1.
A client diagnosed with bronchitis asks the nurse about the function of the bronchi. Which should the nurse include in the response?
Correct Answer
D. Warm and moisten air as it moves through the respiratory tract to the alveoli
Explanation
The bronchi are responsible for warming and moistening the air as it moves through the respiratory tract to the alveoli. This is important because the respiratory system needs warm and moist air to function properly. The warm and moist air helps to prevent irritation and damage to the delicate tissues of the respiratory tract and alveoli. Additionally, the moisture in the air helps to keep the respiratory tract hydrated and prevents it from drying out. Therefore, this is the correct answer.
2.
The nurse is assessing an 8-year-old client. Which anatomical difference should the nurse expect to find compared to an adult?
Correct Answer(s)
A. Small mouth with large tongue
C. Smaller nasopHarynx
D. Soft tracheal cartilage
Explanation
In comparison to an adult, an 8-year-old client is expected to have a smaller mouth with a larger tongue, a smaller nasopharynx, and soft tracheal cartilage. These anatomical differences are characteristic of a child's physical development at this age. The atrophy of the tonsils and the lower positioning of the larynx and glottis in the neck are not expected anatomical differences in an 8-year-old client.
3.
Which method is correct for measuring a client's respiratory rate?
Correct Answer
B. Measure the respiratory rate for 1 minute.
Explanation
The correct method for measuring a client's respiratory rate is to measure it for 1 minute. This allows for a more accurate and comprehensive assessment of the client's breathing pattern and rate. Measuring for a shorter duration and then multiplying by a factor may not capture any fluctuations or abnormalities in the respiratory rate that could be important for diagnosis or monitoring.
4.
The nurse assessing a newborn suspect's respiratory distress. Which finding supports the suspicion?
Correct Answer
A. Intercostal retractions
Explanation
Intercostal retractions are inward movements of the muscles between the ribs during breathing, indicating increased effort to breathe. This finding suggests respiratory distress in a newborn. Abdominal breathing, respiratory rate of 44, and acrocyanosis at birth are not specific to respiratory distress and can have other causes.
5.
Which clinical manifestation should the nurse expect to observe in the client with asthma?
Correct Answer(s)
A. Retractions
B. Dyspnea
C. Wheezing
E. Cough
Explanation
The nurse should expect to observe retractions, dyspnea, wheezing, and cough in a client with asthma. Retractions refer to the visible sinking of the skin between the ribs and in the neck area during breathing, indicating increased effort to breathe. Dyspnea is difficulty in breathing, a common symptom of asthma due to narrowed airways. Wheezing is a characteristic high-pitched whistling sound that occurs during breathing, caused by the narrowing of the airways. Coughing is also a common symptom of asthma, as the airways become irritated and inflamed. Bradycardia, a slow heart rate, is not typically associated with asthma.
6.
The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make?
Correct Answer
C. "Antibiotics are not indicated unless a bacterial infection is present."
Explanation
The nurse should respond, "Antibiotics are not indicated unless a bacterial infection is present." This is the correct answer because viral laryngotracheobronchitis, also known as croup, is caused by a viral infection and antibiotics are ineffective against viruses. Antibiotics are only prescribed when there is a bacterial infection present. It is important to educate the mother about the appropriate use of antibiotics to prevent the development of antibiotic resistance.
7.
The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the MOST APPROPRIATE nursing action?
Correct Answer
B. Move the infant to a room with another child with RSV.
8.
Which intervention is appropriate for the infant hospitalized with bronchiolitis?
Correct Answer
D. Give cool, humidified oxygen.
Explanation
Cool, humidified oxygen is given to relieve dyspnea, hypoxemia, and insensible
fluid loss from tachypnea.
9.
A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory
phase of respiration. This suggests
Correct Answer
A. Asthma
Explanation
Children with asthma usually have these chronic symptoms
10.
A school-age child had an upper respiratory tract infection for several days and then began
having a persistent dry, hacking cough that was worse at night. The cough has become
productive in the past 24 hours. This is most suggestive of
Correct Answer
A. Bronchitis
Explanation
A Bronchitis is characterized by these symptoms and occurs in children older than 6 years.
11.
Which should the nurse administer to provide quick relief to a child with asthma who is coughing, wheezing, and having difficulty catching her breath?
Correct Answer
C. Albuterol.
Explanation
Albuterol is the correct answer because it is a quick-acting bronchodilator that helps to relax the muscles in the airways, allowing them to open up and improve airflow. This can provide immediate relief to a child with asthma who is experiencing symptoms such as coughing, wheezing, and difficulty breathing. Prednisone, Singulair, and Flovent are all medications used for asthma management, but they are not as fast-acting as albuterol and would not provide quick relief in this situation.
12.
An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial virus (RSV). The nurse knows that a child infected with this virus requires the following isolation:
Correct Answer
C. Contact Precautions.
Explanation
RSV is transmitted through droplets. In addition to Standard Precautions and hand washing, Contact Precautions are required. Caregivers must use gloves and gowns when entering the room. Care is taken not to touch their own eyes or mucous membranes with a contaminated gloved hand. Children are placed in a private room or in a room with other children with RSV infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other children need to be protected from exposure to the virus. The virus is not airborne.
13.
An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is:
Correct Answer
B. Ineffective breathing pattern related to airway inflammation and increased secretions.
Explanation
An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection.
14.
The nurse auscultating breath sounds of an infant with respiratory syncytial virus would immediately report the assessment of:
Correct Answer
C. "quiet chest" from previous assessment of wheezing.
Explanation
A "quiet chest" after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest. All other options are within normal range for infants undergoing oxygen administration.
15.
The mother of an infant diagnosed with bronchiolitis asks the nurse what causes this disease. The nurse's response would be based on the knowledge that the majority of infections that cause bronchiolitis are a result of_______
Correct Answer
RSV
Explanation
Respiratory syncytial virus
16.
The nurse is caring for a 4-month-old patient diagnosed with a mild case of bronchiolitis.
Which action should the nurse take to help the patient at this time?
Correct Answer
D. Suction the nose frequently, especially before feeding.
Explanation
To help a 4-month-old patient with bronchiolitis, the nurse should suction the nose frequently, especially before feeding. This action is important because bronchiolitis often causes nasal congestion, which can make it difficult for the baby to breathe and feed properly. Suctioning the nose helps to clear the airway and improve breathing, allowing the baby to feed more comfortably. It is important to suction before feeding to ensure that the baby can breathe and eat without difficulty. Using an inhaled bronchodilator, administering antibiotics, or administering palivizumab are not appropriate actions for a mild case of bronchiolitis.
17.
The nurse is teaching the parents of a child with bronchiolitis about the care needed at home.
Which statement by the parents indicates instructions have been effective?
Correct Answer
D. "It is important to give our child extra fluids."
Explanation
The correct answer indicates that the parents understand the importance of giving their child extra fluids. This is important because bronchiolitis can cause dehydration due to increased respiratory effort and fever. Providing extra fluids helps prevent dehydration and keeps the child hydrated, which is crucial for their recovery. The other statements do not demonstrate a clear understanding of the care needed for bronchiolitis.
18.
A child with respiratory syncytial virus (RSV) is admitted to a care area.
Which action by the nurse will prevent the spread of infection?
Correct Answer
A. Prohibit contact with patients who do not have RSV.
Explanation
Prohibiting contact with patients who do not have RSV will prevent the spread of infection because RSV is highly contagious and can easily spread from person to person. By keeping the child with RSV away from patients who do not have the virus, the nurse can minimize the risk of transmission to others. This action helps to protect both the child with RSV and other patients from contracting the infection.
19.
_________is a common respiratory virus that usually causes mild, cold-like symptoms.
Correct Answer
rsv
Explanation
RSV, also known as Respiratory Syncytial Virus, is a common respiratory virus that typically leads to mild symptoms similar to a cold. It is a prevalent virus that affects people of all ages, but it is particularly dangerous for infants, older adults, and individuals with weakened immune systems. RSV can cause symptoms such as cough, runny nose, sneezing, fever, and wheezing. While most cases of RSV resolve on their own with proper care and rest, severe cases may require medical intervention. It is important to take precautions to prevent the spread of RSV, especially among vulnerable populations.
20.
The nurse instructs the parents of a patient with a respiratory syncytial virus (RSV) to monitor oral intake and count diapers. The parents ask why this is important.
Which response by the nurse is accurate?
Correct Answer
B. "This will help to identify if your child is becoming dehydrated."
Explanation
Monitoring oral intake and counting diapers is important in a patient with respiratory syncytial virus (RSV) because it helps to identify if the child is becoming dehydrated. RSV can cause increased respiratory secretions and difficulty in feeding, which can lead to dehydration. By monitoring the child's oral intake and counting diapers, the parents can keep track of the child's fluid intake and output. Any significant decrease in oral intake or decrease in the number of wet diapers can indicate dehydration, which needs to be addressed promptly to prevent complications.
21.
The parent of a 2-year-old patient with bronchiolitis caused by a respiratory syncytial virus (RSV) asks the nurse why the child has been coughing so much.
Which response by the nurse is accurate?
Correct Answer
D. "The virus causes dead cells in the lining of the lungs and large amounts of mucus that stimulate the cough reflex."
Explanation
With bronchiolitis caused by RSV, the virus attacks the epithelial cells of the upper and lower respiratory tract. The destruction of epithelial cells leads to the production of debris and mucus, which stimulates coughing. Bronchiolitis caused by RSV does not cause body fluid shifts. RSV is a virus, not a bacterial infection. Coughing with bronchiolitis caused by RSV is not caused by irritation of the bronchial tubes or an attempt to remove white blood cells from the lungs.
22.
The nurse is providing discharge instruction to the parents of a 7-month-old patient admitted with bronchiolitis. The nurse explains the process of observing breathing patterns as a way to determine respiratory distress.
Which statement by the parent displays an understanding of this intervention?
Correct Answer
D. "If I can see the rib cage retract, I should seek medical attention."
Explanation
The correct answer is "If I can see the rib cage retract, I should seek medical attention." This statement displays an understanding of the intervention because it correctly identifies a visual sign of respiratory distress. Retraction of the rib cage indicates that the child is working harder to breathe, which is a sign of respiratory distress and requires medical attention. This statement shows that the parent understands the importance of observing breathing patterns and recognizing signs of respiratory distress in their child.
23.
An 11-month-old patient is admitted to the intensive care unit for treatment of severe bronchiolitis and concurrent pneumonia. Which medication should the nurse anticipate will most likely be prescribed for this patient?
Correct Answer
C. Antibiotic
Explanation
The nurse should anticipate that an antibiotic will most likely be prescribed for this patient because the patient has severe bronchiolitis and concurrent pneumonia. Antibiotics are commonly prescribed to treat bacterial infections, and pneumonia is often caused by bacteria. Bronchiolitis, on the other hand, is usually caused by a viral infection, but the presence of concurrent pneumonia increases the likelihood of a bacterial infection. Therefore, an antibiotic would be the most appropriate medication to address both conditions. Epinephrine and bronchodilators are typically used to treat bronchospasms and are not the first-line treatment for pneumonia. Corticosteroids may be used in some cases, but antibiotics are the primary treatment for bacterial infections.
24.
The parents of a child diagnosed with bronchiolitis ask the nurse how the disorder is treated.
Which response by the nurse is appropriate?
Correct Answer
D. "The focus is on managing symptoms and providing supportive care."
25.
The nurse is discussing the pharmacologic treatment of infant patients with bronchiolitis.
Which medication would the nurse identify as having tachycardia and generalized tremors as a side effect?
Correct Answer
D. Bronchodilators
Explanation
Bronchodilators are medications that help to relax and widen the airways in the lungs, making it easier to breathe. One of the side effects of bronchodilators is tachycardia, which refers to an increased heart rate. This means that the heart beats faster than normal. Additionally, bronchodilators can also cause generalized tremors, which are involuntary shaking or trembling of the body. Therefore, the nurse would identify bronchodilators as the medication that can cause tachycardia and generalized tremors as a side effect.
26.
A 6-year-old patient is diagnosed with bronchiolitis. Which assessment should the nurse prioritize for this patient?
Correct Answer
C. Observe for labored respirations.
Explanation
The nurse should prioritize observing for labored respirations in a 6-year-old patient diagnosed with bronchiolitis. Labored respirations are a common symptom of bronchiolitis, which is characterized by inflammation and congestion of the bronchioles. Labored respirations can indicate increased respiratory effort and potential respiratory distress in the patient. Monitoring for signs of obstruction, lengthening of paroxysms, and assessing for seizures are also important assessments, but observing for labored respirations takes priority in this case.
27.
An infant patient with respiratory syncytial virus (RSV) is ordered delivery of nutrition via an intravenous (IV) line. The infant's parent asks why IV nutrition is being ordered.
Which response by the nurse is correct?
Correct Answer
B. Rapid breathing indicates the need for IV nutrition."
Explanation
Rapid breathing indicates the need for IV nutrition because it suggests that the infant is having difficulty breathing and may not be able to tolerate oral feedings. IV nutrition ensures that the infant receives the necessary nutrients and fluids to support their growth and development while their respiratory symptoms are being managed.
28.
The nurse is speaking to the parents of a patient with bronchiolitis caused by respiratory syncytial virus (RSV).
Which respiratory structure should the nurse identify as being obstructed?
Correct Answer
B. Small airways
Explanation
The nurse should identify the small airways as being obstructed in a patient with bronchiolitis caused by respiratory syncytial virus (RSV). Bronchiolitis is an inflammation of the small airways in the lungs, specifically the bronchioles. RSV infects the lining of the bronchioles, causing them to become swollen and filled with mucus, leading to obstruction and difficulty in breathing. Therefore, it is important for the nurse to recognize that the small airways are affected in this condition.
29.
______________ highly contagious respiratory infection. Affects almost all children before age 2
Correct Answer
rsv
Explanation
RSV stands for Respiratory Syncytial Virus, which is a highly contagious respiratory infection. It is known to affect almost all children before the age of 2. RSV is a common cause of respiratory tract infections and can lead to symptoms such as coughing, sneezing, congestion, and difficulty breathing. It is spread through respiratory droplets and can be particularly severe in infants and young children, as well as in older adults and individuals with weakened immune systems. Taking preventive measures such as practicing good hygiene, avoiding close contact with sick individuals, and getting vaccinated can help reduce the spread of RSV.
30.
______________________ lower respiratory tract illness causing inflammation and obstruction of bronchioles.
Correct Answer
Bronchiolitis
Explanation
Bronchiolitis is a lower respiratory tract illness that causes inflammation and obstruction of the bronchioles. This condition commonly affects infants and young children, causing symptoms such as coughing, wheezing, and difficulty breathing. It is usually caused by a viral infection, most commonly respiratory syncytial virus (RSV). Bronchiolitis can be a serious condition, especially in infants with underlying health issues or weakened immune systems. Treatment typically involves supportive care, such as ensuring hydration, providing oxygen therapy, and using medications to alleviate symptoms.
31.
_________________ a complete or partial collapse of the entire lung or area.
Correct Answer
Atelectasis
Explanation
Atelectasis refers to a complete or partial collapse of the entire lung or a specific area. This condition occurs when the tiny air sacs in the lungs, called alveoli, deflate and prevent the lung from fully expanding. Atelectasis can be caused by various factors, such as blockage of the airways, lung infections, or pressure on the lungs. It can lead to symptoms like shortness of breath, coughing, and chest pain. Treatment for atelectasis involves addressing the underlying cause and may include measures to re-inflate the collapsed lung, such as deep breathing exercises or using a device called a spirometer.
32.
RSV Results debris clogs minute airways.
Correct Answer
A. True
Explanation
The statement is suggesting that the RSV (Respiratory Syncytial Virus) results in debris that clogs the minute airways. This means that when a person is infected with RSV, it can cause blockages in the small air passages of the lungs, making it difficult for air to flow properly. This can lead to respiratory issues and breathing difficulties. Therefore, the given answer "True" is correct as it aligns with the statement provided.
33.
RSV causes _________ sound's in airways.
Correct Answer
A. Crackles
Explanation
RSV causes crackles in airways. Crackles are abnormal lung sounds that are often described as a popping or crackling noise. They are caused by the movement of air through fluid or mucus in the airways. RSV, or respiratory syncytial virus, is a common viral infection that primarily affects the respiratory system, particularly in young children. It can cause inflammation and increased mucus production in the airways, leading to the presence of crackles during breathing.
34.
Number one goal for rsv is to ___________ it.
Correct Answer
prevent
Explanation
Frequent hand cleansing with soap and water Avoid sharing food, cups, utensils with infected individuals
35.
Palivizumab
Correct Answer(s)
A. Infants at high risk for serious RSV infections
B. Not effective in treatment of acute RSV infection
C. Not recommended for use in general prevention of healthcare-associated
RSV infection
Explanation
Palivizumab is a medication that is effective in preventing serious respiratory syncytial virus (RSV) infections in infants who are at high risk. However, it is not effective in treating an acute RSV infection once it has already occurred. Additionally, it is not recommended for use in the general prevention of healthcare-associated RSV infections or for well-immunized children.
36.
RSV can survive on hard surfaces for how long?
Correct Answer
A. Several hours
Explanation
RSV, or respiratory syncytial virus, can survive on hard surfaces for several hours. This means that the virus can remain active and potentially infectious for a significant amount of time after being deposited on a surface. It is important to regularly clean and disinfect commonly touched surfaces to reduce the risk of transmission.
37.
More than 20 seconds without breath is called _________
Correct Answer
apnea
Explanation
Apnea is the correct answer because it refers to the condition of not breathing for more than 20 seconds. It is a medical term used to describe a temporary cessation of breathing, often caused by an obstruction or a neurological disorder. During an apnea episode, the person may experience a lack of oxygen, leading to symptoms such as gasping or snoring upon resuming breathing. Therefore, apnea accurately describes the condition mentioned in the question.
38.
Serious signs, symptoms of RSV
Correct Answer(s)
A. Increased irritability
C. Excessive coughing
D. Wheezing
Explanation
The given signs and symptoms of RSV include increased irritability, excessive coughing, and wheezing. Increased irritability can be a result of the discomfort caused by the infection. Excessive coughing is a common symptom of respiratory infections, including RSV. Wheezing is a high-pitched whistling sound that occurs when air flows through narrowed airways, which can be a sign of RSV-induced inflammation and mucus buildup in the respiratory tract. These symptoms collectively suggest the presence of RSV infection.
39.
Call emergency medical services (EMS) for transport for these symptoms
Correct Answer(s)
A. Marked retractions of ribcage
B. Nasal flaring
C. Rapid respiratory rate
D. Blue skin
Explanation
These symptoms indicate severe respiratory distress, which requires immediate medical attention. Marked retractions of the ribcage and nasal flaring are signs of increased effort to breathe. Rapid respiratory rate suggests that the person is breathing faster than normal. Blue skin indicates a lack of oxygen in the body, known as cyanosis. A low-grade fever may also be present. These symptoms together indicate a serious respiratory problem that requires urgent medical intervention, hence calling emergency medical services (EMS) for transport is necessary.
40.
Infants with bronchopulmonary dysplasia are commonly treated with bronchodilators such as theophylline. Which of the following adverse effects is common with this drug?
Correct Answer
C. Increased heart rate
Explanation
Theophylline is a bronchodilator commonly used to treat infants with bronchopulmonary dysplasia. One of the common adverse effects of this drug is an increased heart rate. This is because theophylline acts as a stimulant to the heart, causing it to beat faster. Other adverse effects of theophylline may include restlessness, tremors, and nausea. However, in the context of the given options, increased heart rate is the most commonly associated adverse effect with the use of theophylline in infants with bronchopulmonary dysplasia.
41.
An infant with a congenital heart defect is receiving palivizumab (Synagis). The purpose of this is to:
Correct Answer
A. Prevent RSV infection.
Explanation
A. prevent RSV infection.
Synagis is a monoclonal antibody specific for RSV. Monthly administration is initiated to prevent infection with RSV.
42.
A child with asthma is having pulmonary function tests. Which explains the purpose of the forced expiratory volume (FEV1)?
Correct Answer
D. Assess the severity of asthma
Explanation
Assess the severity of asthma
The forced expiratory volume measures the maximum amount of air that can be forcefully exhaled in the first second. This can provide an objective measure of pulmonary function compared with the child's baseline.
43.
A 4-year-old child needs to use a metered-dose inhaler to treat asthma. The child cannot coordinate her breathing to use it effectively. The appropriate intervention by the nurse is to use a:
Correct Answer
A. Spacer.
Explanation
spacer.
The medication in a metered-dose inhaler is sprayed into the spacer. The child can then inhale the medication without having to coordinate the spraying and breathing.
44.
One of the goals for children with asthma is to prevent respiratory infection. The reason for this goal is that respiratory infection can:
Correct Answer
D. Trigger an episode or aggravate an asthmatic state.
Explanation
trigger an episode or aggravate an asthmatic state.
Respiratory infections can trigger an asthmatic attack. Annual influenza vaccine is recommended. All respiratory equipment should be kept clean.