Key Pediatric Nursing Interventions
A child with HIV, weighing 25 kg (55.1 lbs), is about to receive an infusion of IVIG. The recommended dose is 400 mg/kg/dose. The medication is available in a concentration of 50 mg/mL. What is the proper amount of infusion that the child will receive? 2000 mL 200 mL 100 mL 1000 mL
200 mL Explanation: The dose is calculated as 25 x 400 = 10,000 mg. Because the concentration is 50 mg/mL, calculate the volume as 10,000/50 = 200 mL.
The nurse is caring for a child with an ileostomy. What nursing intervention will be included in this child's plan of care? Clean the outside of the collection device. Leave the ileostomy open to the air. Check for leakage around the stoma. Apply a sterile dressing around the stoma.
Check for leakage around the stoma. Explanation: An ileostomy is made by bringing a part of the small intestine through the abdominal wall to create an outlet for fecal material. The drainage from the ileostomy contains digestive enzymes, so the stoma must be fitted with a collection device to prevent skin irritation and breakdown. A colostomy is a similar opening in the colon that allows fecal material to be eliminated. A new colostomy may be left open to the air; alternatively a bag, pouch, or other appliance may be used to collect the stool. A urostomy may be created to help in the elimination of urine. Ostomy bags should be checked for leakage, emptied frequently, and changed when needed.
The nurse is preparing to administer regular insulin to a nonverbal pediatric client. Which action will the nurse perform prior to administering the medication? Check the full name and birth date on the client's wristband with the medication administration record. Check the full name and room number on the client's wristband with the medication administration record. Check the birth date and full name on the client's wristband with the medication administration record and have another nurse verify. Check the full name and age on the client's wristband with the medication administration record and have the parent verbally confirm.
Check the full name and birth date on the client's wristband with the medication administration record. Explanation: When administering medications to a child, the nurse needs to use at minimum two client identifiers that are directly associated with the client and the medication to be given, such as full name, client ID number, and birth date. The nurse will take the medication administration record to the room to perform a "double-identifier" check. A client's identity must be verified with two acceptable identifiers, not just one. There is no need to have another nurse verify or have the parent state the client's information. A room number or a bed number is not an acceptable identifier.
A child needs a peripheral IV start as well as a venous blood sample for a laboratory test. The nurse will take what action? Coordinate placing the peripheral IV and the lab blood draw. Make sure the laboratory specimen is drawn prior to placing the IV access device. Delay both the IV start and blood draw until the child is well hydrated orally. Place the IV and start intravenous fluids promptly; then request the laboratory obtain the blood specimen.
Coordinate placing the peripheral IV and the lab blood draw. Explanation: Coordinate the IV placement and lab blood draw to minimize the number of venipunctures for the child. Gaining venous access for each purpose separately does not do this and is not necessary. Having a well-hydrated child makes venous access easier, but oral hydration will take some time, thus delaying needed treatment.
The nurse administers an antipyretic rectal suppository. The child has a bowel movement 15 minutes later. What is the appropriate nursing action? Immediately notify the physician or nurse practitioner. Wait to readminister the medication until the next scheduled dose. Administer another suppository, and then hold the child's buttocks together. Recheck the child's temperature to determine if the suppository is needed. Examine the stool for the presence of the suppository.
Examine the stool for the presence of the suppository. Explanation: The stool should be examined for the suppository that may have been expelled with the bowel movement. If it is found, the physician or nurse practitioner can be notified to determine if the suppository should be repeated. The nurse should not administer another dose without examining the stool or contacting the physician or nurse practitioner. Rechecking the child's temperature would provide little useful information since only a very limited time has elapsed since the temperature was last checked.
The nurse is administering an oral liquid medication to a 5-year-old child. What would be the most appropriate for the nurse to do when administering this medication? Ask the parent to hold the child's arms during administration. Administer the medication using a dropper. Have the child lying down with the head elevated on a pillow. Let the child hold the medication cup.
Let the child hold the medication cup. Explanation: Droppers and oral syringes can be used to administer medications to infants and young children. Medication cups and spoons can be used to administer liquid medications to the older child. The child can hold the medication cup and drink the liquid medication. Depending upon the age of the child, he or she may still prefer to take liquid medications via the syringe. It makes taking the medication fun when the child can squirt it into the mouth by himself or herself. The child who is lying down when being given medications should have the head of the bed elevated to at least 45 degrees A 5-year-old child does not need to be restrained for medication administration.
A toddler requires 1.5 ml of an antibiotic given intramuscularly (IM). How will the nurse administer this medication? Divide the dose. Administer 0.75 ml IM in each vastus lateralis. Administer the antibiotic IM in the rectus femoris. Seek an order for an oral form of the antibiotic. Reduce the volume of the dose using less diluent than recommended to prepare the antibiotic for IM injection.
Divide the dose. Administer 0.75 ml IM in each vastus lateralis. Explanation: The recommended amount of solution a toddler should receive in one IM injection should not exceed 1 ml. Dividing the dose is necessary even though two injections will cause additional stress. These could be given simultaneously by two nurses. Seeking an oral route could be explored, but may not be feasible. The manufacturer's directions regarding the amount of diluent should be followed to ensure safety.
A nurse is preparing a dose of insulin to give the client. Which action takes priority when preparing and administering this medication? Have another RN witness the injection given to the client. Double-check the math calculations. Ask the client if he or she has had any adverse reactions to insulin in the past. Double-check the dose with another RN before giving.
Double-check the dose with another RN before giving. Explanation: Insulin is a high-alert medication and the dosage must be checked with another RN before administering. All rights of medication administration should be adhered to. Insulin dosages come in units and the prescription is to administer a specific number of units; thus, no calculations of dosages are needed. Insulin injections do not have to be witnessed. Insulin is not known for having adverse reactions, but it is always a good practice to ask the client if he or she has experienced any problems receiving insulin.
A child is having difficulty swallowing pills. What is the best action for the nurse to take to help this child swallow medications? Hold the medication and notify the health care provider. Place the pills in a bite of ice cream or applesauce. Obtain small round candy to practice swallowing techniques. Crush all medications and dissolve in water.
Place the pills in a bite of ice cream or applesauce. Explanation: The most useful technique when children cannot swallow pills is to put them into some ice cream or applesauce. This allows the medication to be administered in the original form. The nurse should not use candy for practice, because this may suggest to the child that medicine is the same as candy. The nurse should never crush medications which are enteric coated or time released. The nurse should always strive to administer a prescribed medication, even if doing so may be difficult.
The nurse is caring for a child with an intravenous device in the hand. Which sign would alert the nurse that infiltration is occurring? pain, tenderness warmth, redness cool, puffy skin induration
cool, puffy skin Explanation: Signs of infiltration include cool, puffy, or blanched skin. Warmth, pain, redness, induration, and tender skin are signs of inflammation.
A nurse is educating the parents how to administer daily oral medication to their 5-year-old boy. Which response indicates a need for further teaching? "We checked that the medicine can be mixed with yogurt or applesauce." "He needs to take his medicine or he will lose a privilege." "We should never bribe our child to take the medicine." "I should never refer to the medicine as candy."
"He needs to take his medicine or he will lose a privilege." Explanation: The nurse should emphasize that the parents should never threaten the child in order to make him take his medication. It is more appropriate to develop a cooperative approach that will elicit the child's cooperation since he needs ongoing, daily medication. The other statements are correct.
The nurse has been caring for a 12-year-old boy during his 5-day hospitalization. The child's IV has infiltrated, and the care provider is getting ready to change the intravenous line site. Which statement made by the nurse would be appropriate in supporting the child? "The client is left-handed and likes to draw; an IV site in his right arm would be best." "The nurses on the unit know the client well, so maybe a nurse could start the IV." "Would you like me to stay with you or are you OK alone?" "I will be back after your IV is in place."
"The client is left-handed and likes to draw; an IV site in his right arm would be best." Explanation: The staff nurse may serve as the child's advocate when the care provider comes to start an infusion. The staff nurse who has cared for the child has the child's confidence and knows the child's preferences.
The nurse is caring for a 12-year-old post-appendectomy client who weighs 86 pounds. The child has a temperature of 38.5ºC (101.3ºF). The nurse prepares to give the client a dose of oral acetaminophen. The order reads "Tylenol 15mg/kg/dose every 4 to 6 hours PO PRN for fever or pain." How many milligrams of Tylenol should the nurse give the client? 1,290 milligrams 1.3 milligrams 587 milligrams 147 milligrams
587 milligrams Explanation: The child's weight must first be converted to kilograms by dividing 86 by 2.2. The result is 39.1 kilograms. Next, the 39.1 kilograms must be multiplied by 15 milligrams. This answer is 587 milligrams.
A 5-year-old child is to receive long-term IV antibiotics. The mother is concerned about what type of administration method will be used. Which medication administration route may be the most easily accepted? A peripherally inserted central catheter (PICC) line in an antecubital space A Hickman catheter in the right upper chest A port in the left upper chest An intraosseous line in the left lower leg
A peripherally inserted central catheter (PICC) line in an antecubital space Explanation: If IV antibiotic therapy is going to be needed for an extended period of time, a type of longer-term device needs to be used as opposed to a peripheral IV. A peripheral IV would need to be changed often and the risks of dislodgement or inflammation are much greater. Peripherally inserted central catheters (PICCs) are placed in the upper arm under ultrasound guidance. If maintained properly they can remain for many months. This means no IV sticks for the time the child would need IV therapy. It also leaves the hands free to use. A port must be surgically implanted into the child's chest. It can remain for many months. This would not be warranted for a one-time treatment of antibiotic therapy. A Hickman catheter is inserted via sterile procedure by a surgeon. This catheter is placed near the heart and has an increased risk of infection. An intraosseous line is not a route for long-term administration. It is used for emergent situations.
A nurse needs to measure the urine output of a 5-month-old infant. The infant is experiencing loose stools. Which action by the nurse is appropriate to ensure an accurate output measurement? Weigh the diaper before applying and when removing; subtract the dry weight from the wet weight for the output. Weight the wet diaper. Multiply the weight by 30 to get milliliters. Then divide the weight by 2 for the urine output. Squeeze the contents of the wet diaper into a graduated container. Allow the stool to settle to the bottom, and then measure the urine output. Apply a urine collection bag to the infant, and then apply a dry diaper. Pour the contents of the collection bag into a graduated container and measure the amount.
Apply a urine collection bag to the infant, and then apply a dry diaper. Pour the contents of the collection bag into a graduated container and measure the amount. Explanation: In infants who have liquid stools, it is difficult to separate stool from urine because these blend together in a diaper. The nurse can separate urine from stool by applying a urine collector to the infant. The nurse then checks the collection bag frequently for filling and measuring. If the infant had solid stool, the nurse could use diapers as a method of measuring urine output. The nurse would weigh a diaper before it is placed on an infant and record this weight conspicuously (e.g., mark it on the front of the plastic covering with a ballpoint pen). Then, the nurse would reweigh the diaper after it is wet and subtract the difference to determine the amount of urine present. This difference will be in grams; but because 1 g = 1 ml, the amount can be recorded in milliliters.
A child has undergone a procedure requiring moderate sedation. The child asks the nurse, "I am thirsty; can I have something to drink?" Before giving the child something to drink, what will the nurse do first? Assess the child's level of consciousness. Check the child's vital signs. Ask the child their name and birth date. Check the child's gag reflex.
Check the child's gag reflex. Explanation: Although assessing vital signs and level of consciousness are important, the nurse should check the child's gag reflex to ensure it is intact before offering any fluids to drink to reduce the risk of aspiration. The key is to prevent aspiration. Asking the child's name and birth date would not be effective in preventing aspiration.
When assessing a caregiver's knowledge of proper medication administration, which is the best way for the nurse to determine the caregiver's knowledge? Have the caregiver watch the nurse give the medications using proper administration techniques. Have the caregiver verbalize the exact steps in how to properly administer the prescribed medications. Have the caregiver give a demonstration of the medication administration to the nurse before discharge. Encourage the caregiver to ask the nurse questions about proper medication administration before discharge.
Have the caregiver give a demonstration of the medication administration to the nurse before discharge. Explanation: Return demonstrations are an important evaluation tool to assess safe administration of medication. It is the preferred method to evaluate caregiver knowledge. Asking questions is important but the return demonstration is the best way to assess the caregiver's knowledge. Verbal understanding is also important, but it demonstrates knowledge not proficiency. Having the caregiver watch the nurse give the medications is teaching, not evaluation. It is not a correct way to assess the caregiver's knowledge.
A parent must administer a medication in syrup form to a 2-month-old infant. The nurse suggests: placing the syrup in a small amount of rice cereal. placing the syrup in an medicine syringe. using a measured medicine spoon. mixing the syrup in a small amount of formula.
placing the syrup in an medicine syringe. Explanation: The young infant should naturally and easily suck the medicine through a medicine syringe. Formula and rice cereal are essential foods for the infant and the desirability of them should not be altered by the taste of the medication. In addition, a 2-month-old infant is not developmentally ready for spoon feeding of rice cereal or medication from a medicine spoon.
The nurse is preparing to administer an oral dose of antibiotics to a 10-year-old child who weighs 70 lb (31.75 kg). The prescription reads cephalexin 500 mg orally every 6 hours. The pediatric drug book dosing reads 25 to 100 mg/kg/day in 2 to 4 divided doses. What is the safe range per dose if administering every 6 hours for this client? 794 to 3,175 mg per dose 1,750 to 6,350 mg per dose 438 to 1,750 mg per dose 199 to 794 mg per dose
199 to 794 mg per dose Explanation: Use the client's weight in kilograms. Calculate the low dose by multiplying 31.75 kg by 25 mg to equal 793.75 mg per day. This must be further divided by 4, the amount of times it is given in a 24-hour period (per day): 795 mg divided by 4 is 198.4, rounded up to 199 mg per dose. The high dose is calculated by multiplying 31.75 kg by 100 mg to equal 3,175 mg per day. This must be further divided by 4 because it is being given every 6 hours: 3,175 mg divided by 4 is 793.75, rounded up to 794 mg per dose.
A nurse is administering ear drops to a 7-year-old girl. What should the nurse do? Pull the pinna of the ear up and back to straighten the external ear canal. Hold the child's head in the sideways position while counting to 5 to ensure the medication fills the entire ear canal. Warn the child that the drops will hurt. Administer the medication while it is still cold from the refrigerator.
Pull the pinna of the ear up and back to straighten the external ear canal. Explanation: Remind the child ear drops can feel odd, as if someone were tickling the ear. Ear drops must always be used at room temperature or warmed slightly as cold fluid, such as medication taken from a refrigerator, does cause pain and may also cause severe vertigo as it touches the tympanic membrane. If the child is older than 2 years, pull the pinna of the ear up and back. Instill the specified number of drops into the ear canal. Hold the child's head in the sideways position while you count to 60 to ensure the medication fills the entire ear canal.
If a medication is being administered by the otic route, it will be administered in which way? Rolled between the hands and drawn up into a small syringe Lubricated and gently placed into the rectum Warmed to room temperature and dropped into the eye Warmed to room temperature and dropped into the ear
Warmed to room temperature and dropped into the ear Explanation: Otic means ear. Be sure that the ear drops are at room temperature. If necessary, roll the container between the palms of your hands to help warm the drops. Using cold ear drops can cause pain and possibly vertigo or vomiting when they reach the eardrum. If the medication were to be placed in the rectum the instructions would say "for rectal use only." A ophthalmic drug would be placed in the eye. Medications in a syringe could be for injection or a liquid for oral use.
The nurse is teaching parents of a 12-year-old child how to administer otic medication. Which statement by the parent indicates a need for further education? "After administering the drops, I will ask my child to remain side-lying for several minutes." "After removing the medication from the refrigerator, I need to roll it gently in my palms to warm it." "I will hold the dropper 0.5 in (1.25 cm) above the ear canal and be certain not to touch the ear with the dropper." "I will pull the outer ear down and back before administering the medication."
"I will pull the outer ear down and back before administering the medication." Explanation: The proper technique to instill ear drops in a child older than 3 years of age involves pulling the pinna up and back. Otic medication should not be administered if it is cold. Cold medication may cause discomfort and produce vomiting or vertigo in the child. If an otic medication must be refrigerated, it should be warmed in the palms of the hands. Proper otic administration technique involves holding the dropper 0.5 in (1.25 cm) above the ear canal and being careful not to touch the dropper to the ear to prevent contamination of the dropper with microorganisms. The child should remain in a side-lying (or supine) position for several minutes after administration.
The nurse has prepared an IM injection to give a 13-year-old child. After some searching, the nurse locates the child in the playroom in front of a video game. Which action is best for the nurse to take? Give the injection in the playroom since the child is distracted with the video game. Ask the child when the game will be over. Inform the child that it is time for an injection. Explain why the injection is needed and have the child move to the treatment room. Ask the child to take a break from the game and come back to the child's room to give the injection.
Inform the child that it is time for an injection. Explain why the injection is needed and have the child move to the treatment room. Explanation: Explaining the reason for a medication is appropriate for a 13-year-old child. The medication should not be given in the playroom. The playroom is a safe area for clients. Painful procedures should be done in a treatment room. Asking the child to take a break from the game sounds like the nurse is asking permission to give the medication. A child should not be given the opportunity to refuse a medicine.
A 4-year-old child is admitted to the hospital for surgery. Before the nurse administers medicine, the best way to identify the child would be to: ask the child to state his or her name. read the child's armband. call the child's name and see if he or she answers. tell the child to state his or her nickname.
read the child's armband. Explanation: A child may answer to the wrong name or deny his or her identity to avoid an unpleasant situation or if scared of the unknown. If the child is avoiding the situation he or she may fail to answer. Using the child's nickname is okay in conversation but it is not a legal identification of the child. To verify the correct identity the nurse should verify the child's armband and the correct name with the child's caregiver. Bar code scanning the child's armband would also be a correct method of identification.
A neonate is to receive a hepatitis B vaccine within a few hours after birth. What is the best approach for the nurse to take when giving this medication? Administer the medication in the neonate's vastus lateralis with a 25-gauge needle. Administer the medication in the vastus lateralis with a 20-gauge needle. Administer the medication in the deltoid muscle with a 20-gauge needle. Administer the medication in the dorsogluteal with a 25-gauge needle.
Administer the medication in the neonate's vastus lateralis with a 25-gauge needle. Explanation: The vastus lateralis site is a safe choice for intramuscular (IM) injections in a neonate. A 22- to 25-gauge needle is recommended for neonates, but the nurse must assess the neonate's size before determining needle size to use. The 25-gauge needle is recommended for neonates. The dorsogluteal site should not be used until school age. Neither the deltoid muscle nor the dorsogluteal muscle are recommended IM sites for neonates. These muscles should not be used until toddler age or older. The volume of the medication should not exceed 0.5 ml per injection until the child is preschool age.
Parents asks the nurse why their premature infant is receiving a feeding through the mouth rather than the nose. What is the best explanation by the nurse? It is equally acceptable to use either insertion site. Nasogastric tubes decrease the possibility of striking the vagal nerve. Newborns are obligate nose breathers so nasogastric may obstruct their breathing. Orogastric tube insertion can cause inflammation and obstruction of the nares.
Newborns are obligate nose breathers so nasogastric may obstruct their breathing. Explanation: Whether enteral catheters should be passed through the nares or the mouth is controversial. Because newborns are obligate nasal breathers, passing a catheter through the nose may obstruct their breathing space, and repeated insertion of a nasogastric tube can cause inflammation and obstruction of the nose; thus most tubes are inserted orally in small infants. Orogastric insertion can also decrease the possibility of striking the vagal nerve in the back of the throat and causing bradycardia, whereas nasogastric tubes increase the possibility of striking the vagal nerve.
The nurse is preparing to give a 4-month-old an oral medication. Which technique demonstrates the nurse's accurate knowledge of the infant's developmental level? Place the medication in a bottle with a small amount of the infant's formula and feed the bottle to the infant in an upright position. Place the medication in a bottle with a small amount of juice, then feed the infant the bottle in an upright position. Position the infant supine in bed, and squirt the medication on the tongue toward the cheek. Position the infant upright, offer the infant a bottle of formula, remove the bottle and squirt the medication on the side of the tongue toward the cheek, then offer the infant the bottle again.
Position the infant upright, offer the infant a bottle of formula, remove the bottle and squirt the medication on the side of the tongue toward the cheek, then offer the infant the bottle again. Explanation: Proper medication administration for an infant includes the following: Position the infant upright, present a pleasant- or neutral-tasting substance to ensure that the child is awake and swallowing, give the medication slowly enough to allow the child to swallow and prevent any risk of aspirating, and give a pleasant-tasting "chaser." An infant should not be placed supine since this would increase the risk of aspiration. Medications should not be placed in a client's staple food to avoid an aversion to the food in the future.
The nurse is preparing to administer an IV antibiotic to a child. After calculating the recommended dose with the child's weight, the nurse discovers the prescribed dose exceeds the safe dose range in a pediatric drug book. The medication has been given to the child at this dose for 3 days. What action should the nurse take next? Call the pharmacy. Verify the dose with the prescribing health care provider. Give the prescribed dose since the child has been receiving that dose for 3 days. Ask the child's parents if this dose has been given all week.
Verify the dose with the prescribing health care provider. Explanation: Medication calculations should always be checked before giving the dose. When a medication dose is found to be outside of the safe dose range, the dose should be verified with the prescribing health care provider. Doses that exceed the recommended range should always be verified, even if they have been given before. The parents did not prescribe this medication. Even if the medication has been given for 3 days, it does not make the dose correct. Calling the pharmacy can only verify if the dose is out of the safe range. The pharmacy did not prescribe the medication nor does it know the child's medical background.
The nurse is working to gain a preschooler's cooperation to swallow an oral medication. What would be the nurse's best approach? leave the medicine on the night stand so the child can take it independently compare the taste of the medicine to a chocolate bar ask if the child would like to take the medicine in a cup or through an oral syringe offer to play a game with the child if the child takes the medicine
ask if the child would like to take the medicine in a cup or through an oral syringe Explanation: The preschool age is when the child develops initiative. This is the sense that the child is helping. Thus, the nurse should allow the child to participate in the medication task. The instructions and choices need to be simple. The nurse can ask if the preschooler would like to take the medicine in a cup or through an oral syringe. Medicine never should be compared to candy or any other foods. Doing so can present a safety problem if the child gets into the medication cabinet at home thinking he or she is getting candy. Children cannot be depended on to take medicine without supervision, so leaving the medication on the night stand would not only be ineffective it would also be dangerous. Bribing is ineffective. A preschooler is not going to do a task he or she does not like and the medication is needed to make the child well. The nurse should be gentle but firm in the administration of the medication.
A 6-year-old child is to have an intermittent infusion device inserted for antibiotic administration. The nurse anticipates which site would be used first for insertion? scalp antecubital fossa back of the hand foot
back of the hand Explanation: If the child does not require continuous IV fluid infusion but may still require IV fluids or medications intermittently, an intermittent infusion device, sometimes referred to as a saline or heparin lock, may be used. This method frees the child from IV tubing between medication administrations. The veins on the back of the hand are often used first for insertion of the intermittent infusion device. The foot may be used, but this site is more likely used for contiguous therapy. The antecubital fossa, which restricts movement, is sometimes used only if other sites are not available. The scalp vein has an abundant supply of superficial veins that may be used if no other site can be accessed in infants and toddlers, but not in school-aged children.
The new graduate nurse is preparing to administer medication to a 4-year-old client. When would it be appropriate for the supervising nurse to intervene? The new graduate: had two whole tablets to administer to the child. is going to give an IM injection in the vastus lateralis. used the child's weight to calculate the dosage. explained why the medication was being administered.
had two whole tablets to administer to the child. Explanation: Many children do not have enough coordination to swallow tablets or pills until they are 6 or 7 years of age. Therefore, the supervising nurse would need to intervene. The other actions are correct. The nurse should explain why the medication is being administered. Medications in children are dosed according to body weight (milligrams per kilogram) or body surface area (BSA) (milligrams per square meter). The vastus lateralis is a good location for an IM injection in a 4-year-old child.
