Chapter 34: Pediatric Emergencies

Cardiopulmonary resuscitation (CPR) is in progress on an 8-year-old boy who is in shock. Which nursing intervention is priority? inserting an indwelling urinary catheter to measure urine output obtaining intravenous access with a 22-gauge needle inserting an intraosseous needle via the femoral route drawing a blood sample for arterial blood gas analysis

inserting an intraosseous needle via the femoral route Explanation: Fluid resuscitation is the priority intervention for a child in shock who is receiving CPR. Gaining access via the femoral route will not interfere with CPR efforts. A large-bore IV would be used to gain peripheral venous access, which may be unattainable in children who have significant vascular compromise. Blood samples and urinary catheter placement can wait until fluid is administered.

A nurse is providing care to a child who was involved in a severe car accident. The child sustained significant internal injuries and blood loss. The child has developed refractory shock. Which action is most important for the nurse take? Make arrangements for the parents to meet with the health care team. Monitor the child closely for any further changes in the child's condition. Ask the health care provider to consider changing the child's medications. Increase the rate on the child's intravenous fluid infusion.

Make arrangements for the parents to meet with the health care team. Explanation: Refractory shock is irreversible despite resuscitative measures and death is imminent. The nurse should make arrangements for a parental meeting with the health care team to discuss the child's prognosis. Changing the child's medications or increasing the intravenous infusion rate may or may not improve the child's condition short term but will not improve the child's condition. Closely monitoring the child's condition is something the nurse will continue to do, but the most important action to inform the parents of the child's status.

A 4-year-old girl is brought to the emergency room following ingestion of large amounts of acetaminophen (Tylenol). Which of the following interventions does the nurse expect? assessing for consciousness administration of acetylcysteine stimulation of vomiting performing hands-only CPR

administration of acetylcysteine Explanation: In the emergency department, activated charcoal or acetylcysteine, a mucolytic agent and also the specific antidote for acetaminophen poisoning, will be administered. Acetylcysteine prevents hepatotoxicity by binding with the breakdown product of acetaminophen so that it will not bind to liver cells. Unfortunately, acetylcysteine has an offensive odor and taste. Administering it in a small amount of a carbonated beverage can help the child to swallow it.

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 lb (25.46 kg). Calculate the minimum amount of urine output the child should produce each hour. Record your answer using a whole number.

25 ml/hour Urine output should be calculated using weight in kilograms. 25.46 kg x 1 ml/kg = 25.46 ml/hour. The child must produce 25 ml/hour.

A 13-year-old adolescent has had a near-drowning experience. The nurse notices the client has labored breathing and a cough. What is the priority intervention? Administer 100% oxygen by mask. Check the client's capillary refill time. Perform postural drainage every hour. Have the client sit up straight in a chair.

Administer 100% oxygen by mask Explanation Management of the near-drowning victim focuses on assessing the client's airway, breathing, and circulation (ABCs) and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the adolescent assume the most comfortable position for him or her. Checking capillary refill time helps determine ineffective tissue perfusion, but it does not provide an intervention for the labored breathing. Postural drainage techniques to remove water from the lungs are of no proven value in a near-drowning experience

The beta-adrenergic drug increases cardiac output and blood pressure.

Dopamine

Early signs of shock include bradycardia and tachypnea. TRUE FALSE

False

, which is a medication administered for opioid overdose, may need to be administered multiple times in a short period.

Naloxone

A child is hospitalized with suspected sepsis. The health care provider has prescribed an intravenous fluid bolus of lactated Ringer's solution 15 ml/kg to infuse over 20 minutes. The child weighs 52 lb (23.6 kg). How much fluid should the nurse administer? Record your answer using a whole number.

The nurse will multiply the client's weight in kilograms by the prescribed amount of fluid. 23.6 kg × 15 ml/kg = 354 ml

A side effect of atropine, an anticholinergic drug, is dilation of the pupils. TRUE FALSE

True

Hypovolemic shock can occur following severe vomiting and diarrhea. TRUE FALSE

True

It is important to know the half-life of medications that have been ingested in order to know when peak symptoms should occur. FALSE TRUE

True

Infants and children in respiratory arrest may appear tachypneic, , or apneic.

bradypneic

A nurse is providing care to a 14-year-old child hospitalized after an overdose of fentanyl. Which aspect of the plan of care should the nurse prioritize? perfusion hydration cognition oxygenation

oxygenation

A 6-year-old girl in shock is receiving dobutamine. What would the nurse most likely do? Give adequate fluids prior to administration. Monitor for hypotension or seizures. Monitor for ventricular arrhythmias. Assess for shortness of breath and dyspnea.

Monitor for ventricular arrhythmias. Explanation: Once dobutamine has been administered, the nurse should monitor for the development of ventricular arrhythmias. Monitoring for shortness of breath, dyspnea, or worsening of asthma would be appropriate when administering adenosine. Administering lidocaine requires monitoring for hypotension and seizures. Administering fluids is the priority intervention for any child in shock.

A child who weighs 53 lbs (24 kg) is receiving fluid volume replacement as part of the treatment for shock. The nurse is evaluating the child's hourly urinary output to determine if the child's condition is improving. Which output would the nurse interpret as most indicative of improvement? 12 ml 30 ml 15 ml 22 ml

30 ml Explanation: Improved urinary output of 1 to 2 ml/kg/hour is the goal. The child weighs 53 pounds, which is equivalent to 24 kg. Thus, improvement in this child would be noted by an hourly urinary output between 24 and 48 ml/hour.

Treatment of a child who survived a submersion injury is focused on optimizing oxygenation and cardiac output and controlling -----

Temperature

The nurse is assessing a 7-year-old child with salicylate toxicity. What will the nurse include in the assessment? Select all that apply. Assess for nausea and vomiting. Monitor for tachypnea. Assess for drooling. Assess for bradycardia. Monitor for altered mental status.

Assess for nausea and vomiting. Monitor for tachypnea. The nurse will assess for nausea and vomiting and monitor for tachypnea in the child with salicylate toxicity. Assessing for bradycardia and altered mental status are included for a child with opioid toxicity, not salicylate toxicity. Assessing for drooling should be performed for a child who accidentally ingested corrosives.

The nurse is caring for a 2-year-old child in the emergency department with acetaminophen toxicity. What will the nurse include in the assessment? Select all that apply. Examine the skin for sweating and pallor. Assess for nausea. Assess for bradycardia. Evaluate for bradypnea. Monitor liver function tests.

Assess for nausea. Examine the skin for sweating and pallor. Monitor liver function tests. Explanation: The nurse should assess for nausea, examine the skin for sweating and pallor, and monitor liver function tests for a 2-year-old child with acetaminophen toxicity. Bradycardia and bradypnea are clinical manifestations of opioid toxicity, not acetaminophen toxicity.

A child has fallen from a swing at the playground and the parent states that the child became groggy. After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next? Obtain blood glucose. Obtain a full set of vital signs. Provide pain management. Assess the level of consciousness.

Assess the level of consciousness. Explanation: Once the ABCs are completed, the nurse's next step is to assess the child's level of consciousness or disability. This would be followed by removing the child's clothing (exposure) to assess for underlying signs of illness or injury. Next, full vital signs are taken while facilitating the family's presence, followed by giving comfort by managing pain and providing emotional support. The acronym ABCDEFG is a useful reminder of the order of assessment: airway, breathing, circulation, disability, exposure, full vital signs, and facilitating family, and giving comfort. Capillary blood glucose should be obtained to rule out hypoglycemia as the cause of mental status change.

The nurse is teaching the parents of a 2-year-old child how to avoid accidental poisonings. What will the nurse include in the teaching? Select all that apply. Cook meats to the recommended temperature. Install carbon monoxide detectors. Follow directions for use foral dangerous substances. Store detergents in easy-to-use, personalized containers. Keep cleaning supplies in plain sight at all times.

Cook meats to the recommended temperature. Installcarbonmonoxidedetectors. Followdirectionsforuseforalldangeroussubstances. The nurse should teach the parents to the recommended temperature, install carbon monoxide detectors, and follow the directions for use for all dangerous substances. Detergents should be kept in their original containers, not personalized containers. Cleaning supplies should be stored out of the reach and out of sight of children.

The nurse plans to educate the parents of a child experiencing septic shock about the purpose of administering dobutamine intravenously to their child. What would the nurse include in this educational plan? Dobutamine is used to provide vasodilation, thus increasing blood pressure. Dobutamine will work to eliminate the bacteria causing the infection. Dobutamine will work to dry secretions and inhibit serotonin and histamine. Dobutamine is used to improve cardiac contractility.

Dobutamine is used to improve cardiac contractility. Explanation: Dobutamine improves the contractility of the heart muscle during shock. The medication is not an antibiotic. Vasodilation would result in lower blood pressure. Atropine (anticholinergic) increases cardiac output, dries secretions, and inhibits serotonin and histamine.

In impending respiratory arrest, children may appear confused or excessively sleepy if carbon dioxide levels are low or oxygen levels are high. FALSE TRUE

False

The health care team is performing cardiopulmonary resuscitation on a child following a suspected poisoning. Which action by the nurse would indicate that CPR is warranted? The child is assessed for injury before applying the cardiac monitor. The nurse assesses the child's heart rate at 45 and begins chest compressions. The child is monitored for respiratory complications such as pneumonia. The nurse assesses the child's neurological status following chest compressions.

The nurse assesses the child's heart rate at 45 and begins chest compressions. Explanation: The child with a pulse of less than 60 beats per minute should receive chest compressions to maintain adequate perfusion and circulation. The nurse would assess for injuries, the child's neurologic status, and respiratory complications after CPR has stabilized the child.

The nurse is preparing to open the airway of an unconscious child with a suspected cervical spine injury. What action will the nurse take? Open the mouth gently with fingers. Use the jaw-thrust maneuver. Use a bag and mask to create positive airway pressure. Use the head-tilt, chin-lift maneuver.

Use the jaw-thrust maneuver. Explanation: The nurse will use the jaw-thrust maneuver to open the airway of an unconscious child with a suspected cervical spine injury. The head-tilt, chin-lift maneuver should not be used in this scenario. The nurse should not open the mouth gently with fingers, or force air into the airway with a bag and mask.

Sodium bicarbonate IV should be given to alkalinize the urine following ingestion of----

salicylates

A 9-year-old girl who has fallen from a second-story window is brought to the emergency department. Which assessment would be the priority? Evaluating pupils for equality and reactivity Asking the child if she knows where she is Monitoring oxygen saturation levels Using the appropriate pain assessment scale

Monitoring oxygen saturation levels Explanation: Airway is always the priority in any emergency situation. Therefore, monitoring oxygen saturation levels, part of the rapid cardiopulmonary assessment, would be performed before any of the other assessments. Evaluating pupils for equality and reactivity, asking the child if she knows where she is, and using an appropriate pain assessment scale are assessments that would follow the ABCs.

A nurse is creating a plan of care for a child hospitalized after accidentally ingesting the parent's prescription opioid. Which outcome is the best indicator that the plan of care was successful?

The child maintains effective gas exchange. Explanation: The most important client outcome is maintenance of effective gas exchange. Effective gas exchange will ensure that the child's vital signs remain within normal range. It is important that the parent is able to verbalize strategies to prevent future poisoning incidents and to understand how to contact the Poison Control Center, but these are not the most important outcomes. It is most important that the child survive the incident with no ongoing effects.

A nurse witnesses a school-aged child hit by an automobile. The child is lying unresponsive in the street. After ensuring a safe environment, which action will the nurse take next? Assess for signs of apparent bleeding. Locate a pulse by palpating the brachial artery. Tilt the head and lift the chin to open the airway. Use the jaw-thrust method to open the airway.

Use the jaw-thrust method to open the airway. Explanation: The action the nurse takes next is to open the airway using the jaw-thrust method. The nurse witnessed the accident but it is unknown whether the cervical spine has been injured, so the head-tilt, chin-lift method is contraindicated. The nurse will locate a pulse by palpating the carotid artery after opening the airway. The nurse would palpate the brachial artery in an infant or toddler. The nurse will assess for actual bleeding after opening the airway and ensuring circulation.

The off-duty nurse is in the park and is present when a child collapses. Which step should be performed first? Implement head tilt-chin lift maneuver.

Implement head tilt-chin lift maneuver. Explanation: When initiating rescue care to a child, implementation of CPR is indicated before activation of the EMS. The first step in the rescue is the establishment of a patent airway. The head tilt-chin lift is used in children.

Before discharging a school-age child being treated for a snake bite, the nurse instructs the child in ways to prevent additional bites in the future. Which statement indicates that teaching provided to this child has been effective? "I should bring a snake deterrent when on walks." "I should wear long pants when outdoors." "I should look at and under rocks before touching them." "I should stay away from going outside in case there are snakes."

"I should look at and under rocks before touching them." Explanation: In order to avoid snake bite, it is important to know common characteristics of snakes and safety rules when in an area where they are common. Common safety rules to avoid snake bites include being aware that snakes like to sit in the sun on warm rocks. They also frequently exist around rocks. The child should look at a rock before touching it to avoid touching or startling a snake. Snakes live in a variety of areas, making it difficult to refrain from all of those areas. Wearing long pants or spraying a snake deterrent will not necessarily prevent snake bites.

A nurse is preparing to administer atropine to a preschool-aged child. Which action will the nurse take when administering this medication? Titrate infusions according to cardiac output. Closely monitor blood glucose levels. Administer for opiate-induced bradypnea as needed. Avoid mixing the medication with sodium bicarbonate.

Avoid mixing the medication with sodium bicarbonate. Explanation: The nurse will avoid mixing atropine with sodium bicarbonate because the medications are incompatible. Dobutamine infusions, not atropine, should be titrated according to blood pressure and cardiac output. Naloxone may be administered as needed for opiate-induced bradypnea and apnea. Blood glucose levels should be closely monitored when administering intravenous dextrose, not atropine.

The nurse is caring for an 8-year-old child with salicylate toxicity. What will the nurse include in the child's plan of care? Select all that apply. Administer activated charcoal. Replace electrolytes. Administer naloxone. Monitor for bleeding. Administer sodium bicarbonate

Administer activated charcoal. Replace electrolytes. Administer sodium bicarbonate. Monitor for bleeding. Explanation: The nurse administers activated charcoal, replaces electrolytes, administers sodium bicarbonate, and monitors for bleeding in the child with salicylate toxicity. Administering naloxone is priority for the child with opioid toxicity, not salicylate toxicity.

The nurse is caring for a 3-year-old child who ingested a dangerous amount of amitriptyline, a tricyclic agent. What will the nurse include in the child's plan of care? Select all that apply. Administer sodium bicarbonate as prescribed. Assess blood sugar frequently. Monitor for lethargy. Do not induce vomiting. Perform continuous EKG monitoring.

Administer sodium bicarbonate as prescribed. Monitor for lethargy. Perform continuous EKG monitoring. Explanation: The nurse will administer sodium bicarbonate as prescribed, monitor for lethargy, and perform continuous EKG monitoring for the child with amitriptyline toxicity. Assessing blood sugar levels frequently is priority in the case of toxicity with a hypoglycemic agent. The nurse should not induce vomiting for corrosive and hydrocarbon toxicity, because vomiting may cause further damage; this is not a priority of care for the child who ingested a toxic amount of tricyclic agents.

The nurse is preparing to administer epinephrine to a child in the emergency department. What consideration(s) will the nurse take into account while administering this therapy? Select all that apply. Monitor for ventricular arrhythmias. Do not mix with sodium bicarbonate. The client is at risk for extravasation and tissue necrosis. Epinephrine causes pupil dilation. Give every 3 minutes during CPR.

Give every 3 minutes during CPR. Monitor for ventricular arrhythmias. The client is at risk for extravasation and tissue necrosis. Explanation: The nurse will administer epinephrine every 3 minutes during cardiopulmonary resuscitation(CPR), monitor for ventricular arrhythmias, and monitor for extravasation and tissue necrosis. Atropine, not epinephrine, causes pupil dilation and should not be mixed with sodium bicarbonate.

A nurse has provided teaching on water safety to the parents of a child hospitalized after a near drowning. What action will the nurse take to evaluate the parents' learning? Ask the parents if they understand the information provided. Have the parents verbalize ways they can reduce the child's risk of drowning. Ask the parents if they plan to teach their child to swim. Provide an opportunity for the parents to ask questions.

Have the parents verbalize ways they can reduce the child's risk of drowning.

The nurse is preparing to administer dopamine to a child in the emergency department. What consideration(s) will the nurse take into account for this medication? Select all that apply. Monitor for ventricular arrhythmias. Consider that dopamine causes pupil dilation. Administer via central line, if possible. Repeat every 3 minutes during CPR. Give as necessary for opiate-induced apnea.

Monitor for ventricular arrhythmias. Administer via central line, if possible. Explanation: The nurse will administer dopamine via central line, if possible. The nurse also will monitor for ventricular arrhythmias. Epinephrine, not dopamine, should be given every 3 minutes during cardiopulmonary resuscitation (CPR). Naloxone is given as necessary for opiate-induced apnea. Atropine, not dopamine, causes pupil dilation

An adolescent is brought to the emergency department after attempting to overdose on acetaminophen about 2 hours ago. The adolescent's serum acetaminophen level is significantly elevated. Which of the following would the nurse expect to administer? deferoxamine sodium bicarbonate N-acetylcysteine naloxone

N-acetylcysteine Explanation: N-acetylcysteine is the antidote for acetaminophen toxicity. Sodium bicarbonate is used for metabolic acidosis. Naloxone is used for opioid overdose. Deferoxamine is used to remove iron from the body as chelation therapy.

The nurse is teaching the parents of a 10-month-old infant at risk for hypovolemic shock about methods of rehydration. What will the nurse include in the teaching? Select all that apply. Encourage the child to drink water. Offer up to 2 tablespoons (30 milliliters) of liquid at a time. Breastfeed for shorter periods of time, but more frequently. Space out fluid intake over 15- to 20-minute intervals. Use electrolyte replacement drinks.

Offer up to 2 tablespoons (30 milliliters) of liquid at a time. Use electrolyte replacement drinks. Space out fluid intake over 15- to 20-minute intervals. Breastfeed for shorter periods of time, but more frequently. Explanation: The nurse will teach the parents to offer up to 2 tablespoons (30 milliliters) of liquid at a time, use electrolyte replacement drinks, space out fluid intake over 15- to 20-minute intervals, and to breastfeed for shorter periods of time, but more frequently. Children younger than 1 year of age should not rehydrate with water.

An adolescent is brought to the emergency department for suspected oxycodone overdose. Which agent will the nurse expect to be prescribed for this client? naloxone atropine lidocaine ketamine

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.

When the nurse is caring for a child presenting with a traumatic injury, which action is priority? Notify the primary health care provider Perform a primary assessment Apply an oxygen saturation monitor Ensure the code cart is available

Perform a primary assessment Explanation: The nurse would perform a primary assessment. When assessing a child with a traumatic injury, airway (A), breathing (B), and circulation (C) 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 would notify the health care provider and apply monitors as needed. The nurse should ensure a code cart is available before the start of the shift.

A toddler is brought to the emergency department after ingesting a corrosive substance. Which intervention will the nurse implement as part of the treatment regimen? Induce vomiting. Perform a respiratory assessment. Administer naloxone. Administer sodium bicarbonate.

Perform a respiratory assessment. Explanation: It is important for the nurse to perform a respiratory assessment, because corrosive substances can cause respiratory compromise resulting in oropharyngeal and tracheal erosion and edema. The nurse would not induce vomiting, because it can cause further damage to the esophagus, pharynx, and trachea. Sodium bicarbonate would be administered if the child ingested tricyclic agents, not a corrosive substance. Naloxone would be administered as an antidote if the child ingested an opiate.

A nurse correctly identifies which data as needing to be obtained from an injured child in relation to his or her respiratory status? Select all that apply. Skin color Rate of respirations Pulse rate Sound of obstruction Quality of respirations

Sound of obstruction Quality of respirations Skin color Rate of respirations When a child is assessed for respiratory distress it is important to first establish there is airway patency. Then assess by "Look, Listen, Feel" — is the chest rising, is there air escaping, is there air movement out of the nose and mouth. This quick assessment should be followed by assessing the quality of the respirations, the rate of respirations, color of the skin, the depth of respirations, and chest rise. The nurse should also assess for the adequacy of airflow in the lungs and for adventitious breath sounds. Pulse is assessed with the cardiovascular/circulatory system.

A nurse is providing care to a child hospitalized with sepsis. The nurse suspects the child's condition has progressed to septic shock, and the child is showing signs of decompensation. Which assessment finding supports the nurse's suspicion? warm skin extreme hypotension altered neurologic status bradycardia

altered neurologic status Explanation: An altered neurologic status is the finding that best supports the nurse's suspicion of decompensated shock. Decompensated shock is manifested by an extremely elevated heart rate, not bradycardia, which is a sign of refractory or irreversible shock. In decompensated shock, the blood pressure is just beginning to drop; extreme hypotension is evidence of irreversible shock. Warm skin is manifested in compensated shock. The skin is cool in decompensated shock

Assessment Name Temperature Blood pressure Heart rate Respiratory rate Lungs Peripheral pulses Capillary refill Time Taken Assessment Result 101.7°F (38.7°C) 80/46 mm Hg 138 beats/min 34 breaths/min Clear to auscultation Thready 4 seconds Mental status 1415 Lethargic but can be aroused A 3-year-old child is brought to the emergency department after ingesting some of the parent's medication. The parents deny that the child has vomited. The nurse has completed an assessment with the above findings. Which type of medication has the child likely ingested? opioid antidepressant hypoglycemic salicylate

antidepressant Explanation: The child has likely ingested an antidepressant, such as a tricyclic, which would cause tachycardia, dry mucous membranes, hyperthermia, and lethargy. A hypoglycemic could cause tachycardia and lethargy, but not dry mucous membranes or hyperthermia. They would cause dizziness, tremors, and pale clammy skin. Salicylates would cause tachypnea, nausea, and vomiting. Opioids would cause respiratory depression and bradycardia.

A toddler is brought to the emergency department after sustaining a life-threatening injury. During an assessment, the nurse utilizes the Glasgow Coma Scale. The toddler's score is 7. Based on this score, what inference can the nurse make about the child? It will be necessary to intubate the child. The child's neurologic system is intact. Naloxone administration will be required. The cardiovascular system is functioning normally.

It will be necessary to intubate the child. Explanation: A Glasgow Coma Scale score less than 8 is an indication to intubate during an emergent situation. Naloxone would be administered for bradypnea or apnea due to opioid toxicity. A Glasgow Coma Scale score of 7 does not indicate that the child's neurologic system is intact. The Glasgow Coma Scale does not assess cardiovascular functioning.

An adolescent is brought to the emergency department after attempting to overdose on acetaminophen about 2 hours ago. The adolescent's serum acetaminophen level is significantly elevated. Which of the following would the nurse expect to administer?

N-acetylcysteine Explanation: N-acetylcysteine is the antidote for acetaminophen toxicity. Sodium bicarbonate is used for metabolic acidosis. Naloxone is used for opioid overdose. Deferoxamine is used to remove iron from the body as chelation therapy.

The nurse is teaching the parents of an 8-year-old child about strategies to prevent accidental poisoning from a snake when the child goes outside. What will the nurse include in the teaching? Select all that apply. Suck venom out of the wound in the case of a snake bite. Do not handle or pick up a snake. If a snake bite occurs, apply a tourniquet. Wear protective clothing. Use a stick while walking in tall grass.

Wear protective clothing. Use a stick while walking in tall grass. Do not handle or pick up a snake. Explanation: The nurse will teach the parents to reduce the risk of snake bites by having the child wear protective clothing, have the child use a stick while walking in tall grass to scare away snakes, and not to handle or pick up a snake. The parents should not attempt to suck venom out of a snake bite or apply a tourniquet.

The nurse is assessing a 4-year-old child for clinical manifestations of compensated shock. What will the nurse include in the assessment? Select all that apply. altered neurologic status heart rate for tachycardia respiratory rate for tachypnea evidence of end-organ damage skin temperature for abnormal warmth or coolness

heart rate for tachycardia respiratory rate for tachypnea skin temperature for abnormal warmth or coolness Explanation: For compensated shock, the nurse will assess the child's heart rate for tachycardia, the respiratory rate for tachypnea, and the skin temperature for abnormal warmth or coolness. Altered neurologic status is a clinical manifestation of decompensated shock, and end-organ damage is a sign of irreversible shock.

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 mostlikely the result of: respiratory failure. underlying heart disease. neurologic trauma. lethal arrhythmia.

respiratory failure. Explanation: Cardiopulmonary arrest in infants and children typically results from disorders that lead to respiratory failure and shock. In adults, the most common causes of cardiopulmonary arrest are lethal arrhythmias secondary to heart disease. Although neurologic trauma can lead to respiratory failure, it alone is not the most likely factor.

The nurse is speaking to the mother of a dying child about the best ways to manage pain and discomfort. Which is the best response by the nurse? "We will provide pain medication around the clock to help prevent recurrence or escalation of pain." "We will not be repositioning your child since it seems to hurt him." "We will keep the lights and a television on in the room at all times so your child doesn't become scared." "We will provide pain medication to your child whenever she seems to be in pain."

"We will provide pain medication around the clock to help prevent recurrence or escalation of pain." Explanation: Provide pain medication around the clock rather than on an "as needed" basis to prevent recurrence or escalation of pain. Minimizing light and noise can help keep a calm environment. Frequent but gentle position changes can also help decrease pain and discomfort.

The nurse is preparing to transfer a child from the busy emergency department to an inpatient pediatric unit. What action by the nurse is best? Accompany the child and parents to the pediatric unit after calling verbal report to the unit and providing hand-off to the client's new nurse. Ask the unlicensed assistive personnel who has cared for the child to take the child and parents to the pediatric unit with a printed copy of the chart. Find another licensed nurse in the emergency department who is not as busy to transport the child and parents to the pediatric unit and call a verbal report. Instruct the hospital's transport team to take the child and parents to the pediatric unit and call a verbal report to the receiving nurse.

Accompany the child and parents to the pediatric unit after calling verbal report to the unit and providing hand-off to the client's new nurse. Explanation: When a child is admitted to the hospital from the emergency department, it is helpful to the child and parents for the nurse to accompany them to the hospital unit. This allows a transition period or "passing of care" that helps the parents accept the new caregivers as dependable and trustworthy. None of the other transport options allow this personal passing of care. Calling report and providing copies of information from the emergency department chart are also important steps in transferring care from one unit to another but lack the psychosocial benefit

An emergency department nurse is caring for a 5-year-old child who was just brought in by ambulance with partial-thickness (second-degree) and full-thickness (third-degree) burns to their face, neck, and chest. The client is awake and alert. Vital signs: temperature, 97.2°F (36.2°C); heart rate, 148 beats/min; blood pressure, 68/39 mm Hg; respiratory rate, 32 breaths/min; oxygen saturation, 90% on 2 liters by nasal cannula. The nurse receives prescriptions for the client. Click to highlight the prescription(s) that requires immediate implementation. Prescriptions: Apply oxygen to maintain oxygen saturations 95% or greater. Administer 100 mcg/kg morphine via intravenous push (IVP) for pain prn q4 hour. Initiate fluid resuscitation per Lund and Browder chart using Parkland formula with 0.9% saline. Administer acetaminophen by mouth (PO) 325 mg q6h prn for fever. Initiate a regular diet as tolerated.

Apply oxygen to maintain oxygen saturations 95% or greater. Initiate fluid resuscitation per Lund and Browder chart using Parkland formula with 0.9% saline. Explanation: The nurse applies oxygen to maintain an oxygen saturation of 95% or greater. The nurse will need to monitor the child's airway closely because the burns are on the chest and neck.Partial-thickness (second-degree) burns are very painful. The nurse administers 100 mcg/kg morphine via intravenous push (IVP) for pain prn q4 hours.Fluid resuscitation is implemented promptly to prevent shock. Fluid resuscitation for children is determined using the Lund and Browder chart and Parkland formula. Because the child sustained burns to the neck and chest, the nurse would not administer anything by mouth including medications such as acetaminophen PO 325 mg q6h prn for fever or a regular diet as tolerated.

Based on the nurse's note (above), which is the nurse's most appropriate next step related to the parents' concern?

Ask the parents what worries them most about their child's condition. Explanation: The nurse's most appropriate next step is to address the parents' concern by asking them what worries them most about their child's condition. While it is appropriate to provide reassurance that the child's pneumonia is resolving, the nurse should find out what specifically concerns the parents. The nurse should address the parents' concerns directly before contacting the health care provider to come and speak to the parents. The importance of completing the course of antibiotics should be included in the discharge instructions, but the nurse's next step should be to address the parents' concerns.

A 14-month-old trauma victim has arrived in the emergency department. What client priority will the nurse need to address first?

Inadequate systemic perfusion Explanation: When caring for a child who has experienced trauma, it is essential to provide care based on the ABCs. The assessment and management of the airway is always the first intervention. Oxygen is administered to prevent hypoxia from any decreased respiratory effort or bleeding. Once the airway is patent and managed, then circulation should be addressed. Perfusion should be assessed by the heart rate and the color and temperature of the skin. Poor perfusion indicates poor functioning of the heart and may precede cardiac arrest. Reduced core temperature and resultant metabolic demands are secondary needs after the ABCs have been established.

The nurse is assessing the breathing of a 6-year-old child who suffered an unwitnessed life-threatening injury. How will the nurse proceed with the assessment? Select all that apply. Evaluate respiratory effort. Assess for the appropriate number of respirations per minute. Monitor for adequate chest rise. Ensure adequate minute ventilation. Open the airway with the head-tilt, chin-lift maneuver.

Monitor for adequate chest rise. Assess for the appropriate number of respirations per minute. Evaluate respiratory effort. Ensure adequate minute ventilation. Explanation: The nurse will monitor for adequate chest rise, assess for the appropriate number of respirations per minute, evaluate respiratory effort, and ensure adequate minute ventilation for a 6-year-old child who suffered an unwitnessed life-threatening injury. The nurse should open the child's airway with the jaw-thrust maneuver. Because the injury was not witnessed, tilting the head back too far can actually occlude the airway.

A 12-year-old child is hospitalized after a submersion injury. After being rescued, the child received cardiopulmonary resuscitation (CPR) for approximately 7 minutes before regaining consciousness and spontaneously breathing. In providing care for the child, which intervention will the nurse prioritize? Administer antibiotics. Administer IV fluids. Monitor temperature. Monitor lung function.

Monitor lung function. Explanation: The nurse's priority is to monitor the child's lung function. Seventy percent of near-drowning survivors develop acute respiratory distress syndrome (ARDS). The nurse will need to monitor the child's temperature and administer antibiotics and IV fluids, but the priority intervention is to monitor the child's lung function.

A child is experiencing shock. Which assessment is essential for the nurse to complete to tell if the child is able to compensate? Monitor the neurological status. Monitor the heart rate. Monitor the blood pressure. Monitor the respiratory status.

Monitor the blood pressure. Explanation: Shock is the inability of blood flow and oxygen delivery through the body to meet metabolic demands. There are two forms of shock—compensated and decompensated. In compensated shock, the child will experience poor perfusion but will not have blood pressure changes. In decompensated shock, the child will experience inadequate perfusion with a decrease in blood pressure. It is essential that the nurse monitor the child's blood pressure to determine if the child is going into uncompensated shock. Monitoring the neurological status, the heart rate, and the respiratory status should also be evaluated, but these findings do not indicate the difference between compensated and decompensated shock.

The nurse is assessing a child in the pediatric inpatient unit and notes mottling of the child's lower extremities. Which nursing action(s) is appropriate at current? Select all that apply. Review the child's most recent electrolyte levels. Assess for signs of hypothermia and monitor the child's temperature. Palpate the child's bladder for fullness. Cover the lower extremities with a warm blanket and reassess mottling after 30 minutes. Monitor the child's oxygen saturation via pulse oximetry.

Monitor the child's oxygen saturation via pulse oximetry. Assess for signs of hypothermia and monitor the child's temperature. Explanation: To provide safe and efficient care, nurses follow the steps of the nursing process. These steps include assessment, followed by diagnosis, planning, intervention, and evaluation. In this case scenario, monitoring for the child's oxygen saturation and temperature and assessing for signs of hypothermia are very important assessment activities to determine what is wrong with the client and to be able to formulate appropriate interventions.

A nurse is preparing to administer resuscitative measures to an 8-month-old unresponsive infant. Which action(s) is appropriate for the nurse to take? Select all that apply. Palpate the brachial pulse. Check the pupils for reactivity. Ensure adequate ventilation. Use the head-tilt, chin-lift maneuver. Place head in a neutral position.

Palpate the brachial pulse. Place head in a neutral position. Check the pupils for reactivity. Ensure adequate ventilation. Explanation: Appropriate resuscitative measures the nurse will take for an infant include palpating the brachial pulse, opening the airway using the jaw-thrust maneuver, and ensuring adequate ventilation by using a bag and mask if necessary. Appropriate resuscitative efforts for infants do not include checking for pupil reactivity. The head-tilt, chin-lift maneuver is used to open the airway of older children, not infants.

A nurse is providing discharge teaching to the parent of a child hospitalized after experiencing respiratory arrest. The parent expresses concerns about the child's well-being. Which action(s) is appropriate for the nurse take? Select all that apply. Encourage the parent to discuss specific concerns about the child. Reassure the parent that the child's infection has been cured. Tell the parent that the child's provider will address any concerns during the follow-up visit. Reinforce when the health care provider should be called. Review signs and symptoms of respiratory distress with the parent.

Reinforce when the health care provider should be called. Encourage the parent to discuss specific concerns about the child. Review signs and symptoms of respiratory distress with the parent. Explanation: The most appropriate actions would be for the nurse to reinforce signs and symptoms of respiratory distress, and when the health care provider or 911 should be called. The nurse should also encourage the parent to share specific concerns about the child and address them at that moment instead of delaying until the follow-up visit. Providing reassurance that the respiratory infection has been cured does not address the parent's expressed concerns.

The nurse is preparing to administer dopamine to a child in the emergency department. What consideration(s) will the nurse take into account for this medication? Select all that apply. Monitor for ventricular arrhythmias. Consider that dopamine causes pupil dilation. Give as necessary for opiate-induced apnea. Administer via central line, if possible. Repeat every 3 minutes during CPR.

The nurse is preparing to administer dopamine to a child in the emergency department. What consideration(s) will the nurse take into account for this medication? Select all that apply. Monitor for ventricular arrhythmias. Administer via central line, if possible. Explanation: The nurse will administer dopamine via central line, if possible. The nurse also will monitor for ventricular arrhythmias. Epinephrine, not dopamine, should be given every 3 minutes during cardiopulmonary resuscitation (CPR). Naloxone is given as necessary for opiate-induced apnea. Atropine, not dopamine, causes pupil dilation.

A child is hospitalized in intensive care for a life-threatening heart condition. The child's treatment regimen includes epinephrine. What will the nurse consider when administering this medication? Pupil dilation and hyperglycemia are potential side effects. The risk for extravasation requires access via a central line. The drug's effects necessitate close monitoring of respirations. Infusions are titrated based on blood pressure and cardiac output.

The risk for extravasation requires access via a central line. Explanation: Epinephrine administered via a peripheral line has a high risk for extravasation and tissue necrosis; a central line is preferred for administration. The effects of epinephrine do not require close monitoring of respirations; however, it does require monitoring for ventricular arrhythmias. Pupil dilation is a side effect of atropine not epinephrine, and hyperglycemia is a potential side effect of dextrose 25%. Dopamine infusions, not epinephrine, require infusion titrations based on cardiac output and blood pressure.

The nurse is preparing to administer dobutamine to a child in the emergency department. What consideration(s) will the nurse take into account for this medication? Select all that apply. Monitor for ventricular arrhythmias. Repeat every 3 minutes during cardiopulmonary resuscitation (CPR). Titrate infusion depending on blood pressure and cardiac output. Administer by central line if possible. Consider that dobutamine causes pupil dilation.

Titrate infusion depending on blood pressure and cardiac output. Monitor for ventricular arrhythmias. Administer by central line if possible. Explanation: The nurse will titrate the infusion of dobutamine depending on the child's blood pressure and cardiac output, monitor for ventricular arrhythmias, and administer the medication by central line if possible. Epinephrine, not dobutamine, causes pupil dilation and should be repeated every 3 minutes during cardiopulmonary resuscitation (CPR).

Which medication is used for symptomatic bradycardia unresponsive to ventilation and oxygenation? atropine sodium bicarbonate naloxone calcium carbonate

atropine Explanation: Atropine is used for symptomatic bradycardia unresponsive to ventilation and oxygenation. Atropine increases cardiac output, dries secretions, and inhibits serotonin and histamine release. Sodium bicarbonate is used to combat acidosis when there is low perfusion. Naloxone reverses the effect of opioids. Calcium carbonate is used for documented or suspected hypocalcemia, hyperkalemia, hypermagnesemia, and calcium channel blocker overdose

The nurse is assessing a 10-year-old child with tachypnea and increased work of breathing. Which finding demonstrates the child is in the late stages of shock? cool and clammy extremities hypotension and capillary refill time greater than 5 seconds

hypotension and capillary refill time greater than 5 seconds Explanation: Compensated shock occurs when poor perfusion exists without a decrease in blood pressure. Once the child in shock is hypotensive, organ perfusion is dramatically impaired and a dire clinical scenario ensues. Commonly, the heart rate will increase in the early stages of shock, but as the heart becomes compromised as a result of poor perfusion, the child will become bradycardic. During compensated shock, the body can maintain some level of blood flow to the vital organs. Peripheral vasoconstriction, the body's compensatory response to diminished blood flow, often results in the child's ability to maintain a normal or near-normal blood pressure, but distal perfusion will be diminished, thereby resulting in cool extremities.

A child experiencing shock has received three boluses of normal saline solution. Which assessment will the nurse make to determine if the child is responding to the fluids? neurological status peripheral and central pulses amount of urine output heart and respiratory rates

peripheral and central pulses Explanation: Isotonic fluids, such as Ringer's lactate or normal saline, are the fluids of choice given rapidly to children experiencing shock. These fluids are administered at a volume of 20 ml/kg. After each fluid bolus, the nurse should assess the child to determine if there is a positive response. The first assessment is to assess the peripheral and central pulses. They will be stronger if the child is responding to the fluid administration. Another way to determine if there is a positive response is to assess the line of demarcation of the extremity coolness. It will be decreased. The blood pressure will also be improved as well as the capillary refill. Assessing the neurological status, the vital signs, and the urine output are components of an emergent assessment, but they do not indicate the response to the fluid replacement.

The nurse is providing care to a child admitted to the unit who survived a near-drowning incident. When assessing the child, the nurse would be especially alert for the development of which complication(s)? Select all that apply. acute respiratory distress syndrome (ARDS) pulmonary edema intestinal obstruction cardiac tamponade subdural hemorrhage

pulmonary edema acute respiratory distress syndrome (ARDS) Explanation: Up to 70% of symptomatic drowning survivors develop pulmonary edema and acute respiratory distress syndrome resulting from aspirated fluid, increased capillary permeability, negative pressure, and neurogenic pulmonary edema. In addition, a lung infection can occur in up to 50% of near-drownings as a result of aspiration of contaminated fluid. Subdural hemorrhage is associated with traumatic brain injury and would only be a concern if the child suffered a head injury with the submersion incident. Cardiac tamponade or intestinal obstruction are not typically associated with near-drowning incidents.

Administration of which medication reverses the histamine release and hypotension that are seen in anaphylaxis? diphenhydramine epinephrine atropine cimetidine

epinephrine Explanation: Epinephrine reverses histamine release and hypotension due to anaphylaxis. It increases the heart rate and systemic vascular resistance. Diphenhydramine and cimetidine are histamine blockers. They are used for milder forms of allergic reactions. Atropine is an anticholinergic. It causes tachycardia, inhibits secretions, and relaxes smooth muscle.

A nurse is providing care to a child diagnosed with septic shock. The nurse believes the child's condition is progressing to decompensated shock. What significance does the nurse's belief have on the child's condition? Additional measures are necessary to meet the child's metabolic requirements. Resuscitative efforts have been successful in improving the child's condition. Homeostatic mechanisms are working to maintain systemic perfusion. The child's condition has deteriorated to terminal status.

Additional measures are necessary to meet the child's metabolic requirements. Explanation: Decompensated shock indicates that the child is no longer able to compensate for the body's decreased perfusion. Without appropriate intervention, hypotension and cardiovascular collapse will occur. It does not indicate that resuscitative efforts have improved the child's condition or that the child's homeostatic mechanisms are working to maintain perfusion (compensated shock). Deterioration to terminal status indicates irreversible or refractory shock.

A nurse is providing care for a toddler who ingested an unknown amount of acetaminophen. Which intervention will the nurse prioritize? Monitor liver function tests. Assess for signs of bleeding. Administer intravenous sodium bicarbonate. Administer activated charcoal.

Administer activated charcoal. Explanation: The nurse will prioritize the administration of activated charcoal, which will bind to acetaminophen so it can be excreted in the stool. The nurse should monitor liver function tests because acetaminophen toxicity adversely affects the liver, but the priority is to administer activated charcoal. The nurse would assess for signs of bleeding if the toddler had ingested a salicylate such as aspirin. Intravenous sodium bicarbonate is part of the treatment for an overdose of salicylates, not acetaminophen.

The nurse is caring for a 4-year-old child who ingested drain cleaner. What will the nurse include in the child's plan of care? Select all that apply. Do not induce vomiting. Give milk or water. Administer n-acetylcysteine. Monitor blood sugar frequently. Administer calcium salts.

Do not induce vomiting. Give milk or water. Explanation: The nurse will not induce vomiting while caring for a child who ingested drain cleaner or other corrosive agents. The child should consume milk or water to dilute the corrosive. Monitoring blood sugar frequently should be performed for toxicity with hypoglycemic agents. Calcium salts are given in the case of a child ingesting calcium channel blockers. N-acetylcysteine is the antidote for acetaminophen toxicity.

A nurse is providing care to a child hospitalized after experiencing respiratory arrest secondary to an asthma exacerbation. The child is scheduled for discharge, but the parents are concerned about the child having a repeat arrest. Which action will best allay the parents' concerns? Review early signs and symptoms of respiratory compromise. Reassure the parents that the child's condition has resolved. Emphasize the importance of maintaining adequate fluid hydration. Encourage the parents to take a community CPR class.

Review early signs and symptoms of respiratory compromise. Explanation: The best action for the nurse to take to allay the parents' concerns would be to help them to recognize early signs and symptoms of respiratory compromise. This allows the parents to intervene early by contacting the health care provider or calling 911. Reassuring the parents that the child's condition has resolved and encouraging them to take a CPR class are appropriate actions, but they do not directly address the parents' concern about a repeat occurrence. Adequate fluid hydration is important to a child's health and well-being, but in this case, it does not address the parents' concerns.

A nurse is providing teaching to a group of parents on how to protect children from accidental poisonings. Which statement made by a parent requires intervention by the nurse? "Hot, soapy water is best for cleaning surfaces used for meat preparation." "Our adolescent always ask us before taking any over-the-counter medication." "My toddler helps out by bringing the gummy vitamins to me every morning." "We have found walking sticks useful whenever we go on hikes."

"My toddler helps out by bringing the gummy vitamins to me every morning." Explanation: The nurse will intervene if a parent states that the toddler is able to get to the vitamins on one's own. Medications, personal care products, and cleaning supplies should be kept locked away and out of sight of small children. Walking sticks can be used to scare snakes and other poisonous creatures away when hiking. Hot, soapy water should always be used to clean surfaces and utensils used for meat prep to avoid cross contamination. Preadolescents and adolescents should be taught about medication safety and to ask parents before using them.

The nurse is caring for a 4-year-old child with opioid toxicity. What will the nurse include in the plan of care? Select all that apply. Monitor for bleeding. Give additional doses of naloxone as necessary. Administer activated charcoal. Administer naloxone. Replace electrolytes.

Administer naloxone. Give additional doses of naloxone as necessary. Explanation: The nurse will administer naloxone and give additional doses of naloxone as needed for a 4-year-old child with opioid toxicity. Monitoring for bleeding, replacing electrolytes, and administering activated charcoal are performed for a child with salicylate toxicity, not opioid toxicity.

The nurse is assessing a 10-year-old child with tachypnea and increased work of breathing. Which finding demonstrates the child is in the late stages of shock? cool and clammy extremities stable blood pressure and cool extremities increased heart rate with weak distal pulses hypotension and capillary refill time greater than 5 seconds

admission for observation overnight Explanation: Although the child is awake and alert and only has mild respiratory symptoms, the child is still at risk for respiratory compromise up to 8 hours after a near-drowning so the nurse would expect admission for overnight observation to closely monitor the child's respiratory status. It would be dangerous to discharge the child right away with next-day follow-up or to monitor for just 2 hours, because the child's condition could deteriorate up 8 hours after a near-drowning incident. At this point, there is no indication for transfer to an intensive care unit. However, if the child's neurologic status was impaired or the respiratory status worsened then transfer to an intensive care unit would be appropriate.

The nurse is preparing to administer atropine to a 4-year-old child in the emergency department. What consideration(s) will the nurse take into account for this medication? Select all that apply. Give as necessary for opiate-induced apnea. Monitor heart rhythm. Give every 3 minutes during CPR. Do not mix with sodium bicarbonate. Atropine causes pupil dilation.

Do not mix with sodium bicarbonate. Monitor heart rhythm. Atropine causes pupil dilation. Explanation: The nurse will not mix atropine with sodium bicarbonate, because the medications are incompatible. The nurse also will monitor the child's heart rhythm, and consider that atropine causes pupil dilation. Epinephrine, not atropine, is given every 3 minutes during cardiopulmonary resuscitation (CPR). Naloxone is given as necessary for opiate-induced apnea.

A nurse is providing care to a child hospitalized with a severe asthma exacerbation. The child had been showing signs of improvement but now seems excessively sleepy, has paradoxical breathing, and a respiratory rate of 9 breaths/min. Which action will the nurse take next? Administer oxygen. Determine the underlying cause. Assess the heart rate. Ensure an open airway.

Ensure an open airway. Explanation: The nurse's next step is to ensure the child has an open airway. Once the airway is open, oxygen can be administered (via bag/mask), and the heart rate assessed. After airway, breathing, and circulation are attained, the nurse can determine the underlying cause of the symptoms.

A community health nurse is planning a class on water safety for families. What information is important for the nurse to include in the class? Select all that apply. Children who have learned to swim require less supervision. The family needs to maintain fencing around pools to deter unsupervised swimming. Small inflatable wading pools are safe options for toddlers. Personal floatation devices are recommended for children riding in boats. It is important for adult supervision at poolside at all times.

It is important for adult supervision at poolside at all times. The family needs to maintain fencing around pools to deter unsupervised swimming. Personal floatation devices are recommended for children riding in boats Explanation: Information that is important for the nurse to include in a water safety class includes the importance of adult supervision for children at poolside, maintaining fencing around pools, and the use of personal floatation devices for children riding in boats. Toddlers can easily drown in a few inches of water so inflatable wading pools can be as hazardous as a full sized pool. Parents and children sometimes misjudge the child's swimming abilities, so children will still require supervision.

A nurse is providing care to a child hospitalized after an accident that resulted in a substantial loss of blood. The nurse is preparing to administer IV fluids using a 60-milliliter syringe attached to the child's IV site. The child's parent asks the nurse why there is no IV bag hanging. What is the best response for the nurse to make? "I need to administer small amounts of fluid as quickly as possible." "Children need much less fluid than adults." "Hanging an IV bag would cause the infusion to flow too quickly." "Your child is too young to receive IV fluids by that method."

"I need to administer small amounts of fluid as quickly as possible." Explanation: Children who require fluid resuscitation should receive several small boluses over short periods of time (20 ml/kg over 5 to 10 minutes). Infusing the fluid via gravity would be too slow for resuscitation purposes. Children are not too young to receive IV infusions via a more traditional method. Children may need less fluid overall than adults but that is not the rationale for using a syringe for fluid resuscitation.

The nurse is caring for a 3-year-old child with sulfonylurea toxicity. What will the nurse include in the client's care? Select all that apply. Assess for bleeding. Monitor blood sugar frequently. Do not induce vomiting. Administer sodium bicarbonate as prescribed. Administer glucagon and dextrose as prescribed.

Administer glucagon and dextrose as prescribed. Monitor blood sugar frequently Explanation: The nurse administers glucagon and dextrose as prescribed and monitors blood sugar frequently in a child with sulfonylurea toxicity. The nurse should administer sodium bicarbonate as prescribed for toxicity with a tricyclic agent. Salicylate toxicity would require that the nurse assess the child for bleeding. The nurse should not induce vomiting for corrosives and hydrocarbon toxicity, because vomiting will cause further damage; this is not a priority of care for the child with sulfonylurea toxicity.

The nurse is preparing to assess a 13-year-old child in the emergency department with opioid toxicity. What will the nurse include in the assessment? Select all that apply. Assess for hypoglycemia. Assess for slowed respiratory rate and apnea. Monitor for bleeding. Monitor for bradycardia. Evaluate mental status.

Assess for slowed respiratory rate and apnea. Evaluate mental status. Monitor for bradycardia. Explanation: The nurse assesses for slowed respiratory rate and apnea, evaluates the child's mental status, and monitors for bradycardia in a 13-year-old child with opioid toxicity. Monitoring for bleeding should be performed for salicylate toxicity. Assessing for hypoglycemia should be performed for a child with toxicity with hypoglycemic agents.

The nurse is assessing a 2-year-old child with sulfonylurea toxicity. What will the nurse include in the assessment? Select all that apply. Examine skin for pallor, clamminess, and sweating. Assess for tremors. Assess for stridor. Evaluate mental status for lethargy. Monitor for mouth and throat pain.

Assess for tremors. Evaluate mental status for lethargy. Examine skin for pallor, clamminess, and sweating. Explanation: The nurse assesses for tremors; evaluates the child's mental status for lethargy; and examines the skin for pallor, clamminess, and sweating. Assessing for stridor should be performed in the case of a child ingesting corrosives, not hypoglycemic agents. Mouth and throat pain is also a finding associated with the accidental ingestion of corrosives.

The nursing instructor is speaking with a group of nursing students about rapid cardiopulmonary assessment. Which statement by a student would indicate a need for further education? "If a child receiving 100% oxygen by mask does not improve, I will need to perform assisted ventilation with a bag-valve-mask device." "For an infant, I use the brachial artery to check for a pulse." "I will place the child on a cardiac monitor. I will use this to assess the child's heart rate." "An interosseous needle will need to be inserted if a peripheral IV access cannot be obtained within 90 seconds in a child."

"I will place the child on a cardiac monitor. I will use this to assess the child's heart rate." Explanation: Always evaluate the presence of a heart rate by auscultation of the heart or by palpation of central pulses. Never use the cardiac monitor to determine if the child has a heart rate. The presence of a cardiac rhythm is not a reliable method for evaluation of the ability to perfuse the body. If a child does not improve with 100% oxygen, the next step is to administer oxygen via a bag-valve-mask. The brachial artery is the correct place to check for a pulse in an infant. Establishment of IO access should be attempted if a peripheral IV is not able to be obtained within 3 attempts or 90 seconds.

The nurse is preparing to assess a 3-year-old child with metoprolol toxicity. What will the nurse include in the assessment? Select all that apply. Assess for right upper quadrant abdominal pain. Monitor for increased liver enzymes. Assess heart rate for bradycardia. Evaluate respiratory rate for bradypnea. Monitor for hypotension.

Assess heart rate for bradycardia. Monitor for hypotension. Explanation The nurse will assess the heart rate for bradycardia and monitor for hypotension in the child with metoprolol toxicity. Evaluating the respiratory rate for bradypnea is part of the assessment of the child with opioid toxicity. Monitoring for increased liver enzymes and assessing for right upper quadrant abdominal pain should be included in the assessment of a child with acetaminophen toxicity.

A pediatric nurse practitioner (PNP) is conducting an in-service education program on the topic of shock for a group of pediatric nurses. The PNP is describing the different categories of shock and the events that occur with each. The PNP determines that the teaching was successful when the group identifies the events of distributive shock. Place the events below in the order from first to last that would demonstrate successful teaching. decreased stroke volume and cardiac output relative hypovolemia massive vasodilation decreased peripheral vascular resistance • insufficient organ perfusion decreased venous return

Massive vasodilation Decreased peripheral vascular resistance Relative hypovolemia Decreased venous return Decreased stroke volume and cardiac output Insufficient organ perfusion

The nurse is caring for a 5-year-old child who ingested a dangerous amount of fluoxetine, a selective serotonin reuptake inhibitor (SSRI). What will the nurse include in the plan of care? Select all that apply. Perform continuous EKG monitoring. Monitor blood pressure. Administer benzodiazepines as prescribed. Give sodium bicarbonate as prescribed. Do not induce vomiting.

Monitor blood pressure. Administer benzodiazepines as prescribed. Perform continuous EKG monitoring. Explanation: The nurse will monitor blood pressure, administer benzodiazepines as prescribred, and continuously monitor the EKG of a child with fluoxetine toxicity. The nurse should not induce vomiting if the child has ingested corrosives or hydrocarbons, such as batteries or paint thinner, respectively. Sodium bicarbonate is given for toxicity with tricyclic agents, not selective serotonin reuptake inhibitors (SSRIs).

The nurse is preparing to administer naloxone to a child in the emergency department. What consideration(s) will the nurse take into account while administering this medication? Select all that apply. Opioid's effects outlast nalone's therapeutic effects. May repeat as necessary for opiate-induced apnea. Monitor for bleeding. Give every 3 minutes during CPR. Naloxone causes pupil dilation.

Opioid's effects outlast nalone's therapeutic effects. May repeat as necessary for opiate-induced apnea. Explanation: The nurse will repeat the administration of naloxone as necessary for opiate-induced apnea, because this is an opioid effect that outlasts the therapeutic effects of naloxone. Monitoring for bleeding is a consideration when treating a client for aspirin toxicity, not while administering naloxone for opioid toxicity. Epinephrine, not naloxone, should be given every 3 minutes during cardiopulmonary resuscitation (CPR), and the nurse should monitor for ventricular arrhythmias when administering this medication. Atropine, not naloxone, causes pupil dilation.

A child is hospitalized with a diagnosis of anaphylactic shock secondary to an allergic reaction to an insect bite. In providing care to the child, what should the nurse prioritize? replacement of electrolytes administration of intravenous fluids administration of inotropic medications assessment of mental status

administration of intravenous fluids Explanation: Anaphylaxis shock results in a reduction of tissue perfusion. The nurse's priority should be to administer IV fluids to enhance perfusion. Assessing the child's mental status is important but enhancing perfusion is the priority. Inotropic medications may be given if the child's condition does not respond to IV fluid resuscitation. Electrolyte replacement should be part of the treatment regimen but it is not the priority.

A child is brought to the emergency department after being submerged for an undetermined amount of time in the family pool. Resuscitative efforts have resulted in a normal heart rate, but the child remains intubated on respiratory support and has not regained consciousness. Which potential complication will have the greatest effect on the child's outcome? infection atelectasis hypovolemia hypothermia

atelectasis Explanation: Atelectasis and other lung conditions including acute respiratory distress syndrome (ARDS) would have the greatest effect on the child's outcome. Poor oxygenation can adversely affect all body systems particularly the brain. Hypothermia, infection, and hypovolemia are all potential complications of a submersion injury; however, atelectasis has the greatest effect on the child's outcome because it adversely affects lung function and oxygenation.

A preschool-aged child is hospitalized after ingesting an unknown amount of sulfonylurea. The nurse is creating a plan of care for the child. Which assessments will the nurse prioritize? Select all that apply. level of consciousness heart rate serum glucose pain temperature

heart rate serum glucose level of consciousness Explanation: The nurse will prioritize assessments of the child's heart rate, serum glucose level, and level of consciousness. Sulfonylureas are used to treat diabetes. These medications can cause hypoglycemia, tachycardia, and lethargy. Although the assessment of temperature and pain should be part of the plan of care, they are not the priority in this case. Monitoring for fever would be a priority for a child who ingested a hydrocarbon. Pain would be a priority assessment for a child who ingested a corrosive substance.

A child's parent calls the clinic nurse and states, "My child just drank an unknown amount of a cleaning solution. What should I do?" Which statement by the nurse is best? "You need to hang up with me and call the poison control center now." "Immediately take your child to your local emergency facility." "Monitor your child's breathing and heart rate closely for the next 24 hours." "You need to give your child ipecac syrup to induce vomiting."

"You need to hang up with me and call the poison control center now." Explanation: The nurse would tell the parent to call a poison control center to receive information of how to best treat the child. A poison control center will provide the most accurate information on the next steps for the client. The nurse would not recommend ipecac syrup, which induces vomiting. Not all poisons should be vomited. Strong acids, for example, could cause as much destruction of tissue being vomited as being swallowed. The child can be brought to the local emergency facility; however, calling a poison control center is best. Health care professionals should be the ones to monitor the child, not the parents or caregivers in this situation.

The nurse is preparing to present an educational session on pediatric cardiopulmonary arrests. The nurse will include which statement in the teaching? "Obtaining an automated external defibrillator (AED) is vital to survival." "Activate the emergency response system first in an unwitnessed event." "Start cardiopulmonary resuscitation (CPR) in an infant if the heart rate is below 75 beats per minute." "Most pediatric arrests stem from airway and breathing issues."

"Most pediatric arrests stem from airway and breathing issues." Explanation: Most pediatric arrests are related primarily to airway and breathing, and usually only secondarily to the heart issues. This information guides the nurse to always assess the airway first in case of an emergency involving cardiopulmonary arrest. While obtaining an AED is important, pediatric arrests are more often respiratory related instead of cardiac. In an unwitnessed event, CPR should be started first. The emergency response system is first activated when the event is witnessed. CPR should be started when an infant's heart rate is less than 60 beats per minute.

A nurse is providing care to a 10-year-old child hospitalized after a near-drowning incident. The child is awake and alert, and vital signs are within normal parameters. The child has a mild, productive cough and has been placed on supplemental oxygen via nasal cannula. The child's parent asks the nurse "Why does my child need to be hospitalized? My child seems ok." Which is the nurse's best response? "Do not worry, your child can come home tomorrow morning." "Even though your child is fine now, the condition could change later." "We need to monitor your child overnight to make sure your child is alright." "Your child's heart and lungs should be monitored for changes for 6 to 8 hours."

"Your child's heart and lungs should be monitored for changes for 6 to 8 hours." "Your child's heart and lungs should be monitored for changes for 6 to 8 hours." Explanation: The nurse's best response is that the child's heart and lungs should be monitored for changes for 6 to 8 hours. This answer provides the parent with a clear rationale for the hospitalization. Telling the parent that the child needs to be monitored overnight to make sure the child is alright and that the child's condition could change later is appropriate, but giving the parents a specific reason for the hospitalization is the best option. Telling the parent not to worry and that the child can come home tomorrow does not answer the parent's question and provide information that cannot be verified at this time.

The nurse is assessing a child in the emergency department who ingested a battery from a toy. What will the nurse include in the assessment? Select all that apply. Examine mouth for redness and irritation. Assess for stridor. Assess for hypotension. Monitor for difficulty swallowing. Assess for right upper quadrant abdominal pain.

Assess for stridor. Examine mouth for redness and irritation. Monitor for difficulty swallowing. Explanation: The nurse assesses for stridor, examines the mouth for redness and irritation, and monitors for difficulty swallowing in the case of a child who ingested a corrosive, such a battery. Assessing for hypotension should be performed for a child with opioid toxicity, and assessing for right upper quadrant abdominal pain should be part of the assessment for a child with acetaminophen toxicity.

The nurse is caring for a 7-year-old child who exhibits symptoms of anaphylactic shock after being stung by a bee. The nurse notes that the child's lips are swelling. The nurse hears audible wheezing with dyspnea. Which intervention will the nurse perform first? Increase fluid intake by having the child drink cold water. Teach the child how to use an epinephrine auto-injection device. Place an endotracheal tube insertion tray at bedside. Administer antihistamine as prescribed.

Place an endotracheal tube insertion tray at bedside. Explanation: The nurse recognizes that an acute situation is happening and client safety is of greatest importance. Common manifestations of anaphylaxis include bronchospasm and laryngeal edema. If symptoms of anaphylaxis continue to develop, an endotracheal tube will need to be inserted to assure a patent airway. Administration of antihistamine is a secondary treatment for anaphylaxis. Increasing fluid intake is appropriate for trauma. Educating the child is an important intervention prior to discharge.

A nurse is providing care to a child who is to receive a dobutamine infusion. Which assessments are most important for the nurse to perform when administering this medication? Select all that apply. temperature cardiac output respiratory rate blood pressure heart rhythm

blood pressure heart rhythm cardiac output Explanation: When administering dobutamine, it is most important for the nurse to assess the client's blood pressure and heart rhythm. Dobutamine should be administered and titrated according to the client's blood pressure and cardiac output. Temperature and respiratory rate are not assessments important to the administration of dobutamine. However, these assessments should be included in the client's plan of care.

A toddler is brought to the emergency department after swallowing some of the parent's prescription opioid medication. The toddler is unresponsive with shallow respirations. The nurse has administered naloxone to the toddler. Which intervention will the nurse expect to implement? Administer additional doses as needed. Maintain a central line for repeat doses. Periodically assess blood glucose levels. Monitor the heart rate for ventricular arrhythmias.

Administer additional doses as needed. Explanation: The nurse will expect to administer additional doses as needed. The opioid effects will outlast the therapeutic effects of naloxone, so additional doses may be needed. A central line is preferable for the administration of dopamine, epinephrine, and dobutamine, not naloxone. Monitoring for ventricular arrhythmias is an intervention for dopamine, epinephrine, and dobutamine, not naloxone. The administration of dextrose requires blood glucose monitoring.

Assessment Add New Assessment Order Acknowledge Pending Orders Assessment Name Blood pressure Heart rate Respiratory rate Mental status Peripheral pulses Time Taken Assessment Result 80/46 mm Hg 148 beats/min 34 breaths/min Semiconscious Diminished Skin 1415 Pale in color, cool to touch A child is hospitalized after sustaining an injury that resulted in a significant loss of blood. The nurse has performed an assessment with the findings charted above. Which medication does the nurse expect to administer? dextrose 25% atropine dopamine naloxone

dopamine Explanation: A significant loss of blood leads to hypovolemia, resulting in tachycardia, and hypotension. Hypovolemia also causes decreased perfusion resulting in changes in mental status, diminished pulses, and pallor. The nurse expects to administer intravenous dopamine, which will increase the blood pressure, decrease the heart rate, and improve perfusion. Dextrose 25% would be administered for hypoglycemia. This child requires IV fluids but would require 0.9% normal saline or lactated Ringer's solution. Naloxone is administered for respiratory depression related to opioid effects. Atropine is administered for bradycardia and to increase cardiac output.

The parents bring their 3-year-old child to the emergency department after ingesting some of the parent's morphine liquid prescription. Which nursing assessment is the priority? noting the child's pulse rate and quality evaluating the child's mental status, skin moisture, and skin color obtaining a complete set of vital signs auscultating all lung fields for signs of edema

evaluating the child's mental status, skin moisture, and skin color Explanation: In cases of poisoning, clinical manifestations vary widely depending on the medication or chemical ingested. Therefore, it is important to place attention on the child's mental status, skin moisture/skin color, and bowel sounds. Mental status change, cold clammy skin, pallor, and/or cyanosis are classic signs of opiate overdose. Evaluating the effectiveness of the child's breathing and noting the child's pulse rate and quality are basic to any rapid cardiopulmonary assessment. Obtaining a full set of vital signs is important, but this can be obtained after mental status, skin color, and skin moisture have been checked. Auscultating all lung fields for signs of pulmonary edema would be critically important for a child who is a near-drowning victim.

The nurse is assessing an 8-year-old child for clinical manifestations of irreversible shock. What should the nurse include in the assessment? Select all that apply. heart rate for bradycardia evidence of end-organ damage altered neurologic status hypotension unresponsive to inotropic agents respiratory rate for bradypnea

evidence of end-organ damage hypotension unresponsive to inotropic agents heart rate for bradycardia The nurse assesses for evidence of end-organ damage, hypotension unresponsive to inotropic agents, and the heart rate for bradycardia. Bradypnea is not a clinical manifestation of irreversible shock. Altered neurologic status is a clinical manifestation of decompensated shock, not irreversible shock.