PEDS - Test 3 (Next Generation Questions)

he patient is now resting comfortably having been admitted to the pediatric unit. His mother is at the bedside and the last numeric pain assessment reveals his level of pain a 3/10. These are the PCA doses used: Loading dose of 0.1 mg/kg (maximum 8 mg); basal rate of 0.01 mg/kg and intermittent dose 0.035 mg/kg (maximum 8 mg) with the interval lockout at approximately 10 minutes. A 4-hour limit of 0.5 mg/kg is set. His weight is 40 kg. Based on these PCA loading doses above, choose the most likely options for the information missing from the table by selecting from the list of options provided. (1) Loading Dose, (2) Basal Rate, (3) Intermittent Dose, (4) Interval Lockout

1- 4 2- 0.4 3- 1.4 4- 10 mins

A 7-year-old child is hospitalized with fever, chills, headache and vomiting the past 2 days. She is irritable when awake but sleeps most of the time and is extremely sensitive to the light in the room. On examination she exhibits nuchal rigidity with + Kernig and Brudzinski signs. A lumbar puncture was performed to confirm the diagnosis. Choose the most likely options for the information missing from the statements below by selecting from the lists of options provided. This child's diagnosis most likely is __________1__________. Because of this diagnosis initial therapeutic management includes __________2__________. There are routine vaccinations available to prevent bacterial meningitis and includes the __________3__________ vaccine for all children beginning at 2 months of age.

1- Bacterial meningitis 2- isolation 3- pneumococcal

A 7-year-old girl with periorbital edema, hypertension, decreased urine output, pallor, and fatigue is admitted to the pediatric unit. She had a cold and sore throat 2 weeks ago that resolved. Her brother and younger sister also had these symptoms. She is active in school and plays soccer. Choose the most likely options for the information missing from the statements below by selecting from the lists of options provided. Children who present with __________1__________ glomerulonephritis may have a history of a __________2__________ infection. __________3__________ tests during the acute phase shows hematuria and proteinuria.

1- Post streptococcal 2- Group A beta-hemolytic 3- urine

Review the case study above. Choose the most likely options for the information missing from the statements below by selecting from the lists of options provided. As a result of this child's diagnosis of sickle cell disease, the nurse is aware, based on the assessment findings, that the child may be experiencing __________1__________. This is caused by __________2__________

1- Vasoocclusive crisis 2- ischemia

The child was transferred by ambulance to the hospital. He had not regained consciousness during the transport. Choose the most likely options for the information missing from the statements below by selecting from the lists of options provided. Since the child is not regaining a premorbid level of consciousness (LOC) between seizures is concerning and meets criteria for a diagnosis of __________1__________. The child's __________2__________ should be monitored closely, and supportive measures (i.e., cardiopulmonary resuscitation) should be initiated as indicated. Simple, effective, and safe treatments for home or prehospital management of prolonged seizures and impending status epilepticus include __________3__________ midazolam and rectal diazepam.

1- staus epilepticus 2- circulatory, airway, breathing (CAB) 3- buccal

Based on these symptoms and history, the nurse anticipates a diagnosis of: _____ that is most frequently caused by a _____ infection. When considering the diagnosis, examination of the throat with a _____ is contradicting without experienced personnel and equipment available for immediate intubation or tracheostomy.

1. Acute Epiglottis 2. Bacterial 3. Tongue Depressor

PEFR measures the maximum _____ that can be forcefully exhaled in _____. Asthma is under reasonable good control when the PEFR indicates _____ of the patient's personal best value is obtained. This value is established by obtaining a PEFR over a _____ period of time.

1. Flow of air 2. 1 second 3. 80-100% 4. 2-3 week

A 3-year-old has a history of chronic diarrhea, lack of weight gain, and abdominal distension. He has a positive serological blood test and small intestine biopsy confirming Celiac Disease. Choose the most likely options for the information missing from the statements below by selecting from the lists of options provided. Because children with celiac disease must limit their intake of products containing __________1__________ in many food items, one being __________2__________ , they are at most risk for __________3__________ as well as a number of other deficiencies.

1. Gluten 2. Toast 3. Iron-deficiency anemia

A 3 month old infant who has not receive her immunizations is seen in the clinic following concerns that there was a Hepatitis outbreak in the day care where the infant was enrolled. The day care notified the mother that other children who were not immunized were also enrolled and that she should take her infant to the clinic. Choose the most likely options for the information missing from the statements below by selecting from the list of options provided. The nurse recognizes that the principle mode of transmission for __________1__________ is by the __________2__________ route. The __________3__________ , an inactivated vaccine, is approved for children 12-23 months of age and given in __________4__________ doses.

1. Hepatitis A 2. Fecal-oral 3. HAV 4. Two

A 10-year-old girl has a 2 day history of generalized periumbilical pain and anorexia. Today she developed a fever and vomiting, so her parents took her to the clinic. d. C-reactive protein (CRP) of 40mg e. Pain intensifies with any activity or deep breathing f. Oral temp of 102F h. Abdominal pain midway between the anterior superior iliac crest and umbilicus i. WBC count of 21,000, 79% bands, 14% lymphocytes, 6% eosinophils Based on the child's assessment data, the nurse determines that the laboratory findings reflect the probable presence of _____. The _____ is elevated and her periumbilical pain, along with other symptoms is most likely due to _____.

1. Infection 2. CRP 3. Acute Abdomen

The nurse realizes that bronchiolitis is the most common infectious disease of _____ airways. RSV affects the _____ cells of the respiratory tract. The respiratory illness usually begins with an upper respiratory infection after an incubation of about _____ days.

1. lower 2. Epithelial 3. 5-8

The nurse reviews the history of this 3-week old infant and reads that he is diagnosed with coarctation of the aorta. The nurse realizes that the symptoms experienced by the infant are caused by this congenital disorder. Choose the most likely options for the information missing from the statements below by selecting from the lists of options provided. Coarctation of the aorta is described as the _____1_____ of the aortic arch that results in ______2______ cardiac output. A classic finding is _____3____ pulses in the arms and _______4_______ femoral pulses.

1. narrowing 2. decreased 3. bounding=3 4. weak or absent=4

You are working with a pediatric nurse who has just transferred to the pediatric clinic from adult surgery. You are role-playing phone triage with a mother of a 10-month-old infant with a head injury. The infant was seen in the emergency center yesterday and sent home after observation. You ascertain that the nurse needs more teaching based on what response? Select all that apply. A. "Another physical examination should take place in 1 or 2 days." B. "After initial physical examination, if there was no loss of consciousness with the head injury the infant is observed at home." C. "If there is a language barrier, written instructions can be given, followed by discharge." D. "Parents should call the doctor if their child has any of these signs: blurred vision, walking unsteadily, or is hard to awaken." E. "An ultrasound of the head is needed to provide important follow-up to determine if your child had bleeding into the head." F. "Parents should give only clear liquids to the infant for the next 24 hours."

A. "Another physical examination should take place in 1 or 2 days." E. "An ultrasound of the head is needed to provide important follow-up to determine if your child had bleeding into the head." F. "Parents should give only clear liquids to the infant for the next 24 hours."

A nurse is working with a new graduate on the pediatric unit, and the patient is returning from the cardiac catheterization lab. The patient is a 3-year-old with a congenital heart disease who is having more symptoms related to heart failure. The nurse determines that the graduate understands the important nursing interventions when she makes which statements? Select all that apply. A. "Check pulses, especially below the catheterization site, for equality and symmetry." B. "Check vital signs, which may be taken as frequently as every 30 to 45 minutes, with special emphasis on the heart rate, which is counted for 1 full minute for evidence of dysrhythmias or bradycardia." C. "Special attention needs to be given to the BP, especially for hypertension, which may indicate hemorrhage or bleeding from the catheterization site." D. "Check the dressing for evidence of bleeding or hematoma formation in the femoral or antecubital area." E. "Allow the child to ambulate because this will prevent skin breakdown from lying so long in one place."

A. "Check pulses, especially below the catheterization site, for equality and symmetry." D. "Check the dressing for evidence of bleeding or hematoma formation in the femoral or antecubital area."

A 9-year-old girl has been diagnosed with severe aplastic anemia. She presented with a two-week history of nosebleeds and developed a fever to 102 F the past few days. She complains of fatigue and notices bruising of her arms and legs. Her peripheral blood counts show marked reduction in the red blood cells, white blood cells and platelets. A bone marrow aspiration and biopsy were performed and demonstrated conversion of the red bone marrow to yellow, fatty bone marrow with a bone marrow cellularity of 20%. Based on her diagnosis, what are the most appropriate nursing actions at this time? Select all the apply. A. Advise the family what to do if fever develops. B. Recommend eating fruits and vegetables each day. C. Review the importance of the spleen and how it works. D. Discuss the diagnosis with the child in an age appropriate manner. E. Review how to use an epinephrine pen at home if anaphylaxis should occur. F. Provide opportunities for the child and family to ask questions and express feelings. G. Discuss how blood cells work and what side-effects to look for due to low blood cell counts.

A. Advise the family what to do if fever develops. D. Discuss the diagnosis with the child in an age appropriate manner. F. Provide opportunities for the child and family to ask questions and express feelings. G. Discuss how blood cells work and what side-effects to look for due to low blood cell counts.

A 7-year-old boy who was playing during physical education class at school when he suddenly stopped his activity, stared into space, repetitively moved his left arm up and down, and smacked his lips. After approximately 1 minute, he stopped the behavior and was drowsy but responsive to his environment. He had no memory of the event. He was accompanied by his teacher to the school nurse for further assessment. While waiting for the parents to arrive, what are the most important subjective and objective data that the nurse would document? Select all that apply. From the boy: A. Aura B. Sensory phenomena that the child can describe during the event (i.e., ability to hear) C. Postictal feelings (i.e., confusion, inability to speak, amnesia, headache, sleepiness) From the person who observed the seizure: A. Duration of seizure B. Time of onset of seizure C. Other students who have the same symptoms D. Change in level of consciousness (LOC) before, during, and after the seizure E. Movements (ask for demonstration of the seizure rather than relying on verbal description)

A. Aura B. Sensory phenomena that the child can describe during the event (i.e., ability to hear) C. Postictal feelings (i.e., confusion, inability to speak, amnesia, headache, sleepiness) A. Duration of seizure B. Time of onset of seizure D. Change in level of consciousness (LOC) before, during, and after the seizure E. Movements (ask for demonstration of the seizure rather than relying on verbal description)

A 7-year-old boy who was playing during physical education class at school a week ago had a seizure. The work-up revealed an abnormal EEG and the physical examination and clinical history supported the decision to begin anticonvulsant therapy with a single medication. This morning he has another seizure while playing with his siblings in the backyard. His brother ran inside to get help and his mother ran outside to see him staring into space with his head turned to the side and his left arm moving rhythmically up and down. This activity stopped for a few seconds and then started again. His mother called for emergency assistance (911), and he was transported to the hospital. Which of the signs and symptoms experienced by this 7-year-old child would the nurse expect to find with a focal seizure? Select all that apply. A. Automatisms B. Aura experienced C. Mental disorientation D. Postictal impairment E. Lasted less than a minute F. Occurs multiple times a day G. Seizure lasted for 45 minutes

A. Automatisms B. Aura experienced C. Mental disorientation D. Postictal impairment E. Lasted less than a minute

A 9-year-old girl diagnosed with CKD is now being followed by a nephrology specialty team and has returned to the clinic for her monthly evaluation. The nurse performing the assessment finds Susie's blood pressure elevated and notices the child's skin is pale and sallow in appearance. The child tells the nurse that she has been really tired lately and her headaches have returned. She also says her feet are more swollen than usual. Which immediate steps would be taken to further evaluate the kidney status? Select all that apply. A. Check CBC. B. Check electrolyte status. C. Check kidney function. D. Check liver function. E. Perform lumbar puncture. F. Document weight, height and blood pressure. G. Compare vital signs and weight to previous visit. H. Evaluate patient adherence to medication and dietary recommendations.

A. Check CBC. B. Check electrolyte status. C. Check kidney function. F. Document weight, height and blood pressure. G. Compare vital signs and weight to previous visit. H. Evaluate patient adherence to medication and dietary recommendations.

The nurse is caring for a 4-year-old girl with a history of frequent urinary tract infections (UTIs). The child presents with strong-smelling urine, frequency and pain on urination. A urinalysis is needed for diagnostic evaluation and the nurse is preparing the child and mother for a clean voided urine specimen for evaluation. What does the nurse need to be aware of before obtaining the urine sample? Select all that apply. A. Children who are toilet trained can provide a clean voided urine sample for culture. B. The nurse should obtain the urine specimen through suprapubic aspiration. C. Because children who have a UTI will have painful urination, have the child drink a large amount of fluid before obtaining the sample. D. The specimen should be sent to the laboratory less than 8 hours after voiding with storage at room temperature or less than 8 hours after voiding with refrigeration. E. The child should be told to urinate in the toilet and that midway through urination a small amount of urine should be collected in a sterile container. F. Because the child is febrile, the nurse should immediately start an antimicrobial and then obtain a urine culture

A. Children who are toilet trained can provide a clean voided urine sample for culture. E. The child should be told to urinate in the toilet and that midway through urination a small amount of urine should be collected in a sterile container.

A preterm infant who had surgery for necrotizing enterocolitis is now 6 months old and has short bowel syndrome. He is unable to absorb most nutrients taken by mouth and is totally dependent on parenteral nutrition, which he receives via a central venous catheter. The clinic nurse following the care for this infant is aware that he should be closely observed for the development of which complications? Select all that apply. A. Cholestasis B. Constipation C. Failure to thrive D. Chronic diarrhea E. Intestinal stricture F. Intestinal failure G. Hepatic dysfunction H. Gastroesophageal reflux

A. Cholestasis E. Intestinal stricture F. Intestinal failure G. Hepatic dysfunction

The infant underwent surgery 3 days ago. Resection of the coarcted portion of the aorta was performed. Cardiopulmonary bypass was not required due to this defect being outside the heart and pericardium. The infant is in stable condition. The nurse is performing a change of shift assessment of the infant. What assessment findings demonstrate that the infant is stable at this time? Select all that apply. A. Color pink B. Lack of edema C. Successful feeding D. Heart rate 120 beats/min E. Skin warm to touch F. Weight gain (0.5kg/day) G. Respiratory 48 breaths/min H. Lack of distended neck veins I. Strong and equal peripheral pulses J. Brisk capillary refill within 5 seconds K. Adequate urinary output (1 to 2 ml/kg/h)

A. Color pink B. Lack of edema C. Successful feeding D. Heart rate 120 beats/min E. Skin warm to touch H. Lack of distended neck veins I. Strong and equal peripheral pulses

The nurse is caring for a 3-week-old male with congenital heart disease (CHD). At birth he initially showed no signs or symptoms, but within the second week of life he developed symptoms of heart failure (HF). He was found to have coarctation of the aorta and is now under the care of the cardiology team and scheduled for surgery. The infant is experiencing increased signs of HF and was hospitalized early this morning. His care is focused on preventing further symptoms before he goes to surgery. What are the most important signs of HF that the nurse would look for in this infant? Select all that apply. A. Edema B. Tachypnea C. Weight loss D. Tachycardia E. Hypotension F. Warm extremities G. Feeding difficulty H. Slow peripheral pulses I. Prolonged capillary refill, longer than 2 or 3 seconds J. Ineffective peripheral circulation, cool extremities

A. Edema B. Tachypnea D. Tachycardia E. Hypotension G. Feeding difficulty I. Prolonged capillary refill, longer than 2 or 3 seconds J. Ineffective peripheral circulation, cool extremities

The hematologist arrives to examine the child. At this time the child has findings that are consistent with a vasoocclusive crisis (VOC). When planning care for this child, which priority interventions would the nurse consider at this time? Select all that apply. A. Hydration B. Antibiotics C. Strict bedrest D. Pain medication E. Pain assessment F. Blood transfusion G. Oxygen therapy

A. Hydration D. Pain medication E. Pain assessment

A 5-year-old boy presents with symptoms that are suspicious of the acute phase of Kawasaki disease. He was playing last week with a cousin who was staying with the family. The nurse completes a history and physical assessment, and the findings are listed below. Which history and assessment findings reflect the diagnosis of Kawasaki disease? Select all that apply. A. Irritability B. Loud pansystolic murmur C. Tender, swollen abdomen D. Cervical lymphadenopathy E. Erythema of the palms and soles F. Bilateral conjunctival inflammation G. Loss of ambulation and weakened muscles H. Temperature over 100° F (37.8° C) for the last 5 days I. Inflammation of the pharynx with red, cracked lips and a "strawberry tongue"

A. Irritability D. Cervical lymphadenopathy E. Erythema of the palms and soles F. Bilateral conjunctival inflammation H. Temperature over 100° F (37.8° C) for the last 5 days I. Inflammation of the pharynx with red, cracked lips and a "strawberry tongue"

A 10-month-old boy is scheduled for a follow-up clinic visit. His mother reports that her son is anemic and needs further evaluation. What assessment findings below would the nurse expect to find to confirm iron deficiency anemia? Select all that apply. A. MCV = 67 fl B. Hematocrit = 30% C. Poor intake of solid food D. Pulse oximetry 98% E. Hemoglobin = 10.2 g/dL F. Respirations- 14 breaths/min G. Blood pressure = 102/50 mm Hg H. Serum iron concentration- 12 mcg/dL I. Total iron-binding capacity = 450 mcl/dL J. History of 28-32 oz/day of cow's milk intake

A. MCV = 67 fl B. Hematocrit = 30% C. Poor intake of solid food E. Hemoglobin = 10.2 g/dL H. Serum iron concentration- 12 mcg/dL I. Total iron-binding capacity = 450 mcl/dL J. History of 28-32 oz/day of cow's milk intake

A 9-year-old girl who has a history of chronic pyelonephritis has increased symptoms. Over the past several months, she has experienced increased fatigue and lack of appetite, is unable to participate in physical activities, and appears pale and listless. Her parents took her to the pediatrician, who on examination found signs and symptoms of weight loss, facial puffiness, bone and joint pain, and dryness of the skin. She told the pediatrician she was having headaches. With the child's history of chronic pyelonephritis, she was immediately referred to a pediatric nephrologist. The nurse in the pediatric nephrology clinic performs a complete history and physical examination and finds the following data. Select the history and physical assessment findings that require follow-up by the nurse. Select all that apply. A. Nausea B. Pallor C. Headache D. Facial edema E. Increased fatigue F. Pulse 90 beats/min G. Muscle cramps H. Height=128 cm (25% for height) I. BP= 128/90 mmHg J. Weight=55 lbs (24.9 kg) K. Respirations= 20 breaths/min L. Temperature 98.4F (36.9C) M. Dryness and itchiness of the skin

A. Nausea B. Pallor C. Headache D. Facial edema E. Increased fatigue G. Muscle cramps I. BP= 128/90 mmHg M. Dryness and itchiness of the skin

A 10-year-old girl who has a 2-day history of generalized periumbilical pain and anorexia. Today she developed a fever and vomiting, so her parents took her to her pediatrician. On review of the history, physical examination, and laboratory results, the nurse notes the following: • Oral temperature of 102° F (38.9° C) • Pulse of 80 beats/min and blood pressure is 108/74 mm/Hg • Abdominal pain midway between the anterior superior iliac crest and umbilicus • Pain intensifies with any activity or deep breathing • White blood cell (WBC) count of 21,000/mm3, 79% bands, 14% lymphocytes, 6% eosinophils • C-reactive Protein (CRP) of 18 mg/dL • Hemoglobin = 13.8 g/dL • Platelets = 252,000/mm3 • Weight 70lb (32kg) 3. The pediatrician examines the child and highly suspects appendicitis. A CT scan of the abdomen has been prescribed and the child is placed on NPO status. When planning care for this child, which priority symptoms would the nurse consider most immediate at this time? Select all that apply. A. Pain B. Anemia C. Infection D. Vomiting E. Weight loss F. Dehydration G. Constipation F. Dehydration H. Hyperthermia I. Rupture of the Appendix

A. Pain C. Infection D. Vomiting F. Dehydration H. Hyperthermia I. Rupture of the Appendix

The nurse is caring for an infant with hydrocephalus who is postoperative day 1 from a shunt revision. A complete assessment is performed by the nurse and findings are below. Which history and assessment findings require immediate follow-up for this infant. Select all that apply. A. Pupil dilation B. Abdominal distention C. Easily awakened and cries D. Sleeping quietly E. Temperature of 38.2°C (100.8°F) F. Decrease in heart rate over the last hour

A. Pupil dilation B. Abdominal distention E. Temperature of 38.2°C (100.8°F) F. Decrease in heart rate over the last hour

A 9-year-old girl diagnosed with CKD is now being followed by a nephrology specialty team. There is concern that the kidney status may be deteriorating based on the history and physical examination. Based on the abnormal history, physical and laboratory findings, what are the most appropriate dietary management strategies at this time? Select all that apply. A. Restrict sodium intake. B. Restrict foods high in sugar. C. Reduce foods high in calories. D. Limit protein to the reference daily intake for age. E. Reduce milk intake to correct sodium-glucose imbalance. F. Give oral medications to decrease creatinine gastrointestinal absorption. G. Provide sufficient calories and protein for growth while limiting excretory demands on the kidneys.

A. Restrict sodium intake. D. Limit protein to the reference daily intake for age. G. Provide sufficient calories and protein for growth while limiting excretory demands on the kidneys.

A nurse is assigned to complete the initial assessment for a 5-year-old child with a basilar skull fracture from a fall this morning. He was taken by ambulance to the Emergency Department after his older brother found him; he had tried to climb a tree in their yard and fell backwards onto the ground. When he arrived at the Emergency Department, he was awake and knew his name. Because of the severity of this type of fracture the nurse completes a comprehensive history and assessment, and findings are found below. Which are clinical manifestations of severe acute head injury and need immediate intervention? Select all that apply. A. Retinal hemorrhages B. Bleeding from the ear C. Respiration = 16 breaths/min D. Pulse oximetry 96% room air E. Clear fluid leaking from the nose F. Oral temperature = 100.4 F (38 C) G. Unsteady gait when moving from wheelchair to stretcher

A. Retinal hemorrhages B. Bleeding from the ear E. Clear fluid leaking from the nose F. Oral temperature = 100.4 F (38 C) G. Unsteady gait when moving from wheelchair to stretcher

The laboratory tests are ordered, and results are found below. Which findings require immediate follow-up? Select all that apply. A. hematocrit, 29% B. hemoglobin, 9.8 gm/dl C. platelets, 150,000/mm3 D. potassium, 4.9 mmol/L E. sodium, 139 mmol/L F. phosphorus 5.4 mmol/L G. serum creatinine, 1.9 mg/dL H. white blood count (WBC), 8,500/mm3 I. blood urea nitrogen (bun), 25 mg/dL J. urinalysis, elevated protein and hematuria K. glomerular function rate (GFR), 45 ml/min/1.73 m2

A. hematocrit, 29% B. hemoglobin, 9.8 gm/dl G. serum creatinine, 1.9 mg/dL I. blood urea nitrogen (bun), 25 mg/dL J. urinalysis, elevated protein and hematuria K. glomerular function rate (GFR), 45 ml/min/1.73 m2

What is a defect in Ventricular Septal Defect?

Abnormal opening between right and left ventricles

Indicate which nursing action listed in the far-left column is appropriate for the potential postoperative complication following appendectomy listed in the middle column. What nursing action works best for infection?

Administer IV antibiotics

Indicate which nursing action listed in the far-left column is appropriate for the potential postoperative complication following appendectomy listed in the middle column. What nursing action works best for nausea and vomiting?

Administer antiemetics

The nurse continues to closely observe the infant since there are obvious signs of heart failure related to the congenital defect. Indicate which nursing action listed in the far-left column is appropriate for each potential complication. Dangers inherent in failure to administer cardiac drugs as prescribed and to perform careful assessment before administration

Administer cardiac drugs on schedule. Assess and record any side effects or any signs and symptoms of toxicity. Follow hospital protocol for administration.

The nurse continues to closely observe the infant since there are obvious signs of heart failure related to the congenital defect. Indicate which nursing action listed in the far-left column is appropriate for each potential complication. Excess water and salt because fluid retention commonly occurs with heart failure.

Administer diuretics on schedule. Assess and record effectiveness and any side effects noted.

Indicate which nursing action number listed in the far-left column is most appropriate for each potential complication listed in the middle column. Which nursing action is used to minimize drying of nasal mucous membranes?

Administer humidified oxygen to maintain oxygen saturation above 90%.

Indicate which nursing action listed in the far-left column is appropriate for the potential postoperative complication following appendectomy listed in the middle column. What nursing action works best for pain?

Administer pain medications

Indicate which nursing action number listed in the far-left column is most appropriate for each potential complication listed in the middle column. Which nursing action is used to prevent constricted airways and decreased air exchange?

Administer rescue medications that can include inhalers, nebulization, and/or oral or intravenous steroids.

Indicate which nursing action number listed in the far-left column is most appropriate for each potential complication listed in the middle column. Which nursing action is used to prevent airway obstruction?

Allow patient to assume position of comfort.

In the last hour an IV dose of morphine (0.1 mg/kg) was given every 10 minutes for three doses. The numeric pain score of 7/10 is assessed after these initial doses. A decision is made to start both morphine and ketorolac since the pain was not relieved after three doses of IV morphine. The morphine is changed to patient-controlled analgesia (PCA). Ketorolac 1 mg/kg for the first dose, then 0.5 mg/kg/dose (maximum of 30 mg/dose) IV every 6 hours also is started. IV fluids at 1½ maintenance rate are administered. What are the most appropriate nursing interventions for this child with SCD experiencing pain who is now receiving morphine by PCA and IV Ketorolac? Indicate which nursing action should be used for each complication. Which nursing action should be used to prevent vasoconstriction that may enhance sickling with cold applications?

Apply heat application or massage to affected area. Avoid applying cold compression.

The nurse continues to closely observe the infant since there are obvious signs of heart failure related to the congenital defect. Indicate which nursing action listed in the far-left column is appropriate for each potential complication. Undetected changes in vital signs and infant's physical status that reflects altered cardiac output and high blood pressure

Assess and record heart rate, respiratory rate, BP, and any signs or symptoms of altered cardiac output every 2 to 4 hours

Indicate which nursing action number listed in the far-left column is most appropriate for each potential complication listed in the middle column. Which nursing action is used for individuals with lack of awareness for more aggressive interventions?

Assess patient's response to rescue medications.

Indicate which nursing action listed in the far-left column is appropriate for the potential postoperative complication following appendectomy listed in the middle column. What nursing action works best for fever?

Assess temperature and report elevation

Indicate which nursing action number listed in the far-left column is most appropriate for each potential complication listed in the middle column. Which nursing action is used when the patient has decreased awareness of factors that exacerbate asthma?

Assist patient in recognizing factors that trigger asthma symptoms.

The nurse is meeting with the child and family to discuss CKD and what to observe for at home. The mother confides she is extremely scared that she will miss something, and symptoms will worsen without her recognizing them. She states, "I did not even realize her blood pressure was up and her kidneys were worse. How will I know when they are abnormal at home?" The nurse spends time reviewing the most important concerns to look for at home. The mother and child also meet with the dietician to review important things to remember about the diet. Which statements by the mother indicate that the health teaching was effective? Select all that apply. A. "My child will need to restrict her total calories each day to under 1,500 a day." B. "Her kidneys do not work to extract wastes from my child's body and we have to be careful about her diet." C. "Her protein intake will be limited to the reference daily intake for her age and outlined by the dietician." D. "I will need to call the health care team if I notice more swelling in her arms and feet and if she develops frequent headaches at home." E. "Frequent rest periods can help my child have more energy since she is anemic." F. "Since her blood pressure is elevated, I will follow the guidelines for medication administration and sodium restriction discussed with me by the dietician."

B. "Her kidneys do not work to extract wastes from my child's body and we have to be careful about her diet." C. "Her protein intake will be limited to the reference daily intake for her age and outlined by the dietician." D. "I will need to call the health care team if I notice more swelling in her arms and feet and if she develops frequent headaches at home." E. "Frequent rest periods can help my child have more energy since she is anemic." F. "Since her blood pressure is elevated, I will follow the guidelines for medication administration and sodium restriction discussed with me by the dietician."

A 4-month-old child has had surgical correction for hypospadias. The nurse is meeting with the mother to give discharge instructions for home care. The mother is young and recently divorced. This is her first child. The infant will have a stent in place to drain urine for the next 5-10 days. The nurse recognizes a need for additional teaching when the mother says which of the following? Select all that apply. A. "I know that the catheter will drain into the diaper for 5-10 days." B. "I will give pain medication around the clock for 14 days after surgery." C. "My child can take a tub bath when we arrive home because it will soothe the area." D. "My child will be on an antibiotic to prevent infection until the catheter is removed." E. "I realize that bladder spasms may occur and my child may arch his back and bring his knees up to his chest during the spasm."

B. "I will give pain medication around the clock for 14 days after surgery." C. "My child can take a tub bath when we arrive home because it will soothe the area."

A three-year-old girl has a urinary tract infection (UTI) and is seen for follow-up in the pediatric office. The nurse after completing a history and physical examination is meeting with the mother to discuss important ways to prevent another urinary tract infection. Which of the topics listed below would be included in the health teaching for the parent before leaving the clinic? Select all that apply. A. Give prophylactic antibiotics. B. Encourage adequate fluid intake. C. Make sure the child is not constipated. D. How to cleanse the genital areas from front to back. E. Encourage the child to hold urine as long as possible. F. Make sure mother is aware of the signs and symptoms of UTI. G. Make sure the child empties the bladder completely and frequently.

B. Encourage adequate fluid intake. C. Make sure the child is not constipated. D. How to cleanse the genital areas from front to back. F. Make sure mother is aware of the signs and symptoms of UTI. G. Make sure the child empties the bladder completely and frequently.

The child is stabilized and has completed the comprehensive neurological evaluation. The evaluation revealed no definitive etiology for the seizures. However, the EEG remains abnormal and the MRI study was also abnormal. He will remain on seizure medications at home and be followed by the neurology team. The child's parents are anxious and upset and concerned about taking their son home. The nurse caring for him is to begin discharge teaching today. What are the most important aspects of home care to discuss with his parents at this time? Select all that apply. A. Have the child wear a helmet to school. B. Have child wear medical identification. C. Arrange for a class presentation to all students to help with observation while at school. D. Educate family about characteristics of seizures, including aura, seizure activity, and postictal state. E. Educate family about safety precautions before and during a seizure, including side-lying positioning, padding area if needed, and not placing items in mouth or attempting to stop the seizure. F. Educate family about medication administration, including scheduled and as necessary (prn) medications and potential side effects of medications. G. Arrange for social worker to meet with family to assess emotional and financial needs. H. Consider consultation with child life specialist to assist with education of school personnel and classmates. I. Have eyes-on supervision when swimming in pools and an adult within arm's reach in natural bodies of water. J. Use protective helmet and padding during bicycle riding, skateboarding, and in-line skating

B. Have child wear medical identification. D. Educate family about characteristics of seizures, including aura, seizure activity, and postictal state. E. Educate family about safety precautions before and during a seizure, including side-lying positioning, padding area if needed, and not placing items in mouth or attempting to stop the seizure. F. Educate family about medication administration, including scheduled and as necessary (prn) medications and potential side effects of medications. G. Arrange for social worker to meet with family to assess emotional and financial needs. H. Consider consultation with child life specialist to assist with education of school personnel and classmates. I. Have eyes-on supervision when swimming in pools and an adult within arm's reach in natural bodies of water. J. Use protective helmet and padding during bicycle riding, skateboarding, and in-line skating

What is the Diagnosis? The characteristics presented are labored respirations, poor feeding, cough, tachypnea, retractions, nasal flaring, and fever.

Bronchiolitis

A nurse is discharging a 5-week-old infant male with a congenital heart defect who will be going home on digoxin. The child was born prematurely, and the medication has shown beneficial effects in increasing cardiac output. The nurse is preparing the family for discharge and has spent time teaching both parents how to give digoxin to the infant. Which of the following answers by the father indicate the need for more teaching? Select all that apply. A. "If more than two doses have been missed, I should call the doctor." B. "If I miss a dose, I don't give an extra dose, but I give the next dose as ordered." C. "If the baby vomits, I should give a second dose of 10mg of the medication." D. I know I should give the drug carefully by slowly directing it to the side and back of the mouth." E. "I give the medication every 8 hours, and I can place it in a bit of formula so that I know the baby will take it."

C. "If the baby vomits, I should give a second dose of 10mg of the medication." E. "I give the medication every 8 hours, and I can place it in a bit of formula so that I know the baby will take it."

A 12-year-old male with sickle cell anemia (homozygous sickle cell disease [HgbSS]) is being seen in the emergency department (ED) for increasing pain over the past 2 days. The mother is giving him the pain medications as prescribed by the hematology team, but she feels that his pain is getting worse. Which assessment findings require follow-up by the nurse? Select all that apply. A. Pulse oximetry 96% B. Hematocrit = 34% C. Pulse = 112 beats/min D. Hemoglobin = 10.6 g/dL E. Respiration = 24 breaths/min F. Abdomen tender to palpation G. 8/10 on the number pain scale H. Blood pressure = 102/50 mm Hg I. Total serum bilirubin = 0.3 mg/dL J. Oral temperature = 100.4° F (38° C) K. Weight = 40 kg

C. Pulse = 112 beats/min E. Respiration = 24 breaths/min F. Abdomen tender to palpation G. 8/10 on the number pain scale J. Oral temperature = 100.4° F (38° C) K. Weight = 40 kg

Chronic kidney disease (CKD) occurs when the diseased kidneys can no longer maintain the normal chemical structure of blood fluids and chronic pyelonephritis can cause CKD. The pediatric nephrologist confirms that this young girl has CKD. What are the most appropriate nursing actions for a child with chronic kidney disease (CKD)? Indicate which nursing action should be used for the complication. What nursing action should be used when changes in kidney status go unrecognized?

Close monitoring of the patient's status. Follow clinical and laboratory findings. Blood studies include CBC, electrolytes, and kidney status.

A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received intravenous fluids, has tolerated some oral fluids in the emergency department, and is being discharged home. For each home care instruction, use an X to indicate whether it was Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) Give a BRAT diet (bananas, rice, apple sauce, and toast) for 24 hours, then a soft diet as tolerated

Contraindicated

A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received intravenous fluids, has tolerated some oral fluids in the emergency department, and is being discharged home. For each home care instruction, use an X to indicate whether it was Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) Give chicken or beef broth for 24 hours, then resume a soft diet

Contraindicated

A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received intravenous fluids, has tolerated some oral fluids in the emergency department, and is being discharged home. For each home care instruction, use an X to indicate whether it was Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) Keep on clear liquids and toast for 24 hours

Contraindicated

The infant has been afebrile for 24 hours and has an SpO2 of 98% on room air. She is now taking oral fluids and there is no longer any nasal discharge. The nurse prepares for discharge teaching and evaluates how prepared the parents are for taking the infant home. IDENTIFY IF TEACHING IS INDICATED, CONTRAINDICATED, OR NON-ESSENTIAL. Parents feel that keeping the infant supine will assist with any nasal secretions the infant may have.

Contraindicated

The infant has been afebrile for 24 hours and has an SpO2 of 98% on room air. She is now taking oral fluids and there is no longer any nasal discharge. The nurse prepares for discharge teaching and evaluates how prepared the parents are for taking the infant home. IDENTIFY IF TEACHING IS INDICATED, CONTRAINDICATED, OR NON-ESSENTIAL. Parents want to purchase a pulse oximeter before taking the infant home so they can constantly monitor the oxygen levels.

Contraindicated

The infant has recovered well from surgery with no complications. The nurse is preparing for discharge and notes that both parents are nervous and afraid of taking their infant home. What education would the nurse provide to the family at this time? Use an X for the health teaching evaluation below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). Inform parents to purchase a pulse oximeter before taking the infant home so they can constantly monitor the oxygen level.

Contraindicated

The infant has recovered well from surgery with no complications. The nurse is preparing for discharge and notes that both parents are nervous and afraid of taking their infant home. What education would the nurse provide to the family at this time? Use an X for the health teaching evaluation below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). Keep the infant supine at all times to assist with blood flow.

Contraindicated

The nurse is discharging a 5-year-old patient newly diagnosed with hemophilia. He was hospitalized because of a severe joint bleed following a fall. Which of the following responses are appropriate for the nurse to discuss with the parents? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "If there is bleeding in a joint, elevation, ice, and rest should prevent the need for factor VIII replacement."

Contraindicated

The nurse is discharging a 5-year-old patient newly diagnosed with hemophilia. He was hospitalized because of a severe joint bleed following a fall. Which of the following responses are appropriate for the nurse to discuss with the parents? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "Your child should remain active to decrease joint problems, and most children with hemophilia can participate in the same activities as their peers."

Contraindicated

The nurse is working with a 4-year-old girl who is newly diagnosed with beta thalassemia. Hemoglobin electrophoresis confirms the diagnosis of β-thalassemia. In preparing for discharge teaching with the parents and patient, which statements below would be discussed? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "We need to check your iron level to make sure you are not anemic."

Contraindicated

The nurse is working with a 4-year-old girl who is newly diagnosed with beta thalassemia. Hemoglobin electrophoresis confirms the diagnosis of β-thalassemia. In preparing for discharge teaching with the parents and patient, which statements below would be discussed? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "I believe your disease is most common in those of Hispanic descent, although you are Mediterranean."

Contraindicated

The nurse is working with a 4-year-old girl who is newly diagnosed with beta thalassemia. Hemoglobin electrophoresis confirms the diagnosis of β-thalassemia. In preparing for discharge teaching with the parents and patient, which statements below would be discussed? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "I think a transfusion will be ordered because your hemoglobin level is 9.5."

Contraindicated

In the last hour an IV dose of morphine (0.1 mg/kg) was given every 10 minutes for three doses. The numeric pain score of 7/10 is assessed after these initial doses. A decision is made to start both morphine and ketorolac since the pain was not relieved after three doses of IV morphine. The morphine is changed to patient-controlled analgesia (PCA). Ketorolac 1 mg/kg for the first dose, then 0.5 mg/kg/dose (maximum of 30 mg/dose) IV every 6 hours also is started. IV fluids at 1½ maintenance rate are administered. What are the most appropriate nursing interventions for this child with SCD experiencing pain who is now receiving morphine by PCA and IV Ketorolac? Indicate which nursing action should be used for each complication. Which nursing action should be used for uncontrollable pain?

Discuss schedule of medication around the clock with parents.

Indicate which nursing action listed in the far-left column is appropriate for the potential postoperative complication following appendectomy listed in the middle column. What nursing action works best for electrolyte imbalance?

Draw blood as scheduled and evaluate results

The child is seen in the Emergency Department after the mother picked him up from school. The physician wants to observe the child while tests results are pending. Blood work and an electroencephalogram (EEG) was done. Indicate which nursing action should be used for the complication Which nursing action should be used if aspiration can occur?

During seizures, place child in side-lying position on a flat surface such as a floor. Do not put anything into the child's mouth.

A 12-year-old male with sickle cell anemia (homozygous sickle cell disease [HgbSS]) was seen this morning in the emergency department (ED) for increasing pain over the past 2 days. He is admitted for pain management and is on IV Morphine and Ketorolac. His pain assessment is 2/10 on the numeric scale. Assessment findings at the nurse's change of shift at 7pm reveal: • Oral temperature = 99.0° F (37.2° C) • Pulse = 60 beats/min • Respiration = 16 breaths/min • Blood pressure = 100/48 mm Hg • Weight = 89 lbs (40kg) • Abdomen slightly tender to palpation • 2/10 on the number pain scale • Pulse oximetry 98% The patient is resting comfortably and the nurse at the end of her shift is assessing important nursing actions for the care of this child.For each nursing action, use an X to indicate whether it was Effective (helped to meet expected quality patient outcomes), Ineffective (did not help to meet expected quality patient outcomes), or Unrelated (not related to the quality patient outcomes). Monitor for side effects of ketorolac; assess for bleeding (gastrointestinal [GI] or renal) closely.

Effective

A 12-year-old male with sickle cell anemia (homozygous sickle cell disease [HgbSS]) was seen this morning in the emergency department (ED) for increasing pain over the past 2 days. He is admitted for pain management and is on IV Morphine and Ketorolac. His pain assessment is 2/10 on the numeric scale. Assessment findings at the nurse's change of shift at 7pm reveal: • Oral temperature = 99.0° F (37.2° C) • Pulse = 60 beats/min • Respiration = 16 breaths/min • Blood pressure = 100/48 mm Hg • Weight = 89 lbs (40kg) • Abdomen slightly tender to palpation • 2/10 on the number pain scale • Pulse oximetry 98% The patient is resting comfortably and the nurse at the end of her shift is assessing important nursing actions for the care of this child.For each nursing action, use an X to indicate whether it was Effective (helped to meet expected quality patient outcomes), Ineffective (did not help to meet expected quality patient outcomes), or Unrelated (not related to the quality patient outcomes). Monitor for side effects of morphine; assess respiratory status closely and prevent constipation.

Effective

A 12-year-old male with sickle cell anemia (homozygous sickle cell disease [HgbSS]) was seen this morning in the emergency department (ED) for increasing pain over the past 2 days. He is admitted for pain management and is on IV Morphine and Ketorolac. His pain assessment is 2/10 on the numeric scale. Assessment findings at the nurse's change of shift at 7pm reveal: • Oral temperature = 99.0° F (37.2° C) • Pulse = 60 beats/min • Respiration = 16 breaths/min • Blood pressure = 100/48 mm Hg • Weight = 89 lbs (40kg) • Abdomen slightly tender to palpation • 2/10 on the number pain scale • Pulse oximetry 98% The patient is resting comfortably and the nurse at the end of her shift is assessing important nursing actions for the care of this child.For each nursing action, use an X to indicate whether it was Effective (helped to meet expected quality patient outcomes), Ineffective (did not help to meet expected quality patient outcomes), or Unrelated (not related to the quality patient outcomes). Administer morphine and ketorolac safely.

Effective

A 12-year-old male with sickle cell anemia (homozygous sickle cell disease [HgbSS]) was seen this morning in the emergency department (ED) for increasing pain over the past 2 days. He is admitted for pain management and is on IV Morphine and Ketorolac. His pain assessment is 2/10 on the numeric scale. Assessment findings at the nurse's change of shift at 7pm reveal: • Oral temperature = 99.0° F (37.2° C) • Pulse = 60 beats/min • Respiration = 16 breaths/min • Blood pressure = 100/48 mm Hg • Weight = 89 lbs (40kg) • Abdomen slightly tender to palpation • 2/10 on the number pain scale • Pulse oximetry 98% The patient is resting comfortably and the nurse at the end of her shift is assessing important nursing actions for the care of this child.For each nursing action, use an X to indicate whether it was Effective (helped to meet expected quality patient outcomes), Ineffective (did not help to meet expected quality patient outcomes), or Unrelated (not related to the quality patient outcomes). Recognize that various analgesics and doses may need to be tried.

Effective

The child is admitted to the hospital after the seizure was stopped in the Emergency Department by administering intravenous lorazepam. The child has gained consciousness and is being monitored closely with his parents at the bedside. He is undergoing a comprehensive neurological examination with neuroimaging studies. The child had no history of signs of infection or head trauma. For each nursing action, use an X to indicate whether it was Effective (helped to meet expected patient outcomes), Ineffective (did not help to meet expected patient outcomes), or Unrelated (not related to the patient outcomes). Monitor circulation, airway, and breathing closely.

Effective

The child is admitted to the hospital after the seizure was stopped in the Emergency Department by administering intravenous lorazepam. The child has gained consciousness and is being monitored closely with his parents at the bedside. He is undergoing a comprehensive neurological examination with neuroimaging studies. The child had no history of signs of infection or head trauma. For each nursing action, use an X to indicate whether it was Effective (helped to meet expected patient outcomes), Ineffective (did not help to meet expected patient outcomes), or Unrelated (not related to the patient outcomes). Do not place anything in child's mouth during the seizure.

Effective

The child is admitted to the hospital after the seizure was stopped in the Emergency Department by administering intravenous lorazepam. The child has gained consciousness and is being monitored closely with his parents at the bedside. He is undergoing a comprehensive neurological examination with neuroimaging studies. The child had no history of signs of infection or head trauma. For each nursing action, use an X to indicate whether it was Effective (helped to meet expected patient outcomes), Ineffective (did not help to meet expected patient outcomes), or Unrelated (not related to the patient outcomes). Ensure antiepileptic drugs are being administered as directed.

Effective

The child is admitted to the hospital after the seizure was stopped in the Emergency Department by administering intravenous lorazepam. The child has gained consciousness and is being monitored closely with his parents at the bedside. He is undergoing a comprehensive neurological examination with neuroimaging studies. The child had no history of signs of infection or head trauma. For each nursing action, use an X to indicate whether it was Effective (helped to meet expected patient outcomes), Ineffective (did not help to meet expected patient outcomes), or Unrelated (not related to the patient outcomes). Monitor and record characteristics, onset, and duration of any new seizures, including motor effects, alterations in consciousness, and postictal state.

Effective

The child is admitted to the hospital after the seizure was stopped in the Emergency Department by administering intravenous lorazepam. The child has gained consciousness and is being monitored closely with his parents at the bedside. He is undergoing a comprehensive neurological examination with neuroimaging studies. The child had no history of signs of infection or head trauma. For each nursing action, use an X to indicate whether it was Effective (helped to meet expected patient outcomes), Ineffective (did not help to meet expected patient outcomes), or Unrelated (not related to the patient outcomes). Observe for hyperthermia, hypertension and respiratory depression.

Effective

The child is admitted to the hospital after the seizure was stopped in the Emergency Department by administering intravenous lorazepam. The child has gained consciousness and is being monitored closely with his parents at the bedside. He is undergoing a comprehensive neurological examination with neuroimaging studies. The child had no history of signs of infection or head trauma. For each nursing action, use an X to indicate whether it was Effective (helped to meet expected patient outcomes), Ineffective (did not help to meet expected patient outcomes), or Unrelated (not related to the patient outcomes). Place child in a side-lying position; suction the oral cavity and posterior oropharynx as needed.

Effective

The child is recovering well following surgery. The nurse performing the assessment finds her oral temperature is 98.6° F (37° C). The child reports that the pain is a 1 out of 10 on a 10 point pain intensity scale). She has no nausea or vomiting. DETERMINE IF THE ACTION IS EFFECTIVE, INEFFECTIVE, OR UNRELATED No complaints of nausea or vomiting and a regular diet is tolerated

Effective

The child is recovering well following surgery. The nurse performing the assessment finds her oral temperature is 98.6° F (37° C). The child reports that the pain is a 1 out of 10 on a 10 point pain intensity scale). She has no nausea or vomiting. DETERMINE IF THE ACTION IS EFFECTIVE, INEFFECTIVE, OR UNRELATED Observe no signs of infection

Effective

The child is recovering well following surgery. The nurse performing the assessment finds her oral temperature is 98.6° F (37° C). The child reports that the pain is a 1 out of 10 on a 10 point pain intensity scale). She has no nausea or vomiting. DETERMINE IF THE ACTION IS EFFECTIVE, INEFFECTIVE, OR UNRELATED Pain is controlled

Effective

The child is recovering well following surgery. The nurse performing the assessment finds her oral temperature is 98.6° F (37° C). The child reports that the pain is a 1 out of 10 on a 10 point pain intensity scale). She has no nausea or vomiting. DETERMINE IF THE ACTION IS EFFECTIVE, INEFFECTIVE, OR UNRELATED Temperature remains in the normal range

Effective

A 15-year-old male with a history of asthma is in the emergency department for immediate treatment. The physician has examined the patient and written orders. Which nursing interventions are of HIGHEST PRIORITY for this adolescent with an asthma exacerbation? INDICATE IF INTERVENTION IS EMERGENT OR NOT EMERGENT. Administer albuterol per hospital protocol

Emergent

A 15-year-old male with a history of asthma is in the emergency department for immediate treatment. The physician has examined the patient and written orders. Which nursing interventions are of HIGHEST PRIORITY for this adolescent with an asthma exacerbation? INDICATE IF INTERVENTION IS EMERGENT OR NOT EMERGENT. Administer humidified oxygen to keep the oxygen saturation above 90%

Emergent

A 15-year-old male with a history of asthma is in the emergency department for immediate treatment. The physician has examined the patient and written orders. Which nursing interventions are of HIGHEST PRIORITY for this adolescent with an asthma exacerbation? INDICATE IF INTERVENTION IS EMERGENT OR NOT EMERGENT. Administer methylprednisolone per the physicians order

Emergent

A 15-year-old male with a history of asthma is in the emergency department for immediate treatment. The physician has examined the patient and written orders. Which nursing interventions are of HIGHEST PRIORITY for this adolescent with an asthma exacerbation? INDICATE IF INTERVENTION IS EMERGENT OR NOT EMERGENT. Place the patient in a comfortable standing, sitting upright or leaning forward position.

Emergent

Surgery is planned for tomorrow. The infant's BP is 120/70mmHg, and the pulses in his arms are 220 beats/min and bounding. You find weak femoral pulses at 40 beats/min and his extremities are cool to touch. His breathing is at 36 breaths/min, and no nasal flaring or intercostal retractions are noted at this time. His color is pale without mottling. The infant is not on mechanical ventilation at this time. What are priority nursing actions? Indicate which nursing action is Emergent or Not Emergent for the patient's care at this time. Administer cardiac drugs on schedule. Assess and record any side effects or any signs and symptoms of toxicity. Follow hospital protocol for administration.

Emergent

Surgery is planned for tomorrow. The infant's BP is 120/70mmHg, and the pulses in his arms are 220 beats/min and bounding. You find weak femoral pulses at 40 beats/min and his extremities are cool to touch. His breathing is at 36 breaths/min, and no nasal flaring or intercostal retractions are noted at this time. His color is pale without mottling. The infant is not on mechanical ventilation at this time. What are priority nursing actions? Indicate which nursing action is Emergent or Not Emergent for the patient's care at this time. Administer cool humidified oxygen to increase available oxygen during inspiration.

Emergent

Surgery is planned for tomorrow. The infant's BP is 120/70mmHg, and the pulses in his arms are 220 beats/min and bounding. You find weak femoral pulses at 40 beats/min and his extremities are cool to touch. His breathing is at 36 breaths/min, and no nasal flaring or intercostal retractions are noted at this time. His color is pale without mottling. The infant is not on mechanical ventilation at this time. What are priority nursing actions? Indicate which nursing action is Emergent or Not Emergent for the patient's care at this time. Frequently assess and record heart rate, respiratory rate, blood pressure (BP), and any signs or symptoms of decreased cardiac output.

Emergent

Surgery is planned for tomorrow. The infant's BP is 120/70mmHg, and the pulses in his arms are 220 beats/min and bounding. You find weak femoral pulses at 40 beats/min and his extremities are cool to touch. His breathing is at 36 breaths/min, and no nasal flaring or intercostal retractions are noted at this time. His color is pale without mottling. The infant is not on mechanical ventilation at this time. What are priority nursing actions? Indicate which nursing action is Emergent or Not Emergent for the patient's care at this time. Keep accurate record of intake and output.

Emergent

In the last hour an IV dose of morphine (0.1 mg/kg) was given every 10 minutes for three doses. The numeric pain score of 7/10 is assessed after these initial doses. A decision is made to start both morphine and ketorolac since the pain was not relieved after three doses of IV morphine. The morphine is changed to patient-controlled analgesia (PCA). Ketorolac 1 mg/kg for the first dose, then 0.5 mg/kg/dose (maximum of 30 mg/dose) IV every 6 hours also is started. IV fluids at 1½ maintenance rate are administered. What are the most appropriate nursing interventions for this child with SCD experiencing pain who is now receiving morphine by PCA and IV Ketorolac? Indicate which nursing action should be used for each complication. Which nursing action should be used for dehydration?

Encourage high level of fluid intake.

What diagnosis goes with this hemodynamic changes; Structures on the left side of the heart (the side which receives oxygen-rich blood from the lungs and pumps it out to the body) are severely underdeveloped?

Hypoplastic Left Heart Syndrome

The child is seen in the Emergency Department after the mother picked him up from school. The physician wants to observe the child while tests results are pending. Blood work and an electroencephalogram (EEG) was done. Indicate which nursing action should be used for the complication Which nursing action should be used when physical harm occurs?

If child is at risk of falling, ease child to floor. Prevent child from hitting head on objects. Do not attempt to restrain child or use force.

A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received intravenous fluids, has tolerated some oral fluids in the emergency department, and is being discharged home. For each home care instruction, use an X to indicate whether it was Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) Offer a regular diet as child's appetite warrants

Indicated

The infant has been afebrile for 24 hours and has an SpO2 of 98% on room air. She is now taking oral fluids and there is no longer any nasal discharge. The nurse prepares for discharge teaching and evaluates how prepared the parents are for taking the infant home. IDENTIFY IF TEACHING IS INDICATED, CONTRAINDICATED, OR NON-ESSENTIAL. Parents able to verbalize definition and characteristics of acute respiratory tract infection.

Indicated

The infant has been afebrile for 24 hours and has an SpO2 of 98% on room air. She is now taking oral fluids and there is no longer any nasal discharge. The nurse prepares for discharge teaching and evaluates how prepared the parents are for taking the infant home. IDENTIFY IF TEACHING IS INDICATED, CONTRAINDICATED, OR NON-ESSENTIAL. Parents able to verbalize treatment, including medication and interventions that promote ventilation and airway clearance.

Indicated

The infant has been afebrile for 24 hours and has an SpO2 of 98% on room air. She is now taking oral fluids and there is no longer any nasal discharge. The nurse prepares for discharge teaching and evaluates how prepared the parents are for taking the infant home. IDENTIFY IF TEACHING IS INDICATED, CONTRAINDICATED, OR NON-ESSENTIAL. Parents can identify discharge medications, including antipyretics, bronchodilators, and antibiotics as prescribed.

Indicated

The infant has recovered well from surgery with no complications. The nurse is preparing for discharge and notes that both parents are nervous and afraid of taking their infant home. What education would the nurse provide to the family at this time? Use an X for the health teaching evaluation below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). Discuss the characteristics of COA and the surgery done to repair the obstructive defect.

Indicated

The infant has recovered well from surgery with no complications. The nurse is preparing for discharge and notes that both parents are nervous and afraid of taking their infant home. What education would the nurse provide to the family at this time? Use an X for the health teaching evaluation below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). Give parents the opportunity to express their fears and concerns.

Indicated

The infant has recovered well from surgery with no complications. The nurse is preparing for discharge and notes that both parents are nervous and afraid of taking their infant home. What education would the nurse provide to the family at this time? Use an X for the health teaching evaluation below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). Review signs and symptoms that could be of concern (fever, blue skin color, poor eating).

Indicated

The infant has recovered well from surgery with no complications. The nurse is preparing for discharge and notes that both parents are nervous and afraid of taking their infant home. What education would the nurse provide to the family at this time? Use an X for the health teaching evaluation below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). Review the infant's daily care including medication administration.

Indicated

The nurse is discharging a 5-year-old patient newly diagnosed with hemophilia. He was hospitalized because of a severe joint bleed following a fall. Which of the following responses are appropriate for the nurse to discuss with the parents? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "All of your son's teachers need to be aware of what to do if he gets a bloody nose."

Indicated

The nurse is discharging a 5-year-old patient newly diagnosed with hemophilia. He was hospitalized because of a severe joint bleed following a fall. Which of the following responses are appropriate for the nurse to discuss with the parents? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "Care should be taken to avoid bleeding of gums; soften the toothbrush in warm water before brushing or using a sponge-tipped disposable toothbrush may be helpful."

Indicated

The nurse is discharging a 5-year-old patient newly diagnosed with hemophilia. He was hospitalized because of a severe joint bleed following a fall. Which of the following responses are appropriate for the nurse to discuss with the parents? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "Signs of internal bleeding should be recognized, such as headache, slurred speech, loss of consciousness (from cerebral bleeding), and black, tarry stools (from gastrointestinal bleeding)."

Indicated

The nurse is working with a 4-year-old girl who is newly diagnosed with beta thalassemia. Hemoglobin electrophoresis confirms the diagnosis of β-thalassemia. In preparing for discharge teaching with the parents and patient, which statements below would be discussed? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "I would like to talk to you about the diagnosis and provide you with some information about β-thalassemia."

Indicated

A 12-year-old male with sickle cell anemia (homozygous sickle cell disease [HgbSS]) was seen this morning in the emergency department (ED) for increasing pain over the past 2 days. He is admitted for pain management and is on IV Morphine and Ketorolac. His pain assessment is 2/10 on the numeric scale. Assessment findings at the nurse's change of shift at 7pm reveal: • Oral temperature = 99.0° F (37.2° C) • Pulse = 60 beats/min • Respiration = 16 breaths/min • Blood pressure = 100/48 mm Hg • Weight = 89 lbs (40kg) • Abdomen slightly tender to palpation • 2/10 on the number pain scale • Pulse oximetry 98% The patient is resting comfortably and the nurse at the end of her shift is assessing important nursing actions for the care of this child.For each nursing action, use an X to indicate whether it was Effective (helped to meet expected quality patient outcomes), Ineffective (did not help to meet expected quality patient outcomes), or Unrelated (not related to the quality patient outcomes). Educate parents on the safety and effectiveness of IV morphine and ketorolac when using them at home.

Ineffective

A 12-year-old male with sickle cell anemia (homozygous sickle cell disease [HgbSS]) was seen this morning in the emergency department (ED) for increasing pain over the past 2 days. He is admitted for pain management and is on IV Morphine and Ketorolac. His pain assessment is 2/10 on the numeric scale. Assessment findings at the nurse's change of shift at 7pm reveal: • Oral temperature = 99.0° F (37.2° C) • Pulse = 60 beats/min • Respiration = 16 breaths/min • Blood pressure = 100/48 mm Hg • Weight = 89 lbs (40kg) • Abdomen slightly tender to palpation • 2/10 on the number pain scale • Pulse oximetry 98% The patient is resting comfortably and the nurse at the end of her shift is assessing important nursing actions for the care of this child.For each nursing action, use an X to indicate whether it was Effective (helped to meet expected quality patient outcomes), Ineffective (did not help to meet expected quality patient outcomes), or Unrelated (not related to the quality patient outcomes). Reassess the child's pain level once a shift after administering morphine and ketorolac.

Ineffective

The child is admitted to the hospital after the seizure was stopped in the Emergency Department by administering intravenous lorazepam. The child has gained consciousness and is being monitored closely with his parents at the bedside. He is undergoing a comprehensive neurological examination with neuroimaging studies. The child had no history of signs of infection or head trauma. For each nursing action, use an X to indicate whether it was Effective (helped to meet expected patient outcomes), Ineffective (did not help to meet expected patient outcomes), or Unrelated (not related to the patient outcomes). Attempt to stop the seizure if one occurs again; keep the child upright.

Ineffective

The child is recovering well following surgery. The nurse performing the assessment finds her oral temperature is 98.6° F (37° C). The child reports that the pain is a 1 out of 10 on a 10 point pain intensity scale). She has no nausea or vomiting. DETERMINE IF THE ACTION IS EFFECTIVE, INEFFECTIVE, OR UNRELATED Child spending all of the time in bed

Ineffective

Indicate which nursing action listed in the far-left column is appropriate for the potential postoperative complication following appendectomy listed in the middle column. What nursing action works best for fluid deficit?

Initiate IV fluids and assess intake and output.

The child is seen in the Emergency Department after the mother picked him up from school. The physician wants to observe the child while tests results are pending. Blood work and an electroencephalogram (EEG) was done. Indicate which nursing action should be used for the complication Which nursing action should be used when parents are unable to cope with the diagnosis and management of their son?

Involve child and parents in discussion of fear, anxieties, and resources and support options available to patient and family.

The nurse continues to closely observe the infant since there are obvious signs of heart failure related to the congenital defect. Indicate which nursing action listed in the far-left column is appropriate for each potential complication. Decreased urinary output is a symptom of heart failure and could go unnoticed.

Keep accurate record of intake and output

Chronic kidney disease (CKD) occurs when the diseased kidneys can no longer maintain the normal chemical structure of blood fluids and chronic pyelonephritis can cause CKD. The pediatric nephrologist confirms that this young girl has CKD. What are the most appropriate nursing actions for a child with chronic kidney disease (CKD)? Indicate which nursing action should be used for the complication. What nursing action should be used for accumulation of minerals?

Limit phosphorus, salt, and potassium as prescribed.

Chronic kidney disease (CKD) occurs when the diseased kidneys can no longer maintain the normal chemical structure of blood fluids and chronic pyelonephritis can cause CKD. The pediatric nephrologist confirms that this young girl has CKD. What are the most appropriate nursing actions for a child with chronic kidney disease (CKD)? Indicate which nursing action should be used for the complication. What nursing action should be used for renal bone disease?

Minimize renal bone disease by maintaining optimal calcium, phosphorous, and intact parathyroid hormone levels, and acid-base balance.

Chronic kidney disease (CKD) occurs when the diseased kidneys can no longer maintain the normal chemical structure of blood fluids and chronic pyelonephritis can cause CKD. The pediatric nephrologist confirms that this young girl has CKD. What are the most appropriate nursing actions for a child with chronic kidney disease (CKD)? Indicate which nursing action should be used for the complication. What nursing action should be used when growth failure is unrecognized?

Monitor growth closely since short stature is a significant side effect.

The child is seen in the Emergency Department after the mother picked him up from school. The physician wants to observe the child while tests results are pending. Blood work and an electroencephalogram (EEG) was done. Indicate which nursing action should be used for the complication Which nursing action should be used as if an accurate description of the seizure is not obtained?

Monitor time, movement, and LOC during seizure.

A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received intravenous fluids, has tolerated some oral fluids in the emergency department, and is being discharged home. For each home care instruction, use an X to indicate whether it was Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) Find out what the infant's favorite food is

Non-essential

A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received intravenous fluids, has tolerated some oral fluids in the emergency department, and is being discharged home. For each home care instruction, use an X to indicate whether it was Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) Sterilize the infant's eating utensils before each meal

Non-essential

The infant has been afebrile for 24 hours and has an SpO2 of 98% on room air. She is now taking oral fluids and there is no longer any nasal discharge. The nurse prepares for discharge teaching and evaluates how prepared the parents are for taking the infant home. IDENTIFY IF TEACHING IS INDICATED, CONTRAINDICATED, OR NON-ESSENTIAL. Parents want to purchase another bed for the infant to keep her close to them all night.

Non-essential

The infant has recovered well from surgery with no complications. The nurse is preparing for discharge and notes that both parents are nervous and afraid of taking their infant home. What education would the nurse provide to the family at this time? Use an X for the health teaching evaluation below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). Parents want to purchase another bed for the infant to keep her close to them at night.

Non-essential

The nurse is discharging a 5-year-old patient newly diagnosed with hemophilia. He was hospitalized because of a severe joint bleed following a fall. Which of the following responses are appropriate for the nurse to discuss with the parents? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "Your child should drink a lot of fluids to decrease the possibility of dehydration."

Non-essential

The nurse is working with a 4-year-old girl who is newly diagnosed with beta thalassemia. Hemoglobin electrophoresis confirms the diagnosis of β-thalassemia. In preparing for discharge teaching with the parents and patient, which statements below would be discussed? Use an X for the health teaching statement below that is Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary). "You look much younger than I would expect. I guess you are a late bloomer."

Non-essential

A 15-year-old male with a history of asthma is in the emergency department for immediate treatment. The physician has examined the patient and written orders. Which nursing interventions are of HIGHEST PRIORITY for this adolescent with an asthma exacerbation? INDICATE IF INTERVENTION IS EMERGENT OR NOT EMERGENT. Discuss possible allergens in the home that might have triggered the attack.

Not Emergent

A 15-year-old male with a history of asthma is in the emergency department for immediate treatment. The physician has examined the patient and written orders. Which nursing interventions are of HIGHEST PRIORITY for this adolescent with an asthma exacerbation? INDICATE IF INTERVENTION IS EMERGENT OR NOT EMERGENT. Review how to use the metered dose inhaler

Not Emergent

Surgery is planned for tomorrow. The infant's BP is 120/70mmHg, and the pulses in his arms are 220 beats/min and bounding. You find weak femoral pulses at 40 beats/min and his extremities are cool to touch. His breathing is at 36 breaths/min, and no nasal flaring or intercostal retractions are noted at this time. His color is pale without mottling. The infant is not on mechanical ventilation at this time. What are priority nursing actions? Indicate which nursing action is Emergent or Not Emergent for the patient's care at this time. Change the infant's position every 2 hours to prevent skin breakdown.

Not Emergent

Surgery is planned for tomorrow. The infant's BP is 120/70mmHg, and the pulses in his arms are 220 beats/min and bounding. You find weak femoral pulses at 40 beats/min and his extremities are cool to touch. His breathing is at 36 breaths/min, and no nasal flaring or intercostal retractions are noted at this time. His color is pale without mottling. The infant is not on mechanical ventilation at this time. What are priority nursing actions? Indicate which nursing action is Emergent or Not Emergent for the patient's care at this time. Maintain a 3-hour feeding schedule.

Not Emergent

Surgery is planned for tomorrow. The infant's BP is 120/70mmHg, and the pulses in his arms are 220 beats/min and bounding. You find weak femoral pulses at 40 beats/min and his extremities are cool to touch. His breathing is at 36 breaths/min, and no nasal flaring or intercostal retractions are noted at this time. His color is pale without mottling. The infant is not on mechanical ventilation at this time. What are priority nursing actions? Indicate which nursing action is Emergent or Not Emergent for the patient's care at this time. Restrict fluids if the intake and output is unbalanced.

Not Emergent

Surgery is planned for tomorrow. The infant's BP is 120/70mmHg, and the pulses in his arms are 220 beats/min and bounding. You find weak femoral pulses at 40 beats/min and his extremities are cool to touch. His breathing is at 36 breaths/min, and no nasal flaring or intercostal retractions are noted at this time. His color is pale without mottling. The infant is not on mechanical ventilation at this time. What are priority nursing actions? Indicate which nursing action is Emergent or Not Emergent for the patient's care at this time. Weigh infant on same scale at same time of day.

Not Emergent

Chronic kidney disease (CKD) occurs when the diseased kidneys can no longer maintain the normal chemical structure of blood fluids and chronic pyelonephritis can cause CKD. The pediatric nephrologist confirms that this young girl has CKD. What are the most appropriate nursing actions for a child with chronic kidney disease (CKD)? Indicate which nursing action should be used for the complication. What nursing action should be used for waste products accumulate?

Observe for evidence of accumulated waste products.

Indicate which nursing action listed in the far-left column is appropriate for the potential postoperative complication following appendectomy listed in the middle column. What nursing action works best for Inflammation at the wound site?

Observe wound site

What are some characteristics of Bronchitis?

Persistent dry, hacking cough worse at night, more productive in 2-3 days.

Chronic kidney disease (CKD) occurs when the diseased kidneys can no longer maintain the normal chemical structure of blood fluids and chronic pyelonephritis can cause CKD. The pediatric nephrologist confirms that this young girl has CKD. What are the most appropriate nursing actions for a child with chronic kidney disease (CKD)? Indicate which nursing action should be used for the complication. What nursing action should be used for increased excretory kidney demands?

Provide dietary instructions for foods that reduce excretory demands on the kidneys and provide sufficient calories and protein for growth.

In the last hour an IV dose of morphine (0.1 mg/kg) was given every 10 minutes for three doses. The numeric pain score of 7/10 is assessed after these initial doses. A decision is made to start both morphine and ketorolac since the pain was not relieved after three doses of IV morphine. The morphine is changed to patient-controlled analgesia (PCA). Ketorolac 1 mg/kg for the first dose, then 0.5 mg/kg/dose (maximum of 30 mg/dose) IV every 6 hours also is started. IV fluids at 1½ maintenance rate are administered. What are the most appropriate nursing interventions for this child with SCD experiencing pain who is now receiving morphine by PCA and IV Ketorolac? Indicate which nursing action should be used for each complication. Which nursing action should be used to avoid needless suffering because of unfounded fear?

Reassure child and family that analgesics, including opioids, are medically indicated; that high doses may be needed; and that children rarely become addicted.

In the last hour an IV dose of morphine (0.1 mg/kg) was given every 10 minutes for three doses. The numeric pain score of 7/10 is assessed after these initial doses. A decision is made to start both morphine and ketorolac since the pain was not relieved after three doses of IV morphine. The morphine is changed to patient-controlled analgesia (PCA). Ketorolac 1 mg/kg for the first dose, then 0.5 mg/kg/dose (maximum of 30 mg/dose) IV every 6 hours also is started. IV fluids at 1½ maintenance rate are administered. What are the most appropriate nursing interventions for this child with SCD experiencing pain who is now receiving morphine by PCA and IV Ketorolac? Indicate which nursing action should be used for each complication. Which nursing action should be used for breakthrough pain?

Recognize that various analgesics, including opioids and medication schedules my need to be tried.

What are hemodynamic changes in Aortic Stenosis?

Resistance of blood flow in the left ventricle causing decreased cardiac output

The child is seen in the Emergency Department after the mother picked him up from school. The physician wants to observe the child while tests results are pending. Blood work and an electroencephalogram (EEG) was done. Indicate which nursing action should be used for the complication Which nursing action should be used for a child experiencing anxiety and fear?

Stay with the child and reassure the child when awakening from seizure.

What is the treatment for Bronchiolitis?

Supplemental oxygen, fluid intake, suctioning as needed

A 12-year-old male with sickle cell anemia (homozygous sickle cell disease [HgbSS]) was seen this morning in the emergency department (ED) for increasing pain over the past 2 days. He is admitted for pain management and is on IV Morphine and Ketorolac. His pain assessment is 2/10 on the numeric scale. Assessment findings at the nurse's change of shift at 7pm reveal: • Oral temperature = 99.0° F (37.2° C) • Pulse = 60 beats/min • Respiration = 16 breaths/min • Blood pressure = 100/48 mm Hg • Weight = 89 lbs (40kg) • Abdomen slightly tender to palpation • 2/10 on the number pain scale • Pulse oximetry 98% The patient is resting comfortably and the nurse at the end of her shift is assessing important nursing actions for the care of this child.For each nursing action, use an X to indicate whether it was Effective (helped to meet expected quality patient outcomes), Ineffective (did not help to meet expected quality patient outcomes), or Unrelated (not related to the quality patient outcomes). Read a children's book to the child while he is asleep.

Unrelated

The child is admitted to the hospital after the seizure was stopped in the Emergency Department by administering intravenous lorazepam. The child has gained consciousness and is being monitored closely with his parents at the bedside. He is undergoing a comprehensive neurological examination with neuroimaging studies. The child had no history of signs of infection or head trauma. For each nursing action, use an X to indicate whether it was Effective (helped to meet expected patient outcomes), Ineffective (did not help to meet expected patient outcomes), or Unrelated (not related to the patient outcomes). Closely monitor hemoglobin and platelet count.

Unrelated

The child is recovering well following surgery. The nurse performing the assessment finds her oral temperature is 98.6° F (37° C). The child reports that the pain is a 1 out of 10 on a 10 point pain intensity scale). She has no nausea or vomiting. DETERMINE IF THE ACTION IS EFFECTIVE, INEFFECTIVE, OR UNRELATED No complaints of headaches

Unrelated

The child is recovering well following surgery. The nurse performing the assessment finds her oral temperature is 98.6° F (37° C). The child reports that the pain is a 1 out of 10 on a 10 point pain intensity scale). She has no nausea or vomiting. DETERMINE IF THE ACTION IS EFFECTIVE, INEFFECTIVE, OR UNRELATED Referral is made to a physical therapist

Unrelated

What is a defect in Tricuspid Atresia?

Valve fails to develop leaving no communication from the right atrium to the right ventricle.

A 15-year-old male with a history of asthma was admitted yesterday for acute asthmatic care. He has responded well to treatment and will be discharged. The nurse will be discussing discharge plans that are essential aspects of asthma care and prevention. What would the nurse include in the teaching plan? SELECT ALL THAT APPLY a. Avoiding smoke and other irritants b. Avoiding Tylenol containing products c. Encourage daily albuterol use d. Identifying early signs of an asthma exacerbation e. Identifying specific asthmatic triggers in the environment f. Reviewing home medications, dosing and precautions g. Recommending physical exercise and mental training h. Avoiding exposure to excessive cold, win d and other extremes of weather.

a. Avoiding smoke and other irritants d. Identifying early signs of an asthma exacerbation e. Identifying specific asthmatic triggers in the environment f. Reviewing home medications, dosing and precautions h. Avoiding exposure to excessive cold, win d and other extremes of weather.

A 15-year-old male presents to the emergency department with the history of asthma and symptoms that are not resolving with his current rescue medication. His asthma symptoms have been controlled with use of a long-acting inhaler twice daily, but an increase in seasonal allergies and a recent upper respiratory infection have caused an exacerbation of his symptoms. The patient rarely uses peak expiratory flow meter; instead he waits until his symptoms become sever before starting to use his rescue medication. Temp- 98.6F, HR- 114, Resp- 28, O2- 88% on room air, BP- 110/64, Wheezing auscultated in both lungs, Unable to lie down on the stretcher, Peak expiratory flow meter results are <50% of baseline Based on these findings, what are the most important subjective and objective data that should be considered as the defining characteristics of an acute asthma exacerbation? SELECT ALL THAT APPLY. a. Dyspna b. Moist Cough c. SOB d. High BP e. Increased respiratory rate f. profuse thick secretions g. Chest tightening or chest pain h. Use of accessory muscles i. Diminished breath sounds and/or adventitious breath sounds

a. Dyspna c. SOB e. Increased respiratory rate g. Chest tightening or chest pain h. Use of accessory muscles i. Diminished breath sounds and/or adventitious breath sounds

A 7-month-old infant girl is being evaluated in the emergency department for fever and cough. Mom reports over the past 2 days that she has not been as active as usual and is eating less. She started coughing during the night and upon awakening had a temperature of 103F. The mother states her infant is "breathing fast and she doesn't seem to be getting enough air." The nurse performs a complete history and assessment and finds the following. SLECT THE ASSESSMENT FINDINGS THAT REQUIRE FOLLOW-UP BY THE NURSE. SELECT ALL THAT APPLY. a. Nasal Flaring b. Decreased Appetite c. Skin Color - Pallor d. Irritable and Restless e. Pulse = 164 f. Retraction visualized g. Respiration - 42 h. SaO2 on Pulse Oximeter 88% i. Blood Pressure - 100/60 j. Rhonchi and fine crackles in left lung k. Axillary Temp - 102.4

a. Nasal Flaring b. Decreased Appetite c. Skin Color - Pallor d. Irritable and Restless e. Pulse = 164 f. Retraction visualized g. Respiration - 42 h. SaO2 on Pulse Oximeter 88% j. Rhonchi and fine crackles in left lung k. Axillary Temp - 102.4

A 5-year-old girl is recovering from tonsillectomy and adenoidectomy and is being discharged home with her mother. She is taking oral fluids but says it still hurts to swallow. She has no fever. The nurse is preparing to discharge the patient. home care instructions for the mother would include which of the following? SELECT ALL THAT APPLY a. Observe the child for ability to swallow b. encourage the child to take sips of cool, clear liquids c. Administer codeine elixir as necessary for throat pain d. Administer an analgesic such as acetaminophen for pain e. Observe the child for restlessness of difficulty to breath f. Encourage the child to cough every 4 to 5 hours to prevent pneumonia

a. Observe the child for ability to swallow b. encourage the child to take sips of cool, clear liquids d. Administer an analgesic such as acetaminophen for pain e. Observe the child for restlessness of difficulty to breath

A 12-year-old is in the urgent care clinic with a complaint of fever, headache, and sore throat. The nurse performs a complete history and physical and obtains a throat swab for rapid antigen testing. A diagnosis of group A beta-hemolytic streptococcus pharyngitis is confirmed. The nurse's assessment findings are listed below. SELECT ALL THE FINDINGS THAT REFLECT THE DIAGNOSIS OF GABHS. a. Tonsils are inflamed and covered with exudate b. temp- 100.4 c. Headache for the past 2 days d. Small, <0.5cm cervical lymph nodes e. constipation for the past 3 days f. Throat pain increased when swallowing g. Abdomen painful to touch

a. Tonsils are inflamed and covered with exudate b. temp- 100.4 c. Headache for the past 2 days d. Small, <0.5cm cervical lymph nodes f. Throat pain increased when swallowing

A 15-year-old male presents to the emergency department with the history of asthma and symptoms that are not resolving with his current rescue medication. His asthma symptoms have been controlled with use of a long-acting inhaler twice daily, but an increase in seasonal allergies and a recent upper respiratory infection have caused an exacerbation of his symptoms. The patient rarely uses peak expiratory flow meter; instead he waits until his symptoms become sever before starting to use his rescue medication. The nurse completes a history and physical assessment and finds the following. WHAT ASSESSMENT FINDINGS REQUIRE FOLLOW-UP BY THE NURSE? a. Temp- 98.6F b. HR- 114 c. Resp- 28 d. O2- 88% on room air e. BP- 110/64 f. Wheezing auscultated in both lungs g. Unable to lie down on the stretcher h. Peak expiratory flow meter results are <50% of baseline

b. HR- 114 c. Resp- 28 d. O2- 88% on room air f. Wheezing auscultated in both lungs g. Unable to lie down on the stretcher h. Peak expiratory flow meter results are <50% of baseline

A 10-year-old girl has a 2 day history of generalized periumbilical pain and anorexia. Today she developed a fever and vomiting, so her parents took her to the clinic. On review of the history, physical examination, and laboratory results, the nurse notes the findings below. SELECT THE FINDINGS THAT REQUIRE FOLLOW-UP BY THE NURSE. SELECT ALL THAT APPLY a. Weight 70lbs b. Hemoglobin 13.8 c. Platalets 252,000 d. C-reactive protein (CRP) of 40mg e. Pain intensifies with any activity or deep breathing f. Oral temp of 102F g. Pulse of 80 and BP is 108/74 h. Abdominal pain midway between the anterior superior iliac crest and umbilicus i. WBC count of 21,000, 79% bands, 14% lymphocytes, 6% eosinophils

d. C-reactive protein (CRP) of 40mg e. Pain intensifies with any activity or deep breathing f. Oral temp of 102F h. Abdominal pain midway between the anterior superior iliac crest and umbilicus i. WBC count of 21,000, 79% bands, 14% lymphocytes, 6% eosinophils