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ENPC FINAL EXAM LATEST 2023-2024 REAL
EXAM 150 QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS)|AGRADED A
When a poison has been ingested by a child, the parents should be instructed to do which of the following first? a) Induce vomiting. b) Call the local poison control center. c) Administer an emetic. d) Get to an emergency facility. - ANSWER- Call the local poison control center. Correct RATIONALE: Not all poisons should be vomited. Strong acids, for example, could cause as much destruction of tissue being vomited as being swallowed. The poison control center will provide the most accurate information on the next steps for the patient. Assessment of a child reveals a tension pneumothorax. The nurse would prepare the child for which of the following? a) Needle thoracotomy b) Suctioning c) Intubation d) Defibrillation - ANSWER- Needle thoracotomy Correct RATIONALE: A needle thoracotomy is indicated for tension pneumothorax to relieve the air collected in the space. Intubation is indicated for apnea and in situations in which the airway cannot be maintained. Suctioning would be indicated for excessive airway secretions that influence airway patency. Defibrillation is used to stimulate or alter the heart's electrical rhythm. A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 BPM. Choose the priority intervention:
a) Administer doses defibrillator shocks in a row b) Initiate cardiac compressions c) Give three doses of epinephrine d) Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR) - ANSWER- Initiate cardiac compressions Correct RATIONALE: The American Heart Association (AHA) emphasizes the importance of cardiac compressions in pulseless clients with arrhythmias, making this the priority intervention in this situation. Current AHA recommendations are for defibrillation to be administered once followed by five cycles of CPR. The AHA now recommends against using multiple doses of epinephrine because they have not been shown to be helpful and may actually cause harm to the child. A 3-year-old girl had a near-drowning incident when she fell into a wading pool. Which intervention would be of the highest priority? a) Inserting a nasogastric tube to decompress stomach b) Assuring the child stays still during an X-ray c) Suctioning the upper airway to ensure airway patency d) Covering the child with warming blankets - ANSWER- Suctioning the upper airway to ensure airway patency Correct RATIONALE: Due to the potentially devastating effects of drowning-related hypoxia on a child's brain, airway interventions must be initiated immediately. The child's airway should be suctioned to ensure patency. Other interventions such as covering the child with blankets, inserting a nasogastric tube, and assuring that the child remains still during X-ray are interventions that are appropriate once airway patency is achieved and maintained. The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of which of the following? a) Underlying heart disease b) Respiratory failure c) Neurologic trauma d) Lethal arrhythmia - ANSWER- Respiratory failure
Atropine is used for symptomatic bradycardia unresponsive to ventilation and oxygenation. Sodium bicarbonate is used for metabolic acidosis. Naloxone reverses the effect of opioids. Calcium carbonate is used for documented or suspected hypocalcemia, hyperkalemia, hypermagnesemia, and calcium channel blocker overdose. The nurse must calculate the adolescent's cardiac output. The child's heart rate is 76 beats per minute and the stroke volume is 75 mL. Calculate the child's cardiac output. - ANSWER- 5700 RATIONALE: Cardiac output (CO) is equal to heart rate (HR) times ventricular stroke volume (SV). That is, CO = HR x SV 76 beats per minute x 75 mL = 5, A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which of the following treatments is most likely appropriate in the immediate treatment of the girl's poisoning? a) Intravenous rehydration b) Administration of activated charcoal c) Gastric lavage d) Inducing vomiting - ANSWER- Administration of activated charcoal RATIONALE: Explanation: Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl's poisoning. The child's ability to perfuse well is poor due to inadequate circulation. The physician writes an order for the child to receive 20 mL of normal saline for each kilogram of body weight. The child will receive the normal saline as a bolus through a central intravenous line. The child weighs 78 pounds. Calculate the amount of normal saline the nurse should administer as a bolus. Round to the nearest whole number. mL - ANSWER- 709 RATIONALE: 78 pounds x 1 kg/2.2 pounds = 35.455 kg x 20 mL/kg = 709.1 mL. When rounded to the nearest whole number = 709 mL
A 16-year-old boy is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to which of the following? a) Play-related injuries b) Falls from beds c) Automobile accidents d) Falls from staircases - ANSWER- Automobile accidents Correct RATIONALE: Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-aged children, and falling from staircases is a common injury among toddlers. Administration of which medication reverses histamine release and hypotension that are seen in anaphylaxis? a) Atropine b) Epinephrine c) Benadryl d) Zantac - ANSWER- Epinephrine Correct RATIONALE: Epinephrine reverses histamine release and hypotension due to anaphylaxis. A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in teaching parents about how to protect a toddler from accidental poisoning? a) Label poisonous solutions. b) Do not leave the toddler alone. c) Closely monitor the toddler's activity. d) Keep cleaning solutions locked up. - ANSWER- Keep cleaning solutions locked up. Correct RATIONALE:
Which finding from the history of a child with extensive burns would make you most alert to assess for respiratory complications? a) Firemen found the child sobbing silently. b) The child's clothing was burned. c) The child was trapped in a closed burning bedroom. d) The fire was caused by burning weeds. - ANSWER- The child was trapped in a closed burning bedroom. Correct RATIONALE: When a child is confined in a closed space during a fire, he or she can inhale a great deal of smoke, causing respiratory tract burns or irritation. The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern? a) Palpation of the head reveals a closed posterior fontanel. b) The child is crying and looking around fearfully. c) The child's eyes remain closed unless she is spoken to. d) Inspection shows a sluggish pupillary reaction. - ANSWER- Inspection shows a sluggish pupillary reaction. Correct RATIONALE: A sluggish pupillary reaction may occur with increased intracranial pressure, which would be cause for concern. A closed posterior fontanel in an 11-month-old would be a normal finding. Crying and looking around are encouraging signs indicating improved neurologic status. Opening the eyes when being spoken to is an encouraging sign. When assessing a child with a traumatic injury, which of the following would be the priority assessment? a) Airway patency and airflow b) Breathing effectiveness and breath sounds c) Level of consciousness and papillary reaction d) Pulse rate and skin color - ANSWER- Airway patency and airflow Correct RATIONALE: When assessing the child with a traumatic injury, the ABCs are assessed first: assess the patency of the airway and establish the effectiveness of breathing,
examining the child's respiratory effort, breath sounds, and color; evaluate the circulation, noting pulse rate and quality and observing the color, skin temperature, and perfusion. Once this is accomplished, the nurse assesses for disability (D), rapidly assessing critical neurologic function including level of consciousness, pupillary reaction, and verbal and motor responses to auditory and painful stimuli. A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which of the following actions should the nurse take first? a) Provide oral analgesics as ordered. b) Draw blood for type and cross-match. c) Begin hyperventilation. d) Establish a suitable IV site. - ANSWER- Establish a suitable IV site. Correct RATIONALE: The goal of treating shock is to restore circulating blood volume. This requires that vascular access be obtained to administer fluids and vasoactive drugs. Hyperventilation is reserved for temporary treatment of severe intracranial pressure. Analgesics should not be administered prior to neurologic and cardiovascular examination being performed. Chelation therapy is a treatment for metallic poisoning. A 14-year-old child is brought to the emergency department. His parents state that they think he took "too many of his pain pills." The child had been prescribed oxycodone every 4 hours for pain secondary to a bone infection. Which agent would the nurse expect to be administered to counteract the analgesics?
- Atropine
- Naloxone
- Lidocaine
- Ketamine - ANSWER- Naloxone Correct RATIONALE: Oxycodone is an opioid analgesic whose effects can be reversed by the administration of naloxone. Atropine decreases secretions and reduces the vagal effects of intubation. It also is used for sinus bradycardia, asystole, and pulseless electrical activity. Lidocaine is used to correct ventricular arrhythmias. Ketamine may be used for rapid-sequence intubation.
d) Have the child sit up straight in a chair. - ANSWER- Administer 100% oxygen by mask. Explanation: Management of the near-drowning victim focuses on assessing his airway, breathing, and circulation (ABCs) and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the child assume the most comfortable position for him. Checking capillary refill time helps determine ineffective tissue perfusion. Providing sedation is an intervention for pain that will be assessed after effective breathing is established. An 8-year-old girl with tachycardia is alert, breathing comfortably, and exhibiting signs of adequate tissue perfusion. Which nursing intervention would be most appropriate for this child? a) Administering epinephrine as ordered b) Oxygenating and ventilating the child c) Applying ice to the child's face d) Initiating cardiac compressions - ANSWER- Applying ice to the child's face Explanation: The child is exhibiting compensated supraventricular tachycardia (SVT). Vagal maneuvers such as ice to the face or blowing through a straw that is obstructed are priority interventions for compensated SVT. Oxygenating and ventilating the child as ordered are interventions for bradycardia. Epinephrine is given for bradycardia. Initiating cardiac compressions is the priority intervention for collapsed (pulseless) rhythms. Which of the following nursing diagnoses would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub? a) Risk for Falls b) Risk for Imbalanced Body Temperature c) Noncompliance d) Risk for Suffocation - ANSWER- Risk for Suffocation Correct Explanation: Death from drowning occurs from suffocation. Nearly half of all drowning victims are children under the age of 5. Most drowning deaths in young children occur because of inadequate supervision of a bathtub or pool.
The nurse has performed an across-the-room assessment of an 8-year-old child and has classified her as emergent. Which of the following signs and symptoms has the nurse seen? a) The child is guarding one hand. b) The child is asleep on the mother's lap. c) The child is scratching a rash. d) There is a blue color to the lips. - ANSWER- There is a blue color to the lips. Correct Explanation: Blue lips is a sign of cyanosis. The child is in respiratory distress and should be cared for on an emergency basis. An injured hand and a rash are not emergencies. The sleeping child could have a fever that may be the result of an underlying pathology; however, this cannot be determined from across the room. The nurse is caring for a 10-month-old infant with signs of respiratory distress. Which is the best way to maintain this child's airway? a) Inserting a small towel under shoulders b) Using the head tilt chin lift technique c) Employing the jaw-thrust maneuver d) Placing the hand under the neck - ANSWER- Inserting a small towel under shoulders Explanation: Inserting a small, folded towel under shoulders best positions the infant's airway in the "sniff" position as is recommended by the American Heart Association (AHA) Basic Cardiac Life Support (BCLS) guidelines. The hand should never be placed under the neck to open the airway. The head tilt chin lift technique and the jaw- thrust maneuver are used with children over the age of 1 year. A child is learning to ride a bicycle. He should be instructed to use a(an) a) Helmet b) Knee pads c) Light d) Wrist guard - ANSWER- Helmet Correct Explanation: Children should wear properly fitted helmets when cycling, riding, or playing contact sports
Explanation: An adolescent, not a 9-year-old, would most likely require an oxygen flow rate of 15 L/minute for effective ventilation. A flow rate of 10 L/minute is appropriate for infants and children. All other options are valid for preparing to ventilate with a bag valve mask. A 14-month-old trauma victim has arrived in the emergency department. Which of the following challenges will the nurse need to address first? a) Risks from reduced core temperature b) Inadequate systemic perfusion c) Increased metabolic demands d) Possible tissue damage from hypoxia - ANSWER- Possible tissue damage from hypoxia Explanation: Oxygen should be administered by a non-rebreather mask until oxygenation and perfusion status is completely assessed. This will stabilize the effects of hypoxia. Reduced core temperature and resultant metabolic demands, as well as the need for epinephrine, are secondary to the ABCs (airway, breathing, and circulation). A 10-year-old boy who was in a car wreck has been brought to the emergency room for evaluation. He appears to have suffered abdominal trauma do to his seat belt. He has tenderness in the left upper quadrant of the abdomen, especially on deep inspiration. Given these circumstances, the nurse should suspect injury to which of the following organs? a) Pancreas b) Spleen c) Liver d) Stomach - ANSWER- Spleen Correct Explanation: In children, the spleen is the most frequently injured organ when there is abdominal trauma, because it is usually palpable under the lower left rib. Frequent causes of injury are inappropriately applied seat belts in automobiles, handlebar injuries in bicycle accidents, or skateboard or snowboard accidents. The child will have tenderness in the left upper quadrant, of the abdomen, especially on deep inspiration, when the diaphragm moves down and touches the spleen.
The child's physician requests that the nurse should notify her if the child's urine output is less than 1 mL/kg of body weight each hour. The child weighs 56 pounds. Calculate the minimum amount of urine output the child should produce each hour. Round to the nearest whole number. mL/hour - ANSWER- 25 Correct Explanation: 56 pounds x 1 kg/2.2 pounds = 25.455 kg of body weight. 25.455 kg x 1 mL/kg = 25.455 mL/hour The child must produce 25 mL/hour A young patient in the intensive care unit is in a coma after a severe head injury. The primary nurse is teaching a nursing student how to assess the patient's level of consciousness by using a coma scale. This scale is referred to as which of the following? a) Apgar scale b) Visual analogue scale c) Glasgow scale d) Wong-Baker FACES scale - ANSWER- Glasgow scale Correct Explanation: The Glasgow Coma Scale is used to grade coma according to level of consciousness. The Apgar score is assigned immediately after delivery to determine how the infant tolerated the birth. Wong-Baker FACES and the visual analogue scales are used to rate pain. The condition of an 11-year-old boy who is on mechanical ventilation begins to deteriorate. Which of the following would the nurse do next? a) Confirm that the ventilator is working properly. b) Examine the child for signs of pneumothorax. c) Suction the tube to remove a mucus plug. d) Check to see if the tracheal tube is displaced. - ANSWER- Check to see if the tracheal tube is displaced. Explanation: Use the mnemonic DOPE for troubleshooting when the status of a child who is intubated deteriorates. This means checking for displacement and disconnections first. Checking the ventilator, suctioning for obstruction, and examining for signs of pneumothorax would come later.
a) Measuring from the tip of the nose to earlobe to middle of xiphoid process b) Measuring distance from end of nose to tragus of ear c) Placing the airway next to the cheek with tip pointing down d) Inspecting the child's fifth digit to estimate the diameter - ANSWER- Placing the airway next to the cheek with tip pointing down Explanation: The nurse determines the correct size by placing it next to the child's cheek with the tip pointing down. An airway that is too large will extend past the angle of the child's mandible and can obstruct the glottic opening when inserted. Measuring the distance from the end of the nose to the tragus of the ear is appropriate for a nasopharyngeal airway. Looking at the child's fifth digit reflects the approximate diameter of the nasopharyngeal airway. Measuring from the tip of the nose to the earlobe to the middle area between the xiphoid process and umbilicus is used to determine the length of a nasogastric tube. The nurse is attempting to establish peripheral vascular access in child requiring pediatric advanced life support. The decision to use the intraosseous route would be made if the nurse were unsuccessful after how many attempts within 90 seconds? a) Two b) Four c) Three d) Five - ANSWER- Three Explanation: No more than three attempts should be made within 90 seconds to obtain peripheral vascular access. A home care nurse provides health education to parents regarding the care of their toddler. Which of the following precautions should the nurse suggest the parents take to protect the toddler from drowning?
- Teach the toddler water is bad
- Tell the toddler to stay away from the pool
- Avoid unattended baths for the toddler. - ANSWER- Avoid unattended baths for the toddler. Correct Explanation:
The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool or teaching them that water is dangerous is insufficient to ensure safety. The nurse is examining a 10-month-old girl who has fallen from the back porch. Which assessment will directly follow evaluation of the "ABCs?" a) Palpating the abdomen for soreness b) Palpating the anterior fontanel c) Auscultating for bowel sounds d) Observing skin color and perfusion - ANSWER- Palpating the anterior fontanel Correct Explanation: Once the ABCs have been evaluated, the nurse will move on to "D" and assess for disability by palpating the anterior fontanel for signs of increased intracranial pressure. Observing skin color and perfusion is part of evaluating circulation. Palpating the abdomen for soreness and auscultating for bowel sounds would be part of the full-body examination that follows assessing for disability. A 7-year-old boy is brought to the emergency room by his parents following an accident in which he was struck in the back of the head with a baseball bat. The nurse is assessing him. Which of the following would indicate increased intracranial pressure in this child? a) Decrease in pulse and temperature and increase in respiratory rate and pulse pressure b) Decrease in temperature and pulse pressure and increase in pulse and respiratory rate c) Decrease in pulse and pulse pressure and increase in temperature and respiratory rate d) Decrease in pulse and respiratory rate and increase in temperature and pulse pressure - ANSWER- Decrease in pulse and respiratory rate and increase in temperature and pulse pressure Explanation: All children with head trauma require a neurologic assessment as soon as they are seen and again at frequent intervals to detect signs and symptoms of increased intracranial pressure (ICP) as increasing pressure puts stress on the respiratory, cardiac, and temperature centers, causing dysfunction in these areas. The mark of increased pressure is a decrease in pulse and respiratory rate and an increase in temperature and pulse pressure (the distance between the diastolic and systolic
The following formula should be used to calculate the correct tracheal tube size for a child: Divide the child's age by 4 and add 4 = size in millimeters (8 years old/4)
- 4 = 6 mm The nurse is examining a 10-year-old boy with tachypnea and increased work of breathing. Which finding is a late sign that the child is in shock? a) Significantly decreased skin elasticity b) Delayed capillary refill with cool extremities c) Blood pressure slightly less than normal d) Equally strong central and distal pulses - ANSWER- Significantly decreased skin elasticity Explanation: Decrease skin turgor is a late sign of shock. Blood pressure is not a reliable method of evaluating for shock in children because they tend to maintain normal or slightly below normal blood pressure in compensated shock. Equal central and distal pulses are not a sign of shock. Delayed capillary refill with cool extremities are signs of shock that occur earlier than changes in skin turgor. When developing the plan of care for a 10-month-old infant in septic shock, which of the following would the nurse most likely include? a) Administering intravenous saline as ordered b) Administering intravenous dopamine as ordered c) Giving blood if saline provides inadequate response d) Inserting a urinary catheter for monitoring urinary output - ANSWER- Administering intravenous dopamine as ordered Explanation: Although isotonic intravenous solutions such as saline, blood transfusion, and urinary catheter insertion are important for any child with shock, children experiencing septic shock often require larger volumes of fluid as a result of the increased capillary permeability. Thus, fluid alone may not improve the status of a child with septic shock, necessitating the use of vasoactive medications such as dopamine. Saline is the first choice for restoring fluid volume, but this child will most likely need vasoactive medications. Children in shock from trauma may require blood transfusions to restore volume. Once fluids are given, a urinary catheter will be placed to monitor urine output.
A 14-year-old girl arrives at the hospital in a comatose state. Her father, who found her comatose in her room, tells you that she has an opiate addiction. Which of the following would confirm that the coma was caused by opiate intoxication? a) Both pupils are pinpoints b) Both pupils are dilated c) One pupil dilated and the other normal d) One pupil dilated and the other deviated downward - ANSWER- Both pupils are pinpoints Correct Explanation: Observe the child's eyes for signs of dilated pupils from increased ICP. If both pupils are dilated, irreversible brainstem damage is suggested, although such a finding may also be present with poisoning with an atropine-like drug. Pinpoint pupils suggest barbiturate or opiate intoxication. One pupil dilated or the eye deviated downward or laterally more than the other suggests third cranial nerve compression or a tentorial tear (laceration of the membrane between the cerebellum and cerebrum) with herniation of the temporal lobe into the torn membrane. A 3-year-old child has sustained injuries from a fall. Once the airway is secured, which of the following interventions would be next? a) Stabilize the cervical spine. b) Set up antecubital IV access. c) Administer 100% oxygen. d) Check mouth for debris. - ANSWER- Stabilize the cervical spine. Correct Explanation: If head or spine injuries are suspected, then after the airway is opened, the cervical spine must be stabilized to prevent damage. Checking the mouth for debris is part of securing an airway. Administering oxygen and IV access occur after the C-spine is stabilized. A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 BPM. Choose the priority intervention: a) Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR) b) Initiate cardiac compressions
