LAB220: Module 2- Day 1

Relaxing the child's arm and extending the wrist

Which position best facilitates assessment of a child's radial pulse?

The manufacturer's recommendations for cleaning the probe should be followed.

Which statement about cleaning a Doppler probe is correct?

Guided imagery

A 5-year-old child with brain cancer has intractable pain. What is the best nonpharmacologic strategy for pain management to help with the medications the child is receiving?

To check for hypoxemia

A child has an Hgb of 7 and a pulse oximeter reading of 100% and is restless. The nurse should request that an arterial blood gas analysis be performed for which reason?

Decrease in CO

A child is admitted with syncope and palpitations. What is the potential significance of this sign?

Venous sounds

A 10-year-old child is brought to the emergency department after being attacked by a large dog. The child has a deep laceration on the right leg. While assessing circulation to the lower leg using Doppler ultrasonography, the nurse hears high-pitched sounds that occur with respirations. What do these sounds represent?

This breathing pattern is normal for the infant's age.

A 2-week-old infant is displaying an irregular breathing pattern, with periodic increases in respiratory rate that return to normal. The infant is otherwise eating well and has no other signs of respiratory distress. What should the nurse tell the family about this breathing pattern during family teaching?

Blood flow is greater than the Doppler can detect

A 2-year-old child has just undergone cardiac catheterization via the left groin. The practitioner is assessing the child's left pedal pulse using Doppler ultrasonography but finds no sound when the probe is placed over the pedal pulse point. Which is not a reason for this lack of sound?

The child may be in imminent respiratory failure

A nurse is caring for a 2-year-old child with respiratory distress. The child's respiratory rate has been 50 breaths/min, with intercostal retractions and nasal flaring for the past 45 minutes. The nurse now observes that the child is sleepy, with a respiratory rate of 16 breaths/min. The child has received no pain medication. What must the nurse consider in performing a respiratory assessment of this child?

The child is experiencing pain

A nurse is caring for a 7-year-old child who is recovering after surgery. The nurse receives no verbal response to questions about how the child is feeling today. Meanwhile the child is rocking and thumb sucking. How should the nurse interpret this behavior?

Treatment Room

A nurse is caring for a toddler who is about to have a wound cleansing and dressing change. The child requires an IV line for analgesic medication before wound care. Where is the best place to perform these procedures?

Waiting before assessing pulse rate

A peripheral IV line has just been inserted in a 4-year-old child, and it is now time to obtain routine vital signs. What action best reflects the appropriate care?

Once the child calms down with reassurance and explanations

A school-age child is being seen for a school physical and vaccine administration. The child is tearful regarding the "shots." When would be the best time to obtain an accurate apical pulse rate?

Speak calmly to the child and obtain assistance with holding the child.

As an IV line is being started on a 2-year-old child, the child demonstrates escalating screaming and kicking and pushes the nurse's hand away. Which response from the nurse is the most appropriate?

Sinus arrhythmia

During an apical pulse assessment on a child, the nurse notices an increasing HR every time the child inhales and a decreasing HR every time the child exhales. What should the nurse suspect?

Opioid analgesic

During an examination of a child who was admitted for postoperative pain management, the nurse assesses a decreased respiratory rate. What should the nurse consider as the most likely cause for a decrease in the rate?

Apical pulse rates give valuable information about perfusion.

During the assessment of a 14-month-old toddler, why should the apical pulse rate be checked rather than radial pulse rate?

Continue to count the patient's breaths for a full 60 seconds.

During the assessment of a patient's respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time?

3+

How would the nurse document a full, increased pulse amplitude?

Count breaths for 60 seconds.

On the last assessment of a patient's respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient's respiratory rate?

FLACC scale

When performing a pain assessment on a 2-month-old infant, which pain scale is the most appropriate to use?

Discuss the procedure with the child immediately before it is performed.

When preparing a 3-year-old child for an IV line insertion, which step is the most appropriate?

Correlate the oximeter reading with the heart rate.

When spot checking a child's oxygen saturation, which action would the nurse take to ensure an accurate reading?

"Place the tips of your first two fingers over the groove along the thumb side of your child's inner wrist."

When teaching the family members of a 4-year-old child how to assess a radial pulse, which technique should the nurse recommend?

Hurts the worst

When using the Wong-Baker FACES pain rating scale, the child points to the picture of the face with tears coming from the eyes. What is the correct interpretation of this gesture?

Assess respiration after measuring the pulse.

Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment?

Tachycardia and decreased peripheral perfusion

Which assessment findings would the nurse recognize as indicative of early shock?

Lower than the saturation would normally indicate

The nurse admits a child who has an inhalation injury from a house fire. For any given saturation level, what should the nurse expect the partial pressure of arterial oxygen on arterial blood gas analysis to be?

Mark the spot with a marker to assist with future assessments.

The nurse cannot palpate a distal pulse in a child with an open femur fracture. Using a Doppler instrument, the nurse hears loud, repetitive, pulsatile sounds on the dorsum of the foot. What is the most appropriate next step?

Closure of the aortic and pulmonic valves at the end of systole

The nurse is assessing a child's apical pulse and auscultating heart sounds. What does the S2 sound indicate?

"Are you playing sports regularly?"

The nurse is assessing the apical pulse on an otherwise healthy adolescent and auscultates a regular rate of 60 beats per minute. The teen reports that his HR is usually in the 80s and asks why it is so low. What would be an appropriate question to ask the teen at this time?

FLACC Scale

The nurse is caring for a 13-year-old child with cerebral palsy and a developmental delay. The family states that the child functions at the level of a 6-month-old. Which pain scale is the most appropriate to use?

Allow the child plenty of time to process information given.

The nurse is caring for a child who is cognitively impaired. How should the nurse approach pain assessment for this child?

Facilitating the release of oxygen at the cellular level

The nurse is caring for a child with sepsis. The child has a temperature of 39°C (102.2°F) and an oxygen saturation of 95%. When evaluating arterial blood gas values, the nurse sees that the partial pressure of arterial oxygen is lower than expected with a saturation of 95%. What is the reason for the difference in the partial pressure of oxygen?

Review the recent medication administration record.

The nurse is caring for a young child who has been receiving opioids for pain relief for several weeks. The nurse finds that the child is restless. The child states that the child cannot sleep and is nauseated and vomits during the assessment. What action should the nurse take?

Big toe

The nurse is caring for an infant with a continuous pulse oximetry probe on the earlobe. Which site would the nurse select when rotating the pulse oximetry probe?

Hgb level and perfusion

The nurse is evaluating a child's pulse oximeter reading. What should the nurse consider when evaluating the reliability of the reading?

Warm the diaphragm of the stethoscope.

The nurse is preparing to assess an apical pulse on an anxious child. What would be an appropriate action before listening to the child's heart?

"Listening and counting the heartbeat is more reliable than the pulse in the wrist."

The nurse is providing discharge instructions to the family members of a preschooler who has recently begun taking digoxin and is providing education on how to check a pulse. What statement by the family member indicates that the teaching was effective?

Directly proportional to the SV

The nurse knows that the strength of a peripheral pulse correlates how?

Count the radial pulse for a full 60 seconds.

The nurse notes that the radial pulse of a 6-year-old child is irregular. What is the most appropriate intervention?

Encourage the patient to rest for 10 minutes before assessing respiration.

The nurse plans to assess a patient's respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient's respiratory rate?

Capillary refill of less than 3 seconds

Which examination finding would the nurse expect when assessing the probe site for a child receiving continuous pulse oximetry monitoring?

Place the diaphragm of the stethoscope at the PMI (third ICS, to the left of the sternum).

To assess an apical pulse rate in an infant, how should the nurse proceed?

Sinus arrhythmia

Which heart rhythm would the nurse recognize in a child who has a fluctuation in the radial pulse that corresponds to the respiratory cycle (increases with inspiration and slows with expiration)?

Child with diaphoresis

Which patient would the nurse expect to be at risk for altered pulse oximetry readings?

Arterial oxygen saturation

What does pulse oximetry measure?

Turn down tv if noisy

What is the most appropriate nursing action before taking an apical pulse on a child?

The cuff should be placed high on the extremity to avoid rubbing on the probe.

What should the nurse recall when using Doppler ultrasonography to assess an infant's blood pressure?

Abdominal movement for 1 full min

When assessing an accurate respiratory rate for a 3-month-old infant, what should the nurse directly observe?

Skin condition and perfusion

When assessing the circumferential pulse oximeter probe on a child's finger, what would be important for the nurse to consider?

Reassessment of HR is appropriate at this time.

When documenting the apical pulse of a child, the nurse observes that the current measurement differs significantly from previous measurements. What does this signify?

The number of inspirations and expirations per minute.

When measuring a patient's respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle?

"She's breathing fine; the monitor numbers have been good all day."

Which statement by the child's mother indicates the family needs further education about accurate respiratory rate measurement?

Document the findings and notify the practitioner immediately.

While assessing a child with a left forearm cast, the nurse notes as weakened radial pulse compared to the other arm. Which action would the nurse take?