2024/2025 N328 Exam 2 Practice Questions | Answered with Complete Solutions
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Course
N328
Institution
N328
2024/2025 N328 Exam 2 Practice Questions | Answered with Complete Solutions A nurse is obtaining an infant's vital signs. The HR is 180 bpm, and the temperature is 40C (104F). The father asks the nurse, "Why is my baby's heart beating so fast?" Which of the following is an appropriate response b...
A nurse is obtaining an infant's vital signs. The HR is 180 bpm, and the temperature is
40C (104F). The father asks the nurse, "Why is my baby's heart beating so fast?" Which
of the following is an appropriate response by the nurse?
A. "This is within the expected range for your baby."
B. "The fever is causing an increase in your baby's heart rate."
C. "As your baby begins to fall asleep, the heart rate will decrease."
D. "Your baby's heart is beating fast in an attempt to cool down the body."
Rationale: The expected range for the temperature of an infant from birth to 1 year is
36.5° C (97.7° F) to 37.2° C (98.9° F). This infant has a fever. The infant's heart rate will
increase as a result of the fever. The expected range for heart rate in an infant 3 months
to 2 years old is 80-150/min while awake and 70-120/min while asleep. If the infant is
active or has a fever, the heart rate may be as high as 220/min.
A nurse is caring for a child who is diagnosed with otitis media. Which of the following
assessment findings should the nurse expect?
A. Tugging on the affected ear lobe
B. Clear drainage from the affected ear
C. Pain when manipulating the affected ear lobe
D. Erythema and edema of the affected ear
Rationale: Otitis media is a middle ear infection. Expected findings include fever,
purulent drainage (only if the tympanic membrane is ruptured), and pain, demonstrated
by the child tugging at the ear. Pain when manipulating the ear lobe is the classic sign
of otitis externa, swimmer's ear. Swimmer's ear is also associated with erythema and
edema of the affected ear. Clear drainage from the ear is more commonly associated
with CSF drainage.
A nurse is preparing to begin chest compressions for an infant. The nurse should
perform compressions using which of the following techniques?
A. Deliver compressions at 1/3 to 1/2 the depth of the chest.
B. Deliver compressions with the heel of one hand only.
C. Deliver compressions just above the nipple line.
D. Deliver compressions at a depth of 1 1/2 to 2 inches.
A nurse is monitoring a child who has just had a tonsillectomy for signs of hemorrhage.
Which of the following findings is a sign of this postoperative complication?
,A. Mouth breathing
B. Frequent swallowing
C. Reports of thirst
D. Reports of pain
A nurse is caring for a child who is experiencing an acute asthma attack. Which of the
following medications should the nurse administer first?
A. Fluticasone (Flovent)
B. Budesonide (Pulmicort)
C. Montelukast (Singulair)
D. Albuterol (Proventil)
A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the
following medications should reduce the symptoms?
A. Cromolyn (Intal) via metered-dose inhaler
B. Oral montelukast (Singular)
C. Budesonide (Pulmicort) via dry-powder inhaler
D. Albuterol (Proventil) via jet nebulizer
A nurse is assessing a client who has asthma and signs of central cyanosis. Which of
the following is a reliable indicator of cyanosis?
A. Oral mucosa
B. Finger tips
C. Ear lobes
D. Eye lids
Rationale: The nurse should assess the oral mucosa as an indicator of cyanosis
because changes can be seen easily in areas with less pigmentation.
A nurse is caring for a child with a suspected diagnosis of cystic fibrosis. Which of the
following diagnostic tests will the nurse prepare the child for to confirm the diagnosis?
A. Sweat chloride test
B. A sputum culture
C. A stool fat content analysis
D. Pulmonary function test
Rationale: Clients with cystic fibrosis have an increase of sodium and chloride in both
saliva and sweat. Therefore, a sweat chloride test is a definitive diagnostic test to
determine the diagnosis of cystic fibrosis.
A nurse is caring for a child who has cystic fibrosis (CF) and is being discharged after
initial diagnosis and treatment. The nurse should recognize that the parent understands
,the child's nutritional needs when she states which of the following?
A. "I will make certain that pancreatic enzymes are taken with all of my child's snacks
and meals."
B. "I will restrict the amount of salt in my child's food."
C. "I will limit my child's fluid intake."
D. "I will prepare low-fat meals for my child."
Rationale: CF interferes with the availability of pancreatic enzymes necessary for
normal digestion and absorption of nutrients. Therefore, pancreatic enzymes must be
taken with all meals and snacks.
A nurse is preparing a 4 year old client for discharge following a bilateral myringotomy
with tympanostomy tube placement. The mother asks what to do if the tubes fall out.
The nurse should give the parent which of the following instructions?
A. Gently reinsert the tubes.
B. Take the child to the emergency department.
C. Call the health care clinic to report that the tubes have fallen out.
D. Reassure the mother that the tubes will not fall out.
A nurse is teaching the mother of a 5 year old child with CF about pancreatic enzymes.
The nurse understands that further teaching is needed when the mother states which of
the following?
A. "I will give my son the enzymes between meals."
B. "The enzymes probably won't cause a lot of side effects."
C. "The enzymes help him digest fat."
D. "I will put the enzyme crystals in his applesauce."
A nurse is reinforcing discharge teaching with the parents of a preterm infant who has a
prescription for home oxygen and pulse oximetry monitoring. Which of the following
statements by the parents indicates a need for further teaching?
A. "We will rotate the probe of the pulse oximeter every 24 hours."
B. "The probe of the pulse oximeter can be applied to a finger or a toe."
C. "The pulse oximeter may not be accurate during times of excessive movement."
D. "We will notify the doctor if the pulse oximeter consistently reads 100%."
Rationale: Pulse oximeters are a noninvasive method of monitoring oxygen saturation
(SaO2) of the blood. It is obtained by the application of a probe around the hand, foot,
finger, toes, or earlobe, which is then connected to a machine that provides continuous
oxygen saturation levels. The probe should be rotated every 3 to 4 hr to prevent
pressure necrosis from occurring. Excessive movement, as well as heat and light, can
interfere with the results. Due to the risk of oxygen toxicity, which is a particular concern
with preterm infants, the parents should be instructed to notify the provider for
, consistent SaO2 readings over 95%. This may be an indication the infant is receiving
too much oxygen and the amount should be decreased.
A nurse is caring for a toddler admitted with laryngotracheobronchitis who is placed in a
cool mist tent. As a result of this treatment, the nurse expects to observe...
A. barking cough.
B. improved hydration.
C. decreased stridor.
D. decrease in fever.
Rationale: Laryngotracheobronchitis, or croup, is a condition of breathing difficulty
common in infants caused by infection of the upper airway (larynx, trachea, and
bronchus) and characterized by a barking cough. Edema and obstruction in the upper
airways cause the characteristic cough and stridor (noisy breathing). The child's
breathing becomes more difficult and requires increasing physical effort. The direct
purpose of a cool mist tent is to humidify the inspired air, which will decrease the
respiratory effort.
A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy,
the nurse determines that the procedure was effective with which of the following
assessment findings?
A. Increased respiratory rate
B. Stable oxygen saturation
C. Clear breath sounds
D. Brisk capillary refill
A nurse is admitting a 9 year old child who has acute rheumatic fever. When obtaining
the client's history, it is appropriate for the nurse to ask the parent which of the following
questions?
A. "Has your son had a sore throat recently?"
B. "Was your son born with this cardiac defect?"
C. "Has your child had any injuries recently?"
D. "Are you aware that your son will have to be in isolation?"
Rationale: Rheumatic fever typically develops 2 to 6 weeks after an untreated or
ineffectively treated streptococcal infection of the respiratory tract. It is appropriate to
determine whether or not the child previously has a sore throat.
A nurse is planning care for a child with suspected epiglottitis. Which of the following is
an appropriate action for the nurse to take?
A. Obtain a throat culture.
B. Place client in an upright position.
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