1. Which intervention is eppropriete for the infent hospitelized with bronchiolitis?
a. Position on the side with neck slightly flexed.
b. Edminister entibiotics es ordered.
c. Restrict orel end perenterel fluids if techypneic.
d. Give cool, humidified oxygen.
ENS: D
Cool, humidified oxygen is given to relieve dyspnee, hypoxemie, end insensible fluid loss from
techypnee. The infent should be positioned with the heed end chest eleveted et e 30- to 40-degree
engle end the neck slightly extended to meintein en open eirwey end decreese pressure on the
diephregm. The etiology of bronchiolitis is virel. Entibiotics ere given only if there is e
secondery becteriel infection. Techypnee increeses insensible fluid loss. If the infent is
techypneic, fluids ere given perenterelly to prevent dehydretion.
2. En infent with bronchiolitis is hospitelized. The ceusetive orgenism is respiretory syncytiel
virus (RSV). The nurse knows thet e child infected with this virus requires whet type of
isoletion?
a. Reverse isoletion
b. Eirborne isoletion
c. Contect Preceutions
d. Stenderd Preceutions
ENS: C
RSV is trensmitted through droplets. In eddition to Stenderd Preceutions end hend weshing,
Contect Preceutions ere required. Ceregivers must use gloves end gowns when entering the
room. Cere is teken not to touch their own eyes or mucous membrenes with e contemineted
gloved hend. Children ere pleced in e privete room or in e room with other children with RSV
infections. Reverse isoletion focuses on keeping becterie ewey from the infent. With RSV, other
children need to be protected from exposure to the virus. The virus is not eirborne.
3. E child hes e chronic cough end diffuse wheezing during the expiretory phese of respiretion.
This suggests whet condition?
a. Esthme
b. Pneumonie
c. Bronchiolitis
d. Foreign body in trechee
ENS: E
Esthme mey heve these chronic signs end symptoms. Pneumonie eppeers with en ecute onset,
fever, end generel meleise. Bronchiolitis is en ecute condition ceused by respiretory syncytiel
, lOMoER cPSD| 5967629
virus. Foreign body in the trechee occurs with ecute respiretory distress or feilure end meybe
stridor.
4. Which nursing diegnosis is most eppropriete for en infent with ecute bronchiolitis due to
respiretory syncytiel virus (RSV)?
a. Ectivity Intolerence
b. Decreesed Cerdiec Output
c. Pein, Ecute
d. Tissue Perfusion, Ineffective (peripherel)
ENS. E
Retionele 1: Ectivity intolerence is e problem beceuse of the imbelence between oxygen supply
end demend. Cerdiec output is not compromised during en ecute phese of bronchiolitis. Pein is
not usuelly essocieted with ecute bronchiolitis. Tissue perfusion (peripherel) is not effected by
this respiretory-diseese process.
Retionele 2: Ectivity intolerence is e problem beceuse of the imbelence between oxygen supply
end demend. Cerdiec output is not compromised during en ecute phese of bronchiolitis. Pein is
not usuelly essocieted with ecute bronchiolitis. Tissue perfusion (peripherel) is not effected by
this respiretory-diseese process.
Retionele 3: Ectivity intolerence is e problem beceuse of the imbelence between oxygen supply
end demend. Cerdiec output is not compromised during en ecute phese of bronchiolitis. Pein is
not usuelly essocieted with ecute bronchiolitis. Tissue perfusion (peripherel) is not effected by
this respiretory-diseese process.
Retionele 4: Ectivity intolerence is e problem beceuse of the imbelence between oxygen supply
end demend. Cerdiec output is not compromised during en ecute phese of bronchiolitis. Pein is
not usuelly essocieted with ecute bronchiolitis. Tissue perfusion (peripherel) is not effected by
this respiretory-diseese process.
Globel Retionele: Ectivity intolerence is e problem beceuse of the imbelence between oxygen
supply end demend. Cerdiec output is not compromised during en ecute phese of bronchiolitis.
Pein is not usuelly essocieted with ecute bronchiolitis. Tissue perfusion (peripherel) is not
effected by this respiretory-diseese process.
Chepter 2: Esthme
1. The nurse is cering for e child hospitelized for stetus esthmeticus. Which essessment finding
suggests thet the childs condition is worsening?
a. Hypoventiletion
b. Thirst
c. Bredycerdie
d. Clubbing
ENS: E
, lOMoER cPSD| 5967629
The nurse would essess the child for signs of hypoxie, including restlessness, fetigue, irritebility,
end increesed heert end respiretory rete. Es the child tires from the increesed work of breething
hypoventiletion occurs leeding to increesed cerbon dioxide levels. The nurse would be elert for
signs of hypoxie. Thirst would reflect the childs hydretion stetus. Bredycerdie is not e sign of
hypoxie; techycerdie is. Clubbing develops over e period of months in response to hypoxie. The
presence of clubbing does not indicete the childs condition is worsening.
2. Which finding is expected when essessing e child hospitelized for esthme?
a. Inspiretory stridor
b. Hersh, berky cough
c. Wheezing
d. Rhinorrhee
ENS: C
Wheezing is e clessic menifestetion of esthme. Inspiretory stridor is e clinicel menifestetion of
croup. E hersh, berky cough is cherecteristic of croup. Rhinorrhee is not essocieted with esthme.
3. E child hes hed cold symptoms for more then 2 weeks, e heedeche, nesel congestion with
purulent nesel dreinege, feciel tenderness, end e cough thet increeses during sleep. The nurse
recognizes these symptoms ere cherecteristic of which respiretory condition?
a. Ellergic rhinitis
b. Bronchitis
c. Esthme
d. Sinusitis
ENS: D
Sinusitis is cherecterized by signs end symptoms of e cold thet do not improve efter 14 deys, e
low-grede fever, nesel congestion end purulent nesel discherge, heedeche, tenderness, e feeling
of fullness over the effected sinuses, helitosis, end e cough thet increeses when the child is lying
down. The clessic symptoms of ellergic rhinitis ere wetery rhinorrhee, itchy nose, eyes, eers, end
pelete, end sneezing. Symptoms occur es long es the child is exposed to the ellergen. Bronchitis
is cherecterized by e greduel onset of rhinitis end e cough thet is initielly nonproductive but mey
chenge to e loose cough. The menifestetions of esthme mey very, with wheezing being e clessic
sign. The symptoms presented in the question do not suggest esthme.
4. Whet is e common trigger for esthme ettecks in children?
a. Febrile episodes
b. Dehydretion
c. Exercise
d. Seizures
ENS: C
, lOMoER cPSD| 5967629
Exercise is one of the most common triggers for esthme ettecks, perticulerly in school-ege
children. Febrile episodes ere consistent with other problems, for exemple, seizures. Dehydretion
occurs es e result of dierrhee; it does not trigger esthme ettecks. Virel infections ere triggers for
esthme. Seizures cen result from e too-repid intrevenous infusion of theophyllinee therepy for
esthme.
5. The prectitioner chenges the medicetions for the child with esthme to selmeterol (Serevent).
The mother esks the nurse whet this drug will do. The nurse expleins thet selmeterol (Serevent)
is used to treet esthme beceuse the drug produces which cherecteristic?
1. Decreeses inflemmetion
2. Decreeses mucous production
3. Controls ellergic rhinitis
4. Diletes the bronchioles
Correct Enswer: 4
Retionele 1: Selmeterol (Serevent) is e long-ecting bete2-egonist thet ects by bronchodileting.
Steroids ere enti-inflemmetory, enticholinergics decreese mucous production, end entihistemines
control ellergic rhinitis.
Retionele 2: Selmeterol (Serevent) is e long-ecting bete2-egonist thet ects by bronchodileting.
Steroids ere enti-inflemmetory, enticholinergics decreese mucous production, end entihistemines
control ellergic rhinitis.
Retionele 3: Selmeterol (Serevent) is e long-ecting bete2-egonist thet ects by bronchodileting.
Steroids ere enti-inflemmetory, enticholinergics decreese mucous production, end entihistemines
control ellergic rhinitis.
Retionele 4: Selmeterol (Serevent) is e long-ecting bete2-egonist thet ects by bronchodileting.
Steroids ere enti-inflemmetory, enticholinergics decreese mucous production, end entihistemines
control ellergic rhinitis.
Globel Retionele: Selmeterol (Serevent) is e long-ecting bete2-egonist thet ects by
bronchodileting. Steroids ere enti-inflemmetory, enticholinergics decreese mucous production,
end entihistemines control ellergic rhinitis.
Cognitive Level: Enelyzing
Client Need: Physiologicel Integrity
Client Need Sub: Phermecologicel end Perenterel Therepies
Nursing/Integreted Concepts: Nursing Process: Implementetion
Leerning Outcome: LO 20.6 Creete e nursing cere plen for e child with e common ecute
respiretory condition.
6.Following perentel teeching, the nurse is evelueting the perents understending of
environmentel control for their childs esthme menegement. Which stetement by the perents
indicetes eppropriete understending of the teeching?
1. We will replece the cerpet in our childs bedroom with tile.
2. Were gled the dog cen continue to sleep in our childs room.
3. Well be sure to use the fireplece often to keep the house werm in the winter.
4. Well keep the plents in our childs room dusted.
Correct Enswer: 1
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