN: Physiological adaptation;
CL: Evaluate
46. 3. With CPR, effectiveness of external chest
compressions is indicated by palpable peripheral
pulses, the disappearance of mottling and cyanosis,
the return of pupils to normal size, and warm, dry
skin. To determine whether the victim of cardio-
pulmonary arrest has resumed spontaneous breath-
ing and circulation, chest compressions must be
stopped for 5 seconds at the end of the first minute
and every few minutes thereafter.
CN: Physiological adaptation;
CL: Evaluate
47. 2. The nurse should use mechanical force–
back slaps and chest thrusts–in an attempt to
dislodge the object. Blind finger sweeps are not
appropriate in infants and children because the
foreign body may be pushed back into the airway.
Subdiaphragmatic abdominal thrusts are not used
for infants age 1 year or younger because of the risk
of injury to abdominal organs. If the object is not
visible when opening the mouth, time is wasted
in looking for it. Action is required to dislodge the
object as quickly as possible.
CN: Reduction of risk potential;
CL: Apply
48. 1. To deliver back slaps, the nurse should
place the infant face down, straddled over the
nurse’s arm, with the head lower than the trunk and
the head supported. This position, together with the
back slaps, facilitates dislodgment and removal of
a foreign object and minimizes aspiration if vomit-
ing occurs. Placing the infant with the head up and
raised above the trunk would not aid in dislodging
8/7/2010 9:58:54 AM
 210 The Nursing Care of Children
and removing the foreign object. In addition, this
position places the infant at risk for aspiration
should vomiting occur. Placing the head to one side
may minimize the risk of aspiration. However, it
would not help with removal of an object that is
dislodged by the back slaps. Placing the infant with
the head parallel to the nurse and supported at the
buttocks is more appropriate for burping the infant.
CN: Physiological adaptation; CL: Apply
49. 3. The nurse should first obtain an Ambu
bag and assist with CPR by giving breaths at a rate
of 2 breaths per 15 compressions. The PA is using
correct technique by using 2 to 3 fingers on the chest
to administer chest compressions; The heel of both
hands is used for older children and adolescents;
the thumbs are used for premature infants. The com-
pression to breath rate in 2- person CPR is 15 to 2.
CN: Management of care; CL: Apply
50. 2. Back slaps are delivered rapidly and force-
fully with the heel of the hand between the infant’s
shoulder blades. Slowly delivered back slaps are
less likely to dislodge the object. Using the heel of
the hand allows more force to be applied than when
using the palm or the whole hand, increasing the
likelihood of loosening the object. The fingertips
would be used to deliver chest compressions to an
infant younger than 1 year of age.
CN: Physiological adaptation; CL: Apply
51. 4. Crying indicates that the airway obstruc-
tion has been relieved. No additional thrusts are
needed. However, the child needs to be observed
closely for complications, including respiratory
distress. Tapping or shaking the shoulders is used
initially to determine unresponsiveness in some-
one who appears unconscious. Delivering chest or
back slaps could jeopardize the child’s now-patent
airway. Because the obstruction has been relieved,
there is no need to sweep the child’s mouth. Addi-
tionally, blind finger sweeps are contraindicated
because the object may be pushed further back, pos-
sibly causing a complete airway obstruction.
CN: Physiological adaptation;
CL: Synthesize
The Client with Croup
52. 4. This child is in severe respiratory distress
with the potential for complete airway obstruction.
The nurse should refrain from disturbing the child
at this time to avoid irritating the epiglottis and
causing it to completely obstruct the child’s airway.
The child may be intubated or undergo a tracheot-
omy. However, initially, the child should be kept as
calm as possible with as little disruption as possible.
Billings_Part 2_Chap 2_Test 2.indd 210
Any attempt to restrain the child, draw blood, insert
an I.V., or examine her throat could result in total
airway obstruction.
CN: Physiological adaptation;
CL: Synthesize
53. 1. The toddler is exhibiting cold symptoms.
A hoarse cough may be part of the upper respiratory
tract infection. The best suggestion is to have the
father offer the child additional fluids at frequent
intervals to help keep secretions loose and mem-
branes moist. There is no evidence presented to sug-
gest that the child needs to be brought to the clinic
immediately. Although having the father count the
child’s respiratory rate may provide some additional
information, it may lead the father to suspect that
something is seriously wrong, possibly leading to
undue anxiety. A hot air vaporizer is not recom-
mended. However, a cool mist vaporizer would
cause vasoconstriction of the respiratory passages,
making it easier for the child to breathe and loosen-
ing secretions.
CN: Physiological adaptation;
CL: Synthesize
54. 2. The nurse may be having difficulty calming
the child because the child is experiencing increas-
ing respiratory distress. The normal respiratory rate
for a 21-month-old is 25 to 30 breaths/minute. The
child’s respiratory rate is 48 breaths/minute. There-
fore the physician needs to be notified immediately.
Typically, acetaminophen is not given to a child
unless the temperature is 101° F (38.6° C) or higher.
Letting the toddler cry is inappropriate with croup
because crying increases respiratory distress. Offer-
ing fluids every few minutes to a toddler experienc-
ing increasing respiratory distress would do little, if
anything, to calm the child. Also, the child would
have difficulty coordinating breathing and swallow-
ing, possibly increasing the risk of aspiration.
CN: Physiological adaptation;
CL: Synthesize
The Client with Bronchiolitis
or Pharyngitis
55. 1, 2, 4. Viral pharyngitis is treated with
symptomatic, supportive therapy. Treatment
includes use of a cool mist vaporizer, feeding a soft
or liquid diet, and administration of acetaminophen
for comfort. Viral infections do not respond to anti-
biotic administration. The child does not need to be
on secretion precautions because viral pharyngitis is
not contagious.
CN: Psychosocial adaptation;
CL: Synthesize
8/7/2010 9:58:55 AM

56. 3. In an infant with these symptoms, the first
action by the nurse would be to obtain an oxygen
saturation reading to determine how well the infant
is oxygenating, which is valuable information for
an infant with trouble breathing. Because the father
probably can provide no other information, check-
ing the heart rate would be the second action done
by the nurse. Then the nurse would obtain the
infant’s weight.
CN: Reduction of risk potential;
CL: Synthesize
57. 3. Based on the assessment findings of
increased respiratory rate, retractions, and wheez-
ing, this infant needs further evaluation, which
could be obtained in an emergency department.
Without a definitive diagnosis, administering a
nebulizer treatment would be outside the nurse’s
scope of practice unless there was an order for such
a treatment. Sending the infant for a radiograph may
not be in the nurse’s scope of practice. The findings
need to be reported to a physician who can then
determine whether or not a chest radiograph is war-
ranted. The infant is exhibiting signs and symptoms
of respiratory distress and is too ill to send out with
just instructions on cold care for the mother.
CN: Physiological adaptation;
CL: Synthesize
58. 1, 6. An infant with bronchiolitis will have
increased respirations and will tire more quickly,
so it is best and easiest for the infant to take fluids
more often in smaller amounts. The parents also
would be instructed to watch for signs of increased
difficulty breathing, which signal possible complica-
tions. Healthy infants and even those with bronchi-
olitis should sleep in the supine position. Calling
the clinic for an episode of vomiting would not be
necessary. However, the parents would be instructed
to call if the infant cannot keep down any fluids for
a period of more than 4 hours. Parents would not
need to record how much the infant drinks. Chest
physiotherapy is not indicated because it does not
help and further irritates the infant.
CN: Basic care and comfort; CL: Create
59. 4. Handwashing is the best way to prevent
respiratory illnesses and the spread of disease. Bron-
chiolitis, a viral infection primarily affecting the
bronchioles, causes swelling and mucus accumula-
tion of the lumina and subsequent hyperinflation of
the lung with air trapping. It is transmitted primar-
ily by direct contact with respiratory secretions as
a result of eye-to-hand or nose-to-hand contact or
from contaminated fomites. Therefore, handwash-
ing minimizes the risk for transmission. Taking
the child’s temperature is not appropriate in most
cases. As long as the child is getting better, taking
the temperature will not be helpful. The mother’s
Billings_Part 2_Chap 2_Test 2.indd 211
The Child with Respiratory Health Problems 211
statement that she hopes she doesn’t get a cold from
her child does not indicate understanding of what to
do after discharge. For most parents, listening to the
child’s chest would not be helpful because the par-
ents would not know what they were listening for.
Rather, watching for an increased respiratory rate,
fever, or evidence of poor eating or drinking would
be more helpful in alerting the parent to potential
illness.
CN: Physiological adaptation;
CL: Evaluate
60. 4. The child is in respiratory distress
and is sitting in a position to relieve the airway
obstruction; the nurse should provide a humidi-
fied environment with a croup tent with cool mist
to facilitate breathing and liquefy secretions. The
child should remain sitting to facilitate breathing;
the nurse should allow the child to determine the
most comfortable position. After the child is breath-
ing normally, the nurse can offer fluids; the physi-
cian also may order intravenous fluids. The nurse
can call the rapid response team if the respiratory
distress is not relieved by using a croup tent or other
vital signs changes indicate further distress.
CN: Reduction of risk potential;
CL: Synthesize
Managing Care Quality and Safety
61. 3. RSV may be spread though both direct
and indirect contact. While contact and standard
precautions should be employed, a measure to
further decrease the risk of nosocomial infections
is to avoid assigning the same nurse caring for an
RSV client to a client at risk for infection. Children
2 years of age and younger are most at risk for RSV,
especially if they have other chronic problems such
as a heart defect. From an infection control perspec-
tive, pairing 2 clients with RSV is ideal. RSV infec-
tions are unlikely to pose a serious problem in older
children.
CN: Safety and infection control;
CL: Synthesize
62. 4. Restarting an I.V. for 1 dose of a medica-
tion may not be in the infant’s best interest when
the medication can be given in an alternate form.
The prescriber should be contacted to determine
I.M. or P.O. options. Rocephin may be given I.M.,
but changing the route of a medication administra-
tion requires an order. Failing to complete an entire
course of antibiotics contributes to the emergence
of antibiotic resistance and would rarely be the best
option.
CN: Management of care; CL: Synthesize
8/7/2010 9:58:55 AM
 212 The Nursing Care of Children
63. 2. Client safety is enhanced when the
emphasis on medication errors is to determine the
root cause. All errors should be reported so systems
can identify patterns which contribute to errors.
Here, the similar names probably contributed to the
error. The nurse who commits the error knows all
the relevant information and is in the best position
to report it. While the physician should be notified,
it is a nursing responsibility to report errors not a
physician choice. Relating mistakes to a nurse’s
position focuses on personal blame.
CN: Safety and infection control;
CL: Synthesize
Billings_Part 2_Chap 2_Test 2.indd 212
64. 3, 4. To ensure client safety in obtaining
telephone orders, the order must be received by a
registered nurse. The nurse should write the order,
read the order back to the physician, and receive
confirmation from the physician that the order is
correct. It is not necessary to ask the unit clerk to
listen to the order, to require the physician to come
to the hospital to write the order on the chart, or to
have the nursing supervisor cosign the telephone
order.
CN: Safety and infection control;
CL: Synthesize
8/7/2010 9:58:56 AM