Chapter 19 - Prioritization, Delegation, and Assignment
A teenager arrives in the triage area alert and ambulatory, but his clothes are covered with blood. His friends are yelling, "We were goofing around, and he got poked in the abdomen with a stick!" Which comment would be of *most* concern? •"There was a lot of blood, and we used three bandages." •"He pulled the stick out, just now, because it was hurting him." •"The stick was really dirty and covered with mud." •"He has diabetes, so he needs attention right away."
•"He pulled the stick out, just now, because it was hurting him." •An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history, including a more definitive description of the blood loss, depth of penetration, and medical history, should be obtained. Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment plan but can be addressed later.
The nurse is caring for a 5-year-old whose mother asks why he still wets the bed. What is the *best* response? •"He is old enough that he should no longer be wetting the bed." •"Most children outgrow bed-wetting by the time they start school." •"His bed-wetting may be due to an immature bladder or deep sleep pattern." •"He will probably stop once he realizes how embarrassing it is to wet the bed."
•"His bed-wetting may be due to an immature bladder or deep sleep pattern." •Theories about bed-wetting relate it to immature bladder and deep sleep patterns. Although it is true that most children stop bed-wetting by the time they start school, this does not answer the mother's question. Many boys wet the bed until after the age of 5 years. The fourth response is not accurate because often bed-wetting is not within the control of a 5-year-old child.
The nurse caring for a 3-year-old child plans to assess the child's pain using the Wong-Baker FACES® Pain Rating Scale. Which accompanying assessment question would be the *most* useful? •"If number 0 (smiling face) were no pain and number 10 (crying face) were a big pain, what number would your pain be?" •"Can you point to the face picture with one finger and tell me what that pain feels like inside of you?" •"The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" •"If you look at these faces and I give you a paper and pencil, can you draw for me the face that looks most like your pain?"
•"The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" •Pain rating scales using faces (depicting smiling, neutral, frowning, crying, and so on) are appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other questions require abstract reasoning abilities to make analogies and the use of advanced vocabulary.
Parents of a 13-year-old adolescent girl expressed concern because she spends "quite a bit of time in her room alone in front of the mirror." The girl's height and weight are in the 50th percentile. In the exam room, the girl is quiet but does answer questions appropriately. What advice should the nurse provide to the parents? •"Further evaluation by a psychologist is needed because your daughter spends a lot of time alone in her room." •"Limit the amount of time that your daughter is allowed to spend alone in her room." •"This behavior is normal. Your daughter is adjusting to the physical changes she is experiencing." •"This behavior may be associated with depression, and further evaluation by a counselor is advised."
•"This behavior is normal. Your daughter is adjusting to the physical changes she is experiencing." •This is normal behavior in early adolescence. During this time period, adolescents are conscious of their rapid physical changes. As a result, they spend more time in front of the mirror inspecting their bodies. Consider that the height and weight are normal; therefore, an eating disorder is not likely. Also, the girl does answer questions appropriately, so mental health issues are not likely.
The nurse has just received a change-of-shift report about these pediatric patients. Which patient will the nurse assess *first*? •A 1-year-old patient with hemophilia B who was admitted because of decreased responsiveness •A 3-year-old patient with von Willebrand disease who has a dose of desmopressin (DDAVP) scheduled •A 7-year-old patient with acute lymphocytic leukemia who has chemotherapy-induced thrombocytopenia •A 16-year-old patient with sickle cell disease who reports acute right lower quadrant abdominal pain
•A 1-year-old patient with hemophilia B who was admitted because of decreased responsiveness •Because decreased responsiveness in a 1-year-old patient with a clotting disorder may indicate intracerebral bleeding, this patient should be assessed immediately. The other patients also require assessments or interventions but are not at immediate risk for life-threatening or disabling complications.
The pediatric unit charge nurse is working with a newly graduated RN who has been on orientation in the unit for 2 months. Which patient should the charge nurse assign to the new RN? •A 2-year-old patient with a ventricular septal defect for whom digoxin 90 mcg by mouth has been prescribed •A 4-year-old patient who had a pulmonary artery banding and has just been transferred in from the intensive care unit •A 9-year-old patient with mitral valve endocarditis whose parents need teaching about IV antibiotic administration •A 16-year-old patient with a heart transplant who was admitted with a low-grade fever and tachycardia
•A 2-year-old patient with a ventricular septal defect for whom digoxin 90 mcg by mouth has been prescribed •This patient requires the least complex assessments and interventions of the four patients. Safe administration of oral medications such as digoxin would have been included in the orientation of the new RN graduate. The conditions of the other patients are more complex, and they require assessments or interventions (e.g., teaching) that should be carried out by an RN with more experience.
The pediatric unit charge nurse is making patient assignments for the evening shift. Which patient is *most* appropriate to assign to an experienced LPN/LVN? •A 1-year-old patient with severe combined immunodeficiency disease who is scheduled to receive chemotherapy in preparation for a stem cell transplant •A 2-year-old patient with Wiskott-Aldrich syndrome who has orders for a platelet transfusion •A 3-year-old patient who has chronic graft-versus-host disease and is incontinent of loose stools •A 6-year-old patient who received chemotherapy 1 week ago and is admitted with increasing lethargy and a temperature of 101°F (38.3°C)
•A 3-year-old patient who has chronic graft-versus-host disease and is incontinent of loose stools •LPN/LVN scope of practice includes care of patients with chronic and stable health problems, such as the patient with chronic graft-versus-host disease. Chemotherapy medications are considered high-alert medications and should be given by RNs who have received additional education in chemotherapy administration. Platelets and other blood products should be given by RNs. The 6-year-old patient has a history and clinical manifestations consistent with neutropenia and sepsis and should be assessed by an RN as quickly as possible.
The nurse is observing a preschool classroom of children between the ages of 3 to 4 years of age. When planning actions to ensure that each child meets normal developmental goals, which child will require the *most* immediate intervention? •A 3-year-old boy who needs help dressing •A 4-year-old girl who has an imaginary friend •A 4-year-old girl who engages only in parallel play •A 3-year-old boy who draws stick figures
•A 4-year-old girl who engages only in parallel play •At 4 years of age, children engage in pretend play. Parallel play is seen in younger children between the ages of 2 and 3 years when they play side by side with limited interaction. The other behaviors are developmentally appropriate. The nurse will plan interventions to ensure that all the children meet developmental goals, but the 4-year-old child engaging only in parallel play will require the most immediate intervention.
After receiving the change-of-shift report, which patient should the nurse assess *first*? •An 18-month-old patient with coarctation of the aorta who has decreased pedal pulses •A 3-year-old patient with rheumatic fever who reports severe knee pain •A 5-year-old patient with endocarditis who has crackles audible throughout both lungs •An 8-year-old patient with Kawasaki disease who has a temperature of 102.2°F (38.9°C)
•A 5-year-old patient with endocarditis who has crackles audible throughout both lungs •Crackles throughout both lungs indicate that the child has severe left ventricular failure as a complication of endocarditis. Hypoxemia is likely, so the child needs rapid assessment of oxygen saturation, initiation of supplemental oxygen delivery, and administration of medications such as diuretics. The other children should also be assessed as quickly as possible, but they are not experiencing life-threatening complications of their medical diagnoses.
Which pediatric pain patient should be assigned to a newly graduated RN? •An adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose •A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures •A child who is receiving palliative end-of-life care; the child is receiving opioids around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness •A child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful
•A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures •The set of circumstances is least complicated for the child with the fracture, and this would be the best patient for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management, the anxiety will resolve. The other three children have more complex social and psychological issues related to pain management.
Parents of a 6-month-old girl bring the infant to the emergency department because "she has not held anything down for the entire day." The nurse obtains a fingerstick blood glucose of 94 (5.22 mmol/L). The infant's rectal temperature is 101°F (38.3°C), heart rate is 198 beats/min, respiratory rate is 40 breaths/min, and blood pressure 60/38 mm Hg in the left arm. Which nursing action is a *priority*? •Administer an antiemetic rectally •Administer a bolus of D10W •Administer a bolus of normal saline •Administer an antipyretic rectally
•Administer a bolus of normal saline •This infant is experiencing severe dehydration, which is evidenced by tachycardia and hypotension. The child is at risk for hypovolemic shock, which is a life-threatening event. A bolus of normal saline or lactated Ringer's solution of 20 mL/kg is the standard of care to establish hemodynamic stability. The blood glucose is normal. The safety profile for antiemetics have not been established with infants, and the priority for this patient is to establish hemodynamic stability. Fever can cause increased fluid loss; however, the priority in this life-threatening situation is to establish hemodynamic stability.
While working in the pediatric clinic, the nurse receives a telephone call from the parent of a 13-year-old child who is receiving chemotherapy for leukemia. The patient's sibling has chickenpox (varicella). Which action will the nurse anticipate taking *next*? •Administer varicella-zoster immune globulin to the patient •Teach the parent about the correct use of acyclovir •Educate the parent about contact and airborne precautions •Prepare to admit the patient to a private room in the hospital
•Administer varicella-zoster immune globulin to the patient •The administration of varicella-zoster immune globulin can prevent the development of varicella in immunosuppressed patients and will typically be prescribed. Acyclovir therapy and hospitalization may be required if the child develops a varicella-zoster virus infection. Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child is hospitalized with varicella.
The health care provider has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which task will the nurse delegate to the unlicensed assistive personnel (UAP)? •Providing explanations of nursing actions to the family •Assisting the child to remove the outer clothing •Advising the parent to use acetaminophen instead of aspirin •Monitoring the child's level of consciousness and orientation level
•Assisting the child to remove the outer clothing •The UAP can help with the removal of outer clothing, which allows the heat to dissipate from the child's skin. Assessments, advising, and explaining require RN-level education and scope of practice.
A 16-year-old female adolescent arrives at the health center. She tells the nurse that she's been sexually active for 6 months "but only with my boyfriend." Her immunizations are up to date. Screening for which sexually transmitted disease (STD) will be *most* important for this patient? •Syphilis •Genital herpes simplex •Human papillomavirus •Chlamydia
•Chlamydia •Recommendations by the Centers for Disease Control and Prevention recommend annual screening for chlamydia (and gonorrhea) for all sexually active women younger than the age of 25 years. Chlamydia is the most prevalent STD in the United States. Screening for syphilis and genital herpes simplex is recommended only if other risk factors or evidence of disease are present. The patient is fully immunized, which would include the human papillomavirus vaccine.
An excited mother calls the nurse for advice. "My child got cleaning solution in her eyes, and I rinsed her eyes with water for a few minutes. What should I do? She is still screaming!" What does the nurse instruct the caller to do *first*? •Comfort the child and check her vision •Continue to irrigate the eyes with water •Call the Poison Control Center •Call 911 to request an ambulance
•Continue to irrigate the eyes with water •Even though the child is screaming, the mother must continue to irrigate the eyes for at least 20 minutes. Another adult, if present, should call the Poison Control Center and 911.
The school nurse is performing developmental screenings for children who will be entering preschool. A 4-year-old girl excitedly tells the nurse about her recent birthday party. As she relates the details of the event, she frequently stutters. Which action by the nurse is *most* appropriate at this time? •Refer the child to an audiologist •Obtain a detailed birth history from the parents •Document the findings on the child's school record •Refer the child to a speech pathologist
•Document the findings on the child's school record •Stuttering during the preschool years is a normal variation, particularly when excited or upset. The cause is attributed to preschool children's increased cognitive abilities and imagination such that their speech cannot keep up with their thoughts. Documenting this on the child's record is important for continued observation to determine if it extends beyond the preschool years.
A 2-year-old child arrives at the health center for a routine well-child visit. A complete blood count and lead level are obtained. The lead level is less than 10 mcg/dL (0.483 μmol/L). The hemoglobin is 8 g/dL (80 g/L). The hematocrit is 24% (0.24 volume fraction), and the mean corpuscular volume (MCV) is 65 μm3 (65 fL). What questions should the nurse ask the parent to obtain a more thorough history? *Select all that apply.* •Does your child eat nonfood substances? •Is your child more prone to infections? •Has your child experienced hair loss? •Does your child frequently have nosebleeds? •How much milk does your child drink?
•Does your child eat nonfood substances? •How much milk does your child drink? •Iron deficiency anemia is a microcytic anemia. Laboratory findings consistent with iron deficiency anemia include low hemoglobin, hematocrit, and MCV. Additionally, the patient may have thrombocytosis, which is an increase in the number of platelets; so the child will not be more likely to have nosebleeds. The white blood cell count (WBC) and WBC differential are not affected by anemia; therefore, the child will not be more prone to infections. Children with iron deficiency anemia experience pica, which is a consumption of nonfood items. Excessive cow's milk intake has been found to cause anemia by irritating the intestine and resulting in microscopic blood loss from the gastrointestinal tract.
A newborn infant is diagnosed with tracheoesophageal fistula. Which nursing interventions should be implemented in the preoperative period? *Select all that apply.* •Provide small frequent feedings •Elevate the head of the bed •Prepare a tracheostomy tray •Set up suctioning •Administer IV antibiotics
•Elevate the head of the bed •Set up suctioning •Administer IV antibiotics •A tracheoesophageal fistula is a congenital malformation in which the esophagus ends in a blind pouch and there is a fistula (opening) between the esophagus and the trachea. The infant is a high risk for aspiration of esophageal contents into the trachea; hence, the infant is NPO in the preoperative period. IV fluids are administered to maintain hydration. A tracheostomy is not indicated for tracheoesophageal fistula. Surgical intervention for tracheoesophageal fistula include ligation of the fistula and reanastomosis of the esophagus. Suction should be on hand to remove secretions from the blind pouch. IV antibiotics are initiated in the preoperative period.
Which action will the public health nurse take to have the *most* impact on the incidence of infectious diseases in the school? •Make soap and water readily available in the classrooms •Ensure that students are immunized according to national recommendations •Provide written information about infection control to all parents •Teach students how to cover their mouths when they cough or sneeze
•Ensure that students are immunized according to national recommendations •The incidence of once-common infectious diseases such as measles, chickenpox, and mumps has been most effectively reduced by the immunization of all school-age children. The other actions are also helpful but will not have as great an impact as immunization.
An unimmunized 7-year-old child who attends a local elementary school contracts rubeola (measles). The child has two siblings, ages 9 and 11 years, who also attend the elementary school. Which action by the school nurse is a *priority*? •Exclude the child and siblings from attending school for 21 days •Notify all parents of children attending the school of the exposure •Recommend that siblings receive the measles vaccine •Recommend that siblings receive measles immunoglobulin
•Exclude the child and siblings from attending school for 21 days •Rubeola is a highly contagious infectious disease with severe consequences that include death. The Centers for Disease Control and Prevention reports that 9 of 10 susceptible persons with close contact to a person with measles will contract the disease. The incubation period is 7 to 21 days. Excluding the infected and exposed children during this period of time is a priority to prevent exposure of healthy children enrolled in the elementary school. Although it is important to notify the parents of the other children in the school of the exposure, limiting exposure of other children is the priority. Mumps, measles, and rubella vaccine administered within 72 hours of initial measles exposure and immunoglobulin administered within 6 days of exposure may provide some protection or modify the clinical course of the disease in unimmunized children; however, the priority is to prevent an epidemic by limiting exposure.
A 6-year-old child who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is the nurse's *best* response to this behavior? •Remind the child that foods tasted good today and will help her or his body to get strong •Allow the mother and child time alone to review and control the behavior •Ask the mother to leave until the child can finish eating and then invite her back •Explain to the mother that the behavior could be a normal expression of anger
•Explain to the mother that the behavior could be a normal expression of anger •Help the mother to understand that the child may be angry about being left in the hospital or about her inability to prevent the illness and protect the child. Reminding the child about the food and the purpose of the food does not address the strong emotions underlying the outburst. Allowing the mother and child time alone is a possibility, but the assumption would be that the mother understands the child's behavior and is prepared to deal with the behavior in a constructive manner. Asking the mother to leave the child suggests that the mother is a source of stress.
An 18-month-old child has oral mucositis secondary to chemotherapy. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)? •Reporting evidence of severe mucosal ulceration •Assisting the child in swishing and spitting mouthwash •Assessing the child's ability and willingness to drink through a straw •Feeding the child a bland, moist, soft diet
•Feeding the child a bland, moist, soft diet •Helping the child to eat is within the scope of responsibilities for a UAP. Assessing ability and willingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. An 18-month-old child is not able to swish and spit, which could result in swallowing the mouthwash. Mouthwash is not intended for swallowing because it can contain alcohol and other ingredients not safe for ingestion.
The nurse is caring for several children with cancer who are receiving chemotherapy. The nurse is reviewing the morning laboratory results for each of the patients. Which patient condition combined with the indicated laboratory result would cause the nurse the greatest concern? •Nausea and vomiting with a potassium level of 3.3 mEq/L (3.3 mmol/L) •Epistaxis with a platelet count of 100,000/mm3 (100 × 109/L) •Fever with an absolute neutrophil count of 450/mm3 (450 × 109/L) •Fatigue with a hemoglobin level of 8 g/dL (80 g/L)
•Fever with an absolute neutrophil count of 450/mm3 (450 × 109/L) •National guidelines indicate that rapid treatment of infection in neutropenic patients is essential to prevent complications such as overwhelming sepsis and secondary infections; therefore, the child with fever and a low neutrophil count is the priority. A potassium level of 3.3 mEq/L (3.3 mmol/L) is borderline low and should be monitored. Nosebleeds are common, and the patient and parents should be taught to apply direct pressure to the nose, have the child sit upright, and not disturb the clot. Severe spontaneous hemorrhage is not expected until the platelet count drops below 20,000 mm3 (20 × 109/L). Children can withstand low hemoglobin levels. The nurse should help the patient and parents regulate activity to prevent excessive fatigue.
The nurse has obtained this assessment information about a 3-year-old patient who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the *most* immediate follow-up? •Frequent swallowing •Hypotonic bowel sounds •Reports of a sore throat •Heart rate of 112 beats/min
•Frequent swallowing •Frequent swallowing after tonsillectomy may indicate bleeding. The nurse should inspect the back of the throat for evidence of bleeding. The other assessment results are expected in a 3-year-old child after surgery.
Liquid supplemental iron is prescribed for a 10-month-old child with iron deficiency anemia. The parents tell the nurse that their child hates the taste of medicine. Which of the following instructions should the nurse provide to the parents? *Select all that apply.* •Give the iron orally with a syringe •Mix the iron in a little bit of chocolate syrup •Give the iron with food or milk •Let the child drink the iron through a straw •Give the iron with orange juice
•Give the iron orally with a syringe •Give the iron with orange juice •Iron supplementation can stain the teeth and has an unpleasant taste. By administering the iron with a syringe to the back of the throat, it will mask the taste and prevent staining of the teeth. The vitamin C in orange juice increases iron absorption and may mask the unpleasant taste. Chocolate contains caffeine, which interferes with the absorption of iron. Milk and food also interfere with the absorption of iron. Although allowing a child to drink the iron through a straw is feasible for an older child, a 10-month-old child cannot developmentally perform this task.
The nurse is teaching a group of day-care workers about how to avoid transmission of hepatitis A in day-care settings. What is the single *most* effective measure to emphasize? •Hand hygiene should be performed often to prevent and control the spread of infection •Children in whom hepatitis has been diagnosed should not share toys with others •Children with episodes of fecal incontinence should be isolated from others •Immunizations are recommended before children are admitted into day-care settings
•Hand hygiene should be performed often to prevent and control the spread of infection •Hand washing is the most important aspect to emphasize. Addressing fecal incontinence and sharing of personal items may be recommended when the disease is in an infectious stage. Immunizations are recommended, but this would be emphasized to parents rather than day-care workers.
The emergency department receives multiple individuals, mostly children, who were injured when the roof of a day-care center collapsed because of a heavy snowfall. Based on physiologic differences in children compared with adults, for which injuries and complications will the nurse assess *first*? *Select all that apply.* •Head injuries •Bradycardia or junctional arrhythmias •Hypoxemia •Liver and spleen contusions •Hypothermia •Fractures of the long bones •Lumbar spines injuries
•Head injuries •Hypoxemia •Liver and spleen contusions •Hypothermia •Children have proportionately larger heads that predispose them to head injuries. Hypoxemia is more likely because of their higher oxygen demand. Liver and spleen injuries are more likely because the thoracic cages of children offer less protection. Hypothermia is more likely because of children's thinner skin and proportionately larger body surface area. They have strong hearts; therefore, pulse rate will increase to compensate, but other arrhythmias are less likely to occur. Children have relatively flexible bones compared with those of adults. The most likely spinal injury in children is injury to the cervical area.
The nurse is reviewing a complete blood count for a 3-year-old patient with idiopathic thrombocytopenic purpura (ITP). Which information should the nurse report *immediately* to the health care provider (HCP)? •Prothrombin time (PT) of 12 seconds •Hemoglobin level of 6.1 g/dL (61 g/L) •Platelet count of 40,000/mm3 (40 × 109/L) •Leukocyte count of 5600/mm3 (5.6 × 109/L)
•Hemoglobin level of 6.1 g/dL (61 g/L) •The low hemoglobin count may signify bleeding; therefore, alerting the HCP is recommended. ITP is an autoimmune disorder by which circulating platelets are destroyed by autoantibodies. Platelet production from the bone marrow, however, is not affected. Laboratory findings characteristic of ITP include a low platelet count generally less than 20,000/mm3 (20 × 109/L). However, all other indices of the complete blood count are normal. Additionally, the PT and partial thromboplastin time are normal with ITP. In this 3-year-old child, the leukocytes and PT are normal. The platelet count is low but consistent with this disease.
A 10-year-old girl has completed a course of amoxicillin for a urinary tract infection (UTI). This is the second UTI the child has had this year. The child is in the 95th percentile for weight and has a history of constipation. Her parents ask the nurse for preventive strategies for UTIs. Which of the following preventive strategies is *best* for the nurse to recommend? •Increase fiber in the diet •Drink cranberry juice •Increased vitamin C in a diet •Limit fluids at bedtime
•Increase fiber in the diet •Based on the history, this child's constipation is the most likely etiology of the UTI, and increasing dietary fiber is the best intervention. Urinary stasis from constipation is the primary cause of UTIs in children. Stool in the intestine prevents complete emptying of the bladder. There is no conclusive evidence to support that cranberry juice and vitamin C prevent UTIs. Limiting fluids at bedtime has not been shown to decrease UTI. Increasing fluids however, helps to flush bacteria out of the bladder.
A 3-month-old infant arrives at the health center for a scheduled well-child visit. The parents ask the nurse why the infant extends the arms and legs in response to a loud sound. Which response by the nurse is *best*? •Inform the parents that this is a normal reflex that generally disappears by 4 to 6 months of age •Tell the parents that if the behavior does not change by 6 months, the infant will need further evaluation •Remind the parents that this is a normal response that indicates the infant's hearing is intact •Reassure the parents that the behavior is normal and not an indicator of any problem such as cerebral palsy
•Inform the parents that this is a normal reflex that generally disappears by 4 to 6 months of age •The infant's behavior is consistent with the Moro and startle reflexes. The Moro reflex usually disappears by 6 months of age. The startle reflex usually disappears by 4 months of age. A hearing test is not based on response to loud sounds alone. Although it is true that further evaluation may be needed if the reflexes do not disappear, there is no need for the nurse to discuss this with the parents at this time. The infant's behavior is not consistent with cerebral palsy.
The nurse is caring for a child with a foreign body in the ear canal who has not been evaluated by the health care provider. Which actions should the nurse implement? *Select all that apply.* •Inspect the pinna for trauma •Irrigate the auditory canal with warm water •Obtain a history for the type of object •Attempt to remove the object with forceps •Use an otoscope to check for perforation
•Inspect the pinna for trauma •Obtain a history for the type of object •The nurse should assess the pinna for trauma and obtain history for the type of object as a component of a complete assessment which could determine the course of action by the health care provider. Some foreign bodies may swell when water is used for irrigation, further lodging the object in the auditory canal. Removing the object with forceps could traumatize the tympanic membrane and auditory canal further. Placing an otoscope in the auditory canal could wedge the object further into the canal.
These medications have been prescribed for a 9-year-old patient with deep partial- and full-thickness burns. Which medication is *most* important to double-check with another licensed nurse before administration? •Silver sulfadiazine ointment •Famotidine 20 mg IV •Lorazepam 0.5 mg PO •Multivitamin 1 tablet PO
•Lorazepam 0.5 mg PO •Oral sedation agents such as the benzodiazepines are considered high-alert medications when ordered for children, and extra precautions should be taken before administration. Many facilities require that all medications administered to pediatric patients be double-checked before administration, but the lorazepam is the most important to double-check with another nurse.
A 4-year-old patient with acute lymphocytic leukemia has these medications ordered. Which one is *most* important to double-check with another licensed nurse? •Prednisone 1 mg PO •Amoxicillin 250 mg PO •Methotrexate 10 mg PO •Filgrastim 5 mcg subcutaneously
•Methotrexate 10 mg PO •Methotrexate is a high-alert drug, and extra precautions, such as double checking with another nurse, should be taken when administering this medication. Although many pediatric units have a policy requiring that all medication administration to children be double-checked, the other medications listed are not on the high-alert list published by the Institute for Safe Medication Practices.
A 4-month-old infant boy is brought to the emergency department by his parents. He has been vomiting and fussy for the past 24 hours. On exam, there are circular bruises on his back. What *priority* assessment does the nurse anticipate? •Chest x-ray examination •Ultrasonography of the head •Electroencephalography •Ophthalmologic examination
•Ophthalmologic examination •The history and physical examination suggests shaken baby syndrome. An ophthalmologic examination is indicated to determine if the infant has retinal hemorrhages characteristic of shaken baby syndrome. Electroencephalography may be indicated if there is evidence of seizures. Magnetic resonance imaging or computed tomography of the head (not ultrasonography) can detect subdural hematomas. There is no evidence that would support the need for a chest x-ray examination.
A 2-year-old child who has abdominal pain is diagnosed with intussusception. A hydrostatic reduction has been performed. Which finding should be reported *immediately* before surgery proceeds? •Palpable sausage-shaped abdominal mass •Passage of normal brown stool •Passage of currant jelly-like stools •Frequent nausea and vomiting
•Passage of normal brown stool •Passage of brown stool indicates resolution of the intussusception, so surgery may not be necessary. The other findings are part of the clinical presentation of this disorder.
An adolescent who was hospitalized for anorexia nervosa is following the prescribed treatment plan. Her self-esteem and weight have gradually improved, but she continues to refer to herself as "fatty." She is able to verbalize an appropriate diet and exercise plan. At this point, what is the *priority* concern? •Patient needs to continue to gain weight •Patient has an unrealistic body image •Patient needs more information about nutrition •Patient lacks motivation to adhere to therapy
•Patient has an unrealistic body image •The patient continues to refer to herself as "fatty" and still has a disturbed body image; however, she has appropriate knowledge, and her self-esteem has improved. The patient has demonstrated ability to follow the therapeutic plan while in the hospital. Interventions should be designed to help her to continue after discharge.
A 16-year-old patient arrived at the cystic fibrosis (CF) clinic for a routine 3-month visit. The most recent respiratory culture results are negative. Which action is *best* for the nurse to take? •Place the patient in an exam room immediately upon arrival to the clinic •Allow the patient to wait in the reception area until the provider is available to see the patient •Allow the patient to wait in the reception area with a mask until the provider is available to see the patient •Place the patient in a waiting area with other patients who also have negative respiratory cultures
•Place the patient in an exam room immediately upon arrival to the clinic •This is a CF clinic, so this patient may be exposed to others with CF if he or she remains in the reception area. The CF Foundation recommends all individuals with CF, regardless of respiratory culture results, be separated from others with CF to reduce risk of droplet transmission of CF pathogens. National guidelines indicate that the best solution is that patients with CF not wait in common areas but be placed in a private exam room. However, when patients are in common waiting areas, a minimum distance of 3 feet (1 meter) between patients should be maintained if patients have CF.
A toddler is brought to the health center for a fever of 102°F (39°C) and a sore throat. As the nurse places a toddler and his parents in the exam room, the child experiences a tonic-clonic seizure. Which nursing action is a *priority*? •Assess the child's level of consciousness •Obtain an oxygen saturation •Loosen the child's clothing •Position the child in side-lying position
•Position the child in side-lying position •To ensure safety and prevent aspiration the first action by the nurse should be to position the child in side-lying position. Other assessment and actions will follow this initial step.
The RN is working with an LPN/LVN to provide care for a 10-year-old patient with severe abdominal, hip, and knee pain caused by a sickle cell crisis. Which action taken by the LPN/LVN requires the RN to intervene *immediately*? •Administering oral pain medication as needed •Positioning cold packs on the child's knees •Encouraging increased fluid intake •Monitoring vital signs every 2 hours
•Positioning cold packs on the child's knees •Sickle cell crisis may include vaso-occlusive crisis, splenic sequestration, and aplastic crisis. The symptoms experienced by this child are indicative of both vaso-occlusive crisis and splenic sequestration. Placing cold packs on the knees of a child with vaso-occlusive crisis results in vasoconstriction, placing the child at risk for thrombosis formation. Encouraging increased fluid intake is advised to prevent thrombosis formation. Monitoring vital signs is a method to assess for life-threatening complications associated with both vaso-occlusive crisis and splenic sequestration. Vaso-occlusive crisis is associated with severe pain and pain medication is recommended.
A 16-year-old boy comes into the office of the school nurse complaining of left hip pain that began when playing basketball in gym class. The boy is in the 85th percentile for height and weight. He complains of increased pain with weight bearing. The nurse observes out-toeing of the left leg with ambulation. Which nursing action is a *priority*? •Administer ibuprofen and instruct the boy to rest •Apply heat to the hip and elevate the left leg •Refer the boy to the emergency department •Apply ice to the hip and immobilize it with a splint
•Refer the boy to the emergency department •This boy is presenting with classic symptoms of slipped capital femoral epiphysis (SCFE), which is a slippage of the femoral head at the proximal epiphyseal plate. SCFE is an emergency. A delay in treatment can result in necrosis and death of the femoral head. Although the exact cause of SCFE is unknown, there is an increased incidence in boys. Additionally, obesity is a risk factor for SCFE.
Which intervention for a 5-year-old child who still wets the bed would be *best* assigned to the unlicensed assistive personnel (UAP)? •Reminding the child to use the bathroom before going to bed •Teaching the mother about moisture alarm devices •Administering the prescribed dose of imipramine •Discussing research related to the use of hypnosis with the mother
•Reminding the child to use the bathroom before going to bed •Reminding the child about something that has already been taught is within the scope of practice for a UAP. An LPN/LVN could administer the oral medication. Teaching and discussion of other strategies for dealing with bed-wetting require additional education and are more appropriate to the scope of practice of the professional RN.
An adolescent with cystic fibrosis (CF) is admitted to the pediatric unit with increased shortness of breath and pneumonia. Which nursing activity is *most* important to include in the patient's care? •Allowing the adolescent to decide if aerosolized medications are needed •Scheduling postural drainage and chest physiotherapy every 4 hours •Placing the adolescent in a room with another adolescent with CF •Encouraging oral fluid intake of 2400 mL/day
•Scheduling postural drainage and chest physiotherapy every 4 hours •National guidelines indicate that airway clearance techniques are critical for patients with CF; hence, postural drainage and chest physiotherapy are a priority. National guidelines also indicate that children and adolescents with CF who are hospitalized with respiratory illnesses should be placed on contact precautions. Furthermore, people with CF should be separated from others with CF to reduce droplet transmission of CF pathogens. There is no evidence that increased fluid intake adequately thins respiratory secretions, and chest physiotherapy is the priority.
A child with Hirschsprung disease arrives on the pediatric unit from the operating room with a temporary colostomy. Which task should the nurse delegate to unlicensed assistive personnel (UAP)? •Assess the frequency and consistency of stool •Instruct the parents on skin care •Stock the room with ostomy supplies •Assess the patient for pain
•Stock the room with ostomy supplies •Assessment and patient teaching is the responsibility of the RN. The UAP may stock the room with ostomy supplies but the nurse would give instructions or validate the UAP's knowledge of supplies.
The nurse is preparing to care for a 6-year-old child who has just undergone allogenic stem cell transplantation. Which nursing tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? *Select all that apply.* •Stocking the child's room with standard personal protective equipment items •Teaching the child to perform thorough hand washing after using the bathroom •Reminding the child to wear a face mask outside of the hospital room •Assessing the child's oral cavity for signs and symptoms of infection •Talking to the family members about the methods to reduce risk of infection
•Stocking the child's room with standard personal protective equipment items •Reminding the child to wear a face mask outside of the hospital room •Because all patient care staff members should be familiar with standard personal protective equipment, a UAP will be able to stock the room. Reminding the child to wear a face mask is also a task that can be done by a UAP, although the RN is responsible for the initial teaching. Initially teaching the child hand-washing technique, nursing assessments, and family education is within the scope of the registered nurse and not a UAP.
A 7-month-old infant arrives at the health center for a scheduled well-child visit. When the nurse approaches the infant to obtain vital signs, the infant cries vigorously and clings fearfully to the mother. Which of the following phenomena provides the *best* explanation for the infant's behavior? •Separation anxiety •Disassociation disorder •Stranger anxiety •Autism spectrum
•Stranger anxiety •This infant is displaying stranger anxiety; the child becomes anxious when exposed to unfamiliar people (strangers). Separation anxiety occurs when the child is separated from the primary caregiver; anxiety and crying are also common behaviors. Stranger anxiety and separation anxiety are concurrent and generally begin at 7 to 8 months of age. Disassociation disorder is characterized by disconnected thoughts and is not a disorder of infancy. Autism spectrum is characterized by poor social interaction. The age of the child is significant because autism is not usually detected at 7 months of age.
The nurse is assisting with the delivery of a 31-week gestational age premature newborn who requires intubation for respiratory distress syndrome (RDS). Which medication does the nurse anticipate will be needed first for this infant? •Theophylline •Surfactant •Dexamethasone •Albuterol
•Surfactant •Research indicates that the administration of synthetic surfactant improves respiratory status and decreases the incidence of pneumothorax in premature infants with RDS. The other medications may be used if respiratory distress persists, but the first medication administered will be the surfactant.
The nurse is caring for a newborn with a myelomeningocele who is awaiting surgical closure of the defect. Which assessment finding is of *most* concern? •Bulging of the sac when the infant cries •Oozing of stool from the anal sphincter •Flaccid paralysis of both legs •Temperature of 101.8°F (38.8°C)
•Temperature of 101.8°F (38.8°C) •The elevated temperature indicates possible infection and should be reported immediately to the surgeon so that treatment can be started. The other data are typical in an infant with myelomeningocele.
The nurse is obtaining the history and physical information for a child who is recovering from Kawasaki disease and receives aspirin therapy. Which information concerns the nurse the *most*? •The child attends a day-care center 5 days a week •The child's fingers have areas of peeling skin •The child is very irritable and cries frequently •The child has not received any immunizations
•The child has not received any immunizations •Children who receive aspirin therapy are at risk for the development of Reye syndrome if they contract viral illnesses such as varicella or influenza, so the lack of immunization is the greatest concern for this child. Peeling skin on the fingers and toes and irritability are consistent with Kawasaki disease but do not require any change in therapy. Because Kawasaki disease is not a communicable disease, there is no risk for transmission to other children in the day care (although assuring that immunizations are up to date before returning to day care is important).
A tearful parent brings a child to the emergency department after the child takes an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be *immediately* reported to the health care provider? •The ingested children's chewable vitamins contain iron •The child has been treated previously for ingestion of toxic substances •The child has been treated several times before for accidental injuries •The child was nauseated and vomited once at home
•The ingested children's chewable vitamins contain iron •Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxamine is an antidote that can be used for severe cases of iron poisoning. The other information needs additional investigation but will not change the immediate diagnostic testing or treatment plan.
The nurse obtains this information when assessing a 3-year-old patient with uncorrected tetralogy of Fallot who is crying. Which finding requires *immediate* action? •The apical pulse rate is 118 beats/min •A loud systolic murmur is heard in the pulmonic area •There is marked clubbing of the child's nail beds •The lips and oral mucosa are dusky in color
•The lips and oral mucosa are dusky in color •Circumoral cyanosis indicates a drop in the partial pressure of oxygen that may precipitate seizures and loss of consciousness. The nurse should rapidly place the child in a knee-chest position, administer oxygen, and take steps to calm the child. The other assessment data are expected in a child with congenital heart defects such as tetralogy of Fallot.
The nurse is preparing a child for IV moderate (conscious) sedation before repair of a facial laceration. What information should the nurse *immediately* report to the health care provider? •The parent is unsure about the child's tetanus immunization status •The child is upset and pulls out the IV •The parent declines the IV moderate (conscious) sedation •The parent wants information about the IV moderate (conscious) sedation
•The parent declines the IV moderate (conscious) sedation •Parental refusal is an absolute contraindication; therefore, the provider must be notified. Tetanus status can be addressed later. The RN can reestablish the IV access and provide information about moderate (conscious) sedation; if the parent is still not satisfied, the provider can give more information.
The nurse is caring for a 3-year-old patient who has returned to the pediatric intensive care unit after insertion of a ventriculoperitoneal shunt to correct hydrocephalus. Which assessment finding is *most* important to communicate to the surgeon? •The child is crying and says, "It hurts!" •The right pupil is 1 mm larger than the left pupil •The cardiac monitor shows a heart rate of 130 beats/min •The head dressing has a 2-cm area of bloody drainage
•The right pupil is 1 mm larger than the left pupil •Pupil dilation may indicate increased intracranial pressure and should be reported immediately to the surgeon. The other data are not unusual in a 3-year-old patient after surgery, although they indicate the need for ongoing assessments or interventions.
A 6-year-old child arrives in the emergency department with active seizures. Which assessment is a priority for the nurse to obtain? •Heart rate •Body mass index (BMI) •Blood pressure •Weight
•Weight •The child will need medication to control the seizures. Medications for children are based on weight in kilograms. Although heart rate and blood pressure may be obtained, the priority is to stop the seizures with medication. There is no clinical indication for BMI for a child with active seizures.
A 6-year-old girl arrives in the emergency department with her parents. She hit her head when she fell from the jungle gym in the school playground. Which questions are appropriate for the nurse to ask to assess the child's neurologic status? *Select all that apply.* •What is your home address? •What time does your family eat dinner? •What grade are you in? •What is your teacher's name? •What time did you fall? •What is the name of your school?
•What is your home address? •What grade are you in? •What is your teacher's name? •What is the name of your school? •This child is in Piaget's stage of concrete operations. Children in this stage can organize experiences and understand some complex information. However, children in this age group have difficulty conceptualizing time; therefore, asking questions about the time that incidents occur will not be helpful in determining the child's orientation.
A parent calls the emergency department, saying, "I think my toddler might have swallowed a little toy. He is breathing okay, but I don't know what to do." What is the *most* essential question to ask the caller? •"Has he vomited?" •"Have you been checking his stools?" •"What do you think he swallowed?" •"Has he been coughing?"
•"Has he been coughing?" •Even though the caller reports that the child is "breathing okay," additional questions about possible airway obstruction are the priority (e.g., coughing, gagging, choking, drooling, refusing to eat or drink). Gastrointestinal symptoms should be assessed but are less urgent. The type of foreign body, in the absence of symptoms, may dictate a wait-and-see approach, in which case the parent would be directed to check the stools for passage of the foreign body.
The nurse is providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal continuous positive airway pressure ventilation. Which assessment finding is *most* important to report to the health care provider? •Apical pulse rate of 156 beats/min •Crackles audible in both lungs •Tracheal deviation to the right •Oxygen saturation of 93%
•Tracheal deviation to the right •Tracheal deviation suggests tension pneumothorax, a possible complication of positive-pressure ventilation. The nurse will need to communicate rapidly with the health care provider and assist with actions such as chest tube insertion. The heart rate, crackles, and oxygen saturation will be reported to the health care provider but are expected in RDS and do not require immediate intervention.
The pediatric unit charge nurse is working with a new RN. Which action by the new RN requires the *most* immediate action on the part of the pediatric unit charge nurse? •Wearing gloves, gowns, and a mask for a neutropenic child who is receiving chemotherapy •Placing a newly admitted child with respiratory syncytial virus (RSV) infection in a room with another child who has RSV •Wearing a N95 respirator mask when caring for a child with tuberculosis •Performing hand hygiene with soap and water after caring for a child with diarrhea caused by Clostridium difficile
•Wearing gloves, gowns, and a mask for a neutropenic child who is receiving chemotherapy •Protective isolation (wearing gloves, gowns, and mask) revealed no significant differences in infection rates for children who are neutropenic. General standard precautions are advised with routine patient care. Although private rooms are preferred for patients who need droplet precautions, such as patients with RSV infection, they can be placed in rooms with other patients with exactly the same microorganism. An N95 respirator is recommended for tuberculosis. Washing hands with soap and water after caring for a patient with C. difficile is also recommended.
