NUR 307: VSim Sabina Vasquez Pre/Post test
The nurse is caring for a patient who is showing signs of respiratory distress. List the interventions in the order that they should be performed
1) Elevate the head of bed and reposition patient 2) Encourage the patient to cough to clear the airway 3) apply oxygen and titrate flow as needed 4) collect sputum to send to the lab for culture 5) Administer and antipyretic and antibiotic as ordered
The nurse is planning care for a preschooler hospitalized with pneumonia. Which of the following are appropriate choices to offer when administering oral medications? (SATA)
1) after you take your medicine, would you like a puppy sticker or a heart sticker? 2) Which do you want to take first: the pink medicine or the yellow medicine? 3) Do you want to drink water or apple juice with your medicine? 4) Who do you want to squirt the medicine in your mouth, you or me
What techniques can the nurse employ when providing care for Sabina and her family to reduce the overall stress of hospitalization (SATA)
1) involve the family in daily care and give the patient simple choice when possible 2) Provide copies of written materials in both english and Spanish 3) Use a certified medical interpreter to aid in communication
A nurse is explaining the pathophysiology of asthma and asthma exacerbation to a group of nursing students at a workshop. Which of the following statements would be most accurate for the nurse to make? (SATA)
1) the smooth muscles of the airway increases in responsiveness, causing bronchoconstriction 2) Chronic inflammation contributes to irreversible airway changes and decreased lung function 3) exposure to bacterial and viral infections increases airways responsiveness and inflammation
When teaching Sabina's mother how to recognize respiratory distress, what is the best way to determine whether the teaching has been effective?
Have the mother point to areas on the body and describe what she is looking for
Which of the following children should receive the pneumococcal vaccine? (SATA)
1) 4 yr old with congenital heart disease who has recieved an age appropriate series 2) 2 month old who is at a well child check up 3) 3 yr old who has not recieved any immunizations 4) 6 months old who was born 25 wks gestations
The nurse is preparing a 5 year old for a chest x-ray. Which of the following statements would be the nurse's best explanation of this procedure to the patient?
I am sending you to have a big camera take picture of your body
The nurse is caring for a patient hospitalized with an asthma exacerbation secondary to pneumonia. Which of the following is the highest priority nursing diagnosis for this patient?
Impaired gas exchange related to excess mucus production and carbon dioxide retention
During assessment the pediatric patient reports good control of asthma symptoms with no interference in daily activities and one incidence of nighttime cough in the past month. The patient uses a rescue inhaler occasionally during the week for asthma exacerbations. The patient would be classified as having which of the following levels of asthma severity?
Mild intermittent
A nurse must administer maintenance fluid intravenously to a patient weight 43 lb. What is the daily maintenance fluid requirement for this patient?
1,475 mL/day
The provider has given an order for acetaminophen suspension 240 mg orally every 4 - 6 hr as needed for fever. Which of the following considerations does the nurse need to remember when administering acetaminophen?
Acetaminophen can affect lab test results for WBC and H+H
A patient arrives at the emergency department in respiratory distress with a history of asthma. Upon assessment, the nurse notes that the patient sits forward with intercostal retractions, has a productive cough, and wheeze upon auscultation. Which of the following interventions is most appropriate for the nurse to implement at this time?
Elevate the head of the bed and allow the patient to assume a position of comfort
After giving discharge instructions, which response by Sabina's mother indicates that teaching has been effective?
Even is she is feeling better, Sabina must finish taking her oral antibiotics as ordered
A nurse observes that a preschooler who is hospitalized appears stressed. which of the following is the most likely stressor for this child?
Fear of mutilation
The nurse is preparing Sadina for her nebulized albuterol treatment. Which of the following demonstrates that the nurse understands developmentally appropriate communication?
Some kids say the breathing treatment makes them feel a little shaky
A nurse is administering medications and fluids intravenously to a pediatric patient. Which of the following must the nurse do to prevent complications?
Use standard precautions when assessing the insertion site and handling tubing per institution protocol
Sabina was discharged with instructions to complete the course of oral azithromycin started during her hospitalization. The next day, her mother calls asking how to prepare the medication for administration. How would the nurse instruct the mother to prepare 3.8 mL of this medications for administration?
Use the calibrated syringe provided to draw up the medication and check dose to eye level
A patient weighting 43 lb has an order fro intravenous cefuroxime 475 mg Q8 hr. The safe dose range is 50 to 100 mg/kg/day. Is the order safe?
Yes, the safe range is 975 to 1,950 mg/day