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NUR 209 FINAL EXAM EXCELSIOR COLLEGE
NEWEST 2024 ACTUAL EXAM COMPLETE 400
QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+
A localized dilation of an artery either within the original diameter of the artery (fusiform) or an out pouching of the artery (saccular).
- ANSWER >>>Aortic Aneurysm What is aortic aneurysm the result of - ANSWER >>>a weakening of the arterial wall and occurs where arteries curve or flex. Where is the aortic aneurysm located? - ANSWER >>>Can be in the abdominal area such as abdominal aortic aneurysm or thoracic aorta What is the cause of aortic aneurysm? - ANSWER >>>• Hypertension
- Atherosclerosis
- Smoking
- Age
- Family history
- Syphilis
- Marfan's syndrome
- Blunt trauma. Sudden expansion with danger; the patient may experience a sudden increase in pain with radiation to groin, buttocks, and legs with signs and symptoms of hypovolemic shock. - ANSWER
Ruptured Abdominal Aortic Aneurysm
blood has tunneled into the artery wall between the layers of the arterial wall. The effect is decreased perfusion to organs. - ANSWER >>>Aortic Dissection What is Aortic Dissection accompanied by? - ANSWER >>>by diaphoresis, nausea, vomiting, faintness, apprehension. What is the treatment for treatment for Aortic Dissection? - ANSWER >>>for partial dissection is medical management with control of blood pressure maintained below 100-120 mmHg, or in the event of dissection with hemodynamic compromise,surgical repair surgical repair. Blood is diverted into the artery wall. - ANSWER >>>Aortic Dissection A narrowing in the aorta usually near the ductus arteriosus, causing increased pressure in the head and upper extremities and decreased pressure in the body and lower extremities. - ANSWER >>>Coarctation of the Aorta (CoA) Blood flows from the aorta to the pulmonary artery through an opening, which usually closes during the first weeks of life - ANSWER >>>Patent Ductus Arteriosus (PDA): Aortic dissection symptoms - ANSWER >>>are sudden pain described as tearing, ripping, or stabbing in the anterior chest, back, neck, throat, jaw, or teeth. Blood does not flow easily because the entrance of the pulmonary artery is narrow, causing hypertrophy of the RV - ANSWER
Tetralogy of Fallot (TOF):
weight below 3rd percentile. What is the outcome? - ANSWER
The child will gain 2 pounds within one month Impaired Gas Exchange related to poor perfusion as evidenced by cyanosis and clubbing of fingers. What is the outcome? - ANSWER >>>The child will maintain oxygen saturation above 92% on room air by discharge. Imbalanced nutrition: less than body requirements related to inadequate absorption of calories as evidenced by height and weight below 3rd percentile. What is the interventions? - ANSWER >>>-Elicit the patient's food preferences when completing the menu
- Provide pancrelipase with meals and snack Impaired Gas Exchange related to poor perfusion as evidenced by cyanosis and clubbing of fingers. What is the interventions? - ANSWER >>>-Limit feeding times to 20 minutes
- Place child in knee-chest position during that spells
- ANSWER >>>Group B streptococcal infection
- ANSWER >>>Hirschsprung's
- ANSWER >>>necrotizing enterocolitis,
- ANSWER >>>Pyloric stenosis
- ANSWER >>>Choanal atresia,
- ANSWER >>>Bronchopulmonary dysplasia
- ANSWER >>>Hydrocephalus
- ANSWER >>>Omphalocele,
- ANSWER >>>Gastroschisis,
- ANSWER >>>Imperforate anus
- ANSWER >>>Pierre-Robins syndrome
- ANSWER >>>Esophageal atresia
- ANSWER >>>Cleft lip
- ANSWER >>>cleft palate
- ANSWER >>>Cerebral palsy Tetralogy of Fallot abnormality of blood flow - ANSWER >>>
- ANSWER >>> Atria Septal Defects abnormality of blood flow - ANSWER >>> Ventricular Septal Defects abnormality of blood flow, explain. - ANSWER >>> AV Canal Septal defects abnormality of blood flow, explain. - ANSWER >>> Patent ductus arteriosis abnormality of blood flow, explain. - ANSWER >>> Coarctation of the aorta abnormality of blood flow, explain. - ANSWER >>> What are the interventions for Atria Septal Defects? - ANSWER
The grandmother of a newborn comes to the nursery and tells the RN she wants to bring the baby back to the mother. The grandmother is not wearing an identification bracelet. Which response is most appropriate by the RN? - ANSWER >>>Silbert- Flagg and Pillitteri, 8th ed, pp. 451- 452 Which newborn assessment finding would require the RN to report to the health care provider? - ANSWER >>>The newborn whose toes curl when the lateral heel is stroked. : Please review normal newborn characteristics Reference: Silbert-Flagg & Pillitteri 8th edition, pp433- 443 The registered nurse is caring for an infant with the nursing diagnosis of Ineffective thermoregulation. Which is a realistic, measurable patient outcome for this infant? - ANSWER >>>The patient will maintain a body temperature of 97.8° to 98.6° F by discharge. Reference: Silbert-Flagg & Pillitteri 8th edition, p 689 Review the NANDA-I nursing diagnosis of Ineffective thermoregulation The registered nurse is caring for an infant with the nursing diagnosis of Ineffective breathing pattern and the outcome "patient will have a respiratory rate below 60 breaths per minute with no retractions". Which is the priority nursing intervention for a baby? - ANSWER >>>Provide supplemental oxygen Reference: Silbert-Flagg & Pillitteri 8th edition, pp. 698-701 Review Nursing interventions for the NANDA-I of Ineffective breathing pattern A 2-day-old infant received a Vitamin K injection in the delivery room. Which sign and symptom in the infant indicates to the registered nurse the intervention was effective? - ANSWER
Blood clots after heel stick. Reference: Silbert-Flagg & Pillitteri 8th edition, p. 431 Review the indication for Vitamin K.
Which newborn assessment finding would indicate to the registered nurse that a newborn is at risk for physiological jaundice? - ANSWER >>>Cephalhematoma Review risk factors for physiologic jaundice Reference: Silbert-Flagg & Pillitteri 8th edition, p 445 The registered nurse is getting ready to administer the ophthalmic (erythromycin) preparation to the newborn. Which is true regarding the medication? Select all that apply - ANSWER >>>. It is administered to prevent chlamydia conjunctivitis, administered from the inner to the outer canthus in the lower conjunctiva. Reference: Silbert-Flagg & Pillitteri 8th edition, p. 431 Review the indication and administration of ophthalmic erythromycin Which information would the registered nurse include while teaching the mother of a newborn about the function of adipose tissue? - ANSWER >>>Brown adipose tissue provides heat production when the baby needs it. Reference: Silbert-Flagg & Pillitteri 8th edition, p. 429 Review the function of brown fat The RN instructs the parents of a newborn on the actions to prevent sudden infant death syndrome. Which observation indicates that teaching has been effective? - ANSWER
Newborn is placed on the back to sleep. Review the risk factors for SIDS Reference: Silbert-Flagg & Pillitteri 8th edition, pp. 456- 457 The RN is making a client assignment for the shift. Which baby could be appropriately assigned to an LPN/LVN? - ANSWER A stable premature infant being fed every 2 hours. Review ANA Scope of practice for LPN/LVN. Reference: ANA Scope of Practice The RN is caring for a newborn who was born at 31 weeks' gestation. Which assessment finding should the nurse anticipate
Which information would the registered nurse include while teaching the new mother about umbilical cord care? Select all that apply. - ANSWER >>>. Fold the diaper below the cord, Report any foul odor to health care provider,The cord will fall off within 2 weeks. Reference: Silbert-Flagg & Pillitteri 8th edition, p. Review daily care of the newborn A preterm infant has received Beractant. Which assessment best indicates the client is experiencing a side effect of the medication? - ANSWER >>>Heart rate = 70 Review nursing management of Beractant Reference: Burchum 9th edition page 1305 The RN examines the diaper of a 1 day infant and finds there is blackish-green stool in the diaper. Which is the best explanation by the RN to the infant's mother? - ANSWER >>>"All babies pass a sticky, tarlike, blackish stool initially." Reference: Silbert-Flagg & Pillitteri 8th edition, p. 432 Review newborn characteristics, normal newborn stool patterns The RN assesses that the 2-hour-old infant's axillary temperature is 97oF (36.1oC). which intervention should the nurse implement first? - ANSWER >>>Place the infant under a radiant warmer Review care of the newborn with hypothermia Reference: Silbert- Flagg & Pillitteri 8th edition, p. 430
. A newborn develops physiologic jaundice, and the mother asks the registered nurse why this happened. Which response by the RN would be most accurate? - ANSWER >>>"Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." Reference: Silbert-Flagg & Pillitteri 8th edition, p. 441 Review the causes of physiologic jaundice. Which assessment findings would the RN expect to find in the infant with late-onset Group B Streptococcal infection? -
ANSWER >>>Bulging fontanels Review assessment of late onset Group B Streptococcal infection Reference: Silbert-Flagg & Pillitteri 8th edition, p. 1392 Which statement made by the parent indicates to the RN that teaching was effective for the care of the infant with an unrepaired heart defect? - ANSWER >>>"I will make sure to set sensible limits on the baby's activity." Reference: Silbert-Flagg & Pillitteri 8th edition, pp. 1189- 90 A female carrier learns that she is the carrier of an X-linked recessive disease. Her spouse is free of the disease. What would the registered nurse teach the patient about the frequency of this disease in future children? - ANSWER >>>All male children will have a 50% risk to inherit the disease. Reference: Silbert-Flagg & Pillitteri 8th edition, pp 158 Review inheritance patterns for X- linked recessive disorders The registered nurse is caring for a newborn diagnosed with patent ductus arteriosus. What assessment finding would be consistent with this diagnosis? - ANSWER >>>Systolic murmur Reference: Silbert-Flagg & Pillitteri 8th edition, 1140 Review symptoms of patent ductus arteriosus Which statements made by a parent indicates to the RN that appropriate care is being provided to a 4-year-old who has spastic type cerebral palsy? Select all that apply. - ANSWER >>>. "I perform range of motion exercises every 4 hours to help prevent contractures." "I play games with my child every day to help keep my child as independent as possible." "I have utensils with large, padded handles to make it easier for my child to feed himself." Review nursing management of cerebral palsy Reference: Silbert- Flagg & Pillitteri 8th edition, pp. 1388- 1391
An 11-month-old infant with spastic cerebral palsy was seen this week at the developmental pediatrician's office because he is not rolling over or attempting to sit. Which is an expected outcome for the nursing diagnosis Impaired physical mobility? - ANSWER
An 11-month-old infant with spastic cerebral palsy was seen this week at the developmental pediatrician's office because he is not rolling over or attempting to sit. Which is an expected outcome for the nursing diagnosis Impaired physical mobility? The registered nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this patient? Select all that apply. - ANSWER Maintain a thermo-neutral environment, Accurately measure all intake and output, Provide for several periods of uninterrupted rest. Encourage periods of bonding. Reference: Silbert-Flagg & Pillitteri 8th edition Review nursing management for post-op heart defects When counseling potential parents about genetic disorders, what should the registered nurse include in the teaching? - ANSWER Environmental influences may affect multifactorial inheritance. Reference: Silbert-Flagg & Pillitteri 8th edition, pp156-161 Review inheritance patterns of genetic disorders
. What should the registered nurse include in the explanation of the action of Lanoxin to the parents of an infant prescribed on this medication? - ANSWER >>>Slows and strengthens the heartbeat Reference: Silbert-Flagg & Pillitteri 8th edition, p. 1136 Review the indication, action and side effects of digoxin . A child with a heart defect is placed on a maintenance dose of Lanoxin elixir. The ordered dose is 0.07 mg/kg/day in 2 divided doses. The child weighs 19 pounds. What is the maximum amount of medication that will be given per dose by the registered nurse? - ANSWER >>>Record your answer to the nearest tenth
using decimals (for example, write 0.5 instead of ½). Do not include words or abbreviations in your answer. First you need to change pounds to kg. 0.07mg x 8.6 = 0.6 divided by 2= 0.3mg Answer: 0.3 Reference: Treas & Wilkinson 2nd edition, p. 787- 78 8 Review drug calculations What assessment finding would the registered nurse expect to find in the infant suspected of having coarctation of the aorta? - ANSWER >>>Blood pressure in the right arm is different from the blood pressure in the left arm. Many of you chose blood pressure is higher in the arms than in the legs but only the blood pressure in the right arm is higher in the legs. Reference: Silbert-Flagg & Pillitteri 8th edition, p 1146-1147 Review assessment of coarctation of the aorta Which assessment finding requires immediate intervention by the RN in a 3-month old following the first surgery to repair hypoplastic left heart syndrome? - ANSWER >>>Severe intercostal retractions Review complications of heart surgery Reference: Silbert-Flagg & Pillitteri 8th edition, pp 1152- 1153 Which task is most appropriate for the RN to delegate to the UAP on a pediatric unit? - ANSWER >>>Weigh the diaper of infant for output amount Review scope of practice for the UAP Reference: ANA Scope of Practice Which information would the registered nurse include when explaining the implications of Turner syndrome to the parents of an infant? - ANSWER >>>There is an increased incidence of cardiac disorders in children with Turner syndrome. Reference: Silbert-Flagg & Pillitteri 8th edition, p 167 Review characteristics of Turner syndrome When teaching a couple involved with genetic counseling about Down syndrome, which statement, by the couple, would indicate
The RN places the infant with tracheoesophageal fistula under a radiant warmer with the infant's head elevated at a 60-degree angle. Which statement by the mother indicates understanding of the most important reason for this position? - ANSWER >>>This position prevents stomach juices from going upward into my baby's lungs." Review nursing management of an infant with a tracheoesophageal fistula Reference: Silbert-Flagg & Pillitteri 8th edition, p. 730 Which response by the parent indicates to the RN an understanding of the nutritional needs of their child with cystic fibrosis? - ANSWER >>>"We will need to prepare a lot of meat and carbohydrates and some fats in the diet plan." Please review the nutritional requirements for children with cystic fibrosis Reference: Silbert-Flagg & Pillitteri 8th edition, p. 1120 A client with cystic fibrosis is admitted to the hospital with pneumonia. The registered nurse has Ineffective airway clearance as a primary nursing diagnosis. Which outcome should be the priority? - ANSWER >>>The client will have clear breath sounds in bilateral lower lobes by discharge. Review nursing outcomes for Ineffective Airway clearance. Reference: Silbert-Flagg & Pillitteri 8th edition, p. 1121 Which data would the RN most likely assess while caring for the client with hypertrophic pyloric stenosis? - ANSWER
Projectile vomiting Review assessment findings for hypertrophic pyloric stenosis Reference: Silbert-Flagg & Pillitteri 8th edition, p. 1267- 1269 When providing care to a newborn with necrotizing enterocolitis (NEC), which assessment finding would the registered nurse need to immediately consult with the neonatologist? - ANSWER Temperature less than 97 F/36 C Review nursing
management of the newborn with NEC Reference: Silbert-Flagg & Pillitteri 8th edition, pp. 1276- 1277 Following the surgical repair of hypertrophic pyloric stenosis, the registered nurse has formulated the nursing diagnosis of Risk for fluid volume deficit with the expected outcome of "Client will have a flat fontanel by discharge". Which would be an appropriate nursing intervention for this nursing diagnosis? - ANSWER
Monitor for signs and symptoms of dehydration. Review interventions for Risk of fluid volume deficit Reference: Silbert- Flagg & Pillitteri 8th edition, p. 1268 The RN is assessing a 4-year-old with Duchenne muscular dystrophy. Which observation indicates that the child has a Gower sign? - ANSWER >>>Rises from the floor to stand by walking the hands up the legs Review nursing assessments for Duchenne muscular dystrophy Reference: Silbert-Flagg & Pillitteri 8th edition, pp. 1458- 1459 Which patient should the RN refer to the hospital ethics committee? - ANSWER >>>The newborn who is anencephalic whose parents want everything done. Review the purpose of the Ethics Committee Reference: Silbert-Flagg & Pillitteri 8th edition, pp. 775; 1446 The RN is admitting the infant with a tentative diagnosis of intussusception. Which question to the mother would be most helpful in obtaining additional information to confirm intussusception? - ANSWER >>>"What does the infant do when experiencing pain?" Review assessment findings for intussussception. Reference: Silbert-Flagg & Pillitteri 8th edition, p. 1275 The child with cystic fibrosis is receiving albuterol. Which response should the RN expect if albuterol is achieving the
What is the earliest clinical manifestation the registered nurse would expect to assess for in a baby with biliary atresia? - ANSWER >>>Jaundice, Review assessment findings for biliary atresia Reference: Silbert-Flagg & Pillitteri 8th edition, p. 1272
. Which postoperative services would the registered nurse anticipate making arrangements for following a cleft palate repair? Select all that apply. - ANSWER >>>Review long term management of babies with cleft palate • Pediatric otolaryngology
- Hearing screening • Speech therapy • Pediatric dentist Reference: Silbert-Flagg & Pillitteri 8th edition, pp. 724- 728 Which vital sign result should the nurse report in a client who delivered a 7 pound baby four hours ago? - ANSWER
Temperature 100. An elevated blood pressure can indicate the development of post partal hypertension of pregnancy. A bradycardia may develop after delivery as blood volume returns to normal and a slightly elevated temperature can develop from dehydration during labor. Silbert-Flagg, pg 406. A new mother asks the nurse why she is feeling the need to empty her bladder ever few hours after a vaginal birth. What is the nurse's best response? - ANSWER >>>"You are probably drinking extra fluids to establish lactation." A first time mother who gave birth yesterday asks when her milk will come in. What should the nurse teach her? - ANSWER You will notice changes a few days after delivery. A mother has decided not to breastfeed her newborn. What instruction should the nurse provide when she complains that her breasts are very painful and red? - ANSWER >>>Wear a supportive bra.
A mother who delivered 8 hours ago states she has pain of a 6 when she moves due to a third-degree perineal laceration. What information should the nurse to her? - ANSWER >>>Apply ice to the area frequently. In an attempt to latch a newborn to the breast for nursing, the mother pushes the infant's cheek towards her breast. The baby immediately turns his head away from the breast. What is the best explanation for this behavior? - ANSWER >>>The touch elicited the rooting reflex. Which mother should not breastfeed her newborn? - ANSWER
A mother who has HIV disease. The RN places a warm blanket on the cold infant scale before weighing the baby. This method reduces heat loss by minimizing which mechanism? - ANSWER >>>Conduction What are signs of respiratory distress in a neonate? - ANSWER Nasal Flaring What immunization is offered to the parents of a newborn within 12 hours of birth? - ANSWER >>>Hepatitis B What assessment findings are consistent with a diagnosis of small for gestational age secondary to intrauterine growth retardation? - ANSWER >>>An overall wasted appearance What teaching should the RN provide to a mother of an infant with mildly elevated bilirubin levels? - ANSWER >>>increase the frequency of feedings A mother has a prostaglandin inserted into the posterior fornix to Wear a supportive bra. A mother who delivered 8 hours ago states she has pain of a 6 when she moves due to a third-degree perineal laceration. What information should the nurse to her? - ANSWER >>>Apply ice to the area frequently. In an attempt to latch a newborn to the breast for nursing, the mother pushes the infant's cheek towards her breast. The baby immediately turns his head away from the breast. What is the best explanation for this behavior? - ANSWER >>>The touch elicited the rooting reflex. Which mother should not breastfeed her newborn? - ANSWER >>>A mother who has HIV disease. The RN places a warm blanket on the cold infant scale before weighing the baby. This method reduces heat loss by minimizing which mechanism? - ANSWER >>>Conduction What are signs of respiratory distress in a neonate? - ANSWER >>>Nasal Flaring What immunization is offered to the parents of a newborn within 12 hours of birth? - ANSWER >>>Hepatitis B What assessment findings are consistent with a diagnosis of small for gestational age secondary to intrauterine growth retardation? - ANSWER >>>An overall wasted appearance What teaching should the RN provide to a mother of an infant with mildly elevated bilirubin levels? - ANSWER >>>increase the frequency of feedings A mother has a prostaglandin inserted into the posterior fornix to hasten cervical ripening before induction of labor. What are side
