NR 328 Exam 2 Practice Questions & Answers
What factor predisposes an infant to fluid imbalances?
- Immature kidney functioning
- Decreased surface area
- Lower metabolic rate
- Decreased daily exchange of extracellular fluid
(- Answer: A
Rationale: The infant's kidneys are functionally immature at birth and are
inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration.
What is the required number of milliliters of fluid needed per day for a 14 kg child?
- 1200
- 1100
- 1300
- 1400
(- Answer: A
Rationale: For the first 10 kg of body weight, a child requires 100 mL/kg.
For each additional kilogram of body weight, an extra 50 mL is needed.10 kg ´ 100 mL/kg/day = 1000 mL
- kg ´ 50 mL/kg/day = 200 mL
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1000 mL + 200 mL = 1200 ml/day 800 to 1000 mL is too little; 1400 mL is too much.
An infant is brought to the emergency department with the following clinical
manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and
tachypnea. This is suggestive of which situation?
- Water depletion
- Water excess
- Potassium excess
- Sodium depletion
(- Answer: A
Rationale: These clinical manifestations indicate water depletion or
dehydration. Edema and weight gain occur with water excess or over- hydration. Sodium or potassium excess would not cause these symptoms.
What explains physiologically the edema formation that occurs with burns?
- Increased capillary permeability
- Decreased capillary permeability
- Vasoconstriction
- Diminished hydrostatic pressure within capillaries
(- Answer: A
Rationale: With a major burn, capillary permeability increases, allowing
plasma proteins, fluids, and electrolytes to be lost into the interstitial space, causing edema. Maximum edema in a small wound occurs about 8 to 12 hr after injury. In larger injuries, the maximum edema may not occur until 18 to 24 hr later. Vasodilation occurs, causing an increase in hydrostatic pressure.
What is the most immediate threat to life in children with thermal injuries?
- Shock
- Anemia
- Local infection
- Systemic sepsis
(- Answer: A
Rationale: The immediate threat to life in children with thermal injuries is
airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis is the primary complication. 2 / 4
After the acute stage and during the healing process, what is the primary complication from burn injury?
- Infection
- Shock
- Renal shutdown
- Asphyxia
(- Answer: A
Rationale: During the healing phase, local infection or sepsis is the primary
complication. Respiratory problems, primarily airway compromise, and shock are the primary complications during the acute stage of burn injury.Renal shutdown is not a complication of the burn injury but may be a result of the profound shock.
What finding is the most reliable guide to the adequacy of fluid replacement for a small child with burns?
- Urinary output of 1 to 2 mL/kg of body weight/hr
- Increased seepage from burn wound
- Falling hematocrit
- Absence of thirst
(- Answer: A
Rationale: Replacement fluid therapy is delivered to provide a urinary
output of 30 mL/hr in older children or 1 to 2 mL/kg of body weight/hr for children weighing less than 30 kg (66 pounds). Thirst is the result of a complex set of interactions and is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling hematocrit would be indicative of hemodilution. This may reflect fluid shifts and may not accurately represent fluid replacement therapy. Increased seepage from a burn wound would be indicative of increased output, not adequate hydration.
What intervention is contraindicated in a suspected case of appendicitis?
- Enemas
- Palpating the abdomen
- Administration of antibiotics
- Administration of antipyretics for fever (- Answer: A 3 / 4
Rationale: In any instance in which severe abdominal pain is observed and
appendicitis is suspected, the nurse must be aware of the danger of administering laxatives or enemas. Such measures stimulate bowel motility and increase the risk of perforation. The abdomen is palpated after other assessments are made. Antibiotics should be administered, and antipyretics are not contraindicated.
An infant had a gastrostomy tube placed for feedings after a Nissen fundoplication and bolus feedings are initiated. Between feedings while the tube is clamped, the infant becomes irritable, and there is evidence of cramping. What action should the nurse implement?
- Vent the gastrostomy tube.
- Withhold the next feeding.
- Burp the infant.
- Notify the health care provider.
(- Answer: A
Rationale: If bolus feedings are initiated through a gastrostomy after a
Nissen fundoplication, the tube may need to remain vented for several days or longer to avoid gastric distention from swallowed air. Edema surrounding the surgical site and a tight gastric wrap may prohibit the infant from expelling air through the esophagus, so burping does not relieve the distention. Some infants benefit from clamping of the tube for increasingly longer intervals until they are able to tolerate continuous clamping between feedings. During this time, if the infant displays increasing irritability and evidence of cramping, some relief may be provided by venting the tube.The next feeding should not be withheld, and calling the health care provider is not necessary.
The nurse should instruct parents to administer a daily proton pump inhibitor to their child with gastroesophageal reflux at which time?
- 30 minutes before breakfast
- Midmorning
- Bedtime
d. With a meal (- Answer: A
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