41. A nurse is caring for a child in acute respiratory failure. Which blood gas analysis indicates the child is still in respiratory acidosis?

a. pH 7.50, CO2 48

b. pH 7.30, CO2 30

c. pH 7.32, CO2 50

d. pH 7.48, CO2 33

42. A nurse is teaching an adolescent how to use the peak expiratory flowmeter. The adolescent has understood the teaching if which statement is made?

a. “I will record the average of the readings.”

b. “I should be sitting comfortably when I perform the readings.”

c. “I will record the readings at the same time every day.”

d. “I will repeat the routine two times.”

43. A school-age child has been admitted with an acute asthma episode. The child is receiving oxygen by nasal prongs at 2 liters. How often should the nurse plan to monitor the child’s pulse oximetry status?

a. Continuous

b. Every 30 minutes

c. Every hour

d. Every 2 hours

44. A nurse is interpreting the results of a tuberculin skin test (TST) on an adolescent who is HIV positive. Which induration size indicates a positive result for this child 48–72 hours after the test?

a. 5 mm

b. 10 mm

c. 15 mm

d. 20 mm

MULTIPLE RESPONSE

1. An infant has developed staphylococcal pneumonia. Nursing care of the child with pneumonia includes which interventions? (Select all that apply.)

a. Cluster care to conserve energy

b. Round-the-clock administration of antitussive agents

c. Strict intake and output to avoid congestive heart failure

d. Administration of antibiotics

2. The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which intervention should be included in the child’s care? (Select all that apply.)

a. Place in a mist tent.

b. Administer antibiotics.

c. Administer cough syrup.

d. Encourage to drink 8 ounces of formula every 4 hours.

e. Cluster care to encourage adequate rest.

f. Place on noninvasive oxygen monitoring.

3. The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy in 2 hours. Which action should the nurse include in the child’s postoperative care plan? (Select all that apply.)

a. Notify the surgeon if the child swallows frequently.

b. Apply a heat collar to the child for pain relief.

c. Place the child on the abdomen until fully wake.

d. Allow the child to have diluted juice after the procedure.

e. Encourage the child to cough frequently.

4. A nurse is caring for a school-age child with left unilateral pneumonia and pleural effusion. A chest tube has been inserted to promote continuous closed chest drainage. Which interventions should the nurse implement when caring for this child? (Select all that apply.)

a. Positioning child on the right side

b. Assessing the chest tube and drainage device for correct settings

c. Administering prescribed doses of analgesia

d. Clamping the chest tube when child ambulates

e. Monitoring for need of supplemental oxygen

SHORT ANSWER

1. A nurse is interpreting the results of a child’s peak expiratory flow rate. Which percentage, either at this number or less than this number, is considered to be a red zone? (Record your answer in a whole number.)

ESSAY

1. The nurse enters a room and finds a 6-year-old child who is unconscious. After calling for help and before being able to use an automatic external defibrillator, which steps should the nurse take? Place in correct order. Provide answer using lowercase letters separated by commas (e.g.,  a, b, c, d, e, f).

a. Place on a hard surface.

b. Administer 30 chest compressions with two breaths.

c. Feel carotid pulse while maintaining head tilt with the other hand.

d. Use the head tilt–chin lift maneuver and check for breathing.

e. Place heel of one hand on lower half of sternum with other hand on top.

f. Give two rescue breaths.