Ricci Chapter 51 Prep U
A nurse is providing care to a child hospitalized after an accident that resulted in a substantial loss of blood. The nurse is preparing to administer IV fluids using a 60-milliliter syringe attached to the child's IV site. The child's parent asks the nurse why there is no IV bag hanging. What is the best response for the nurse to make? "Children need much less fluid than adults." "I need to administer small amounts of fluid as quickly as possible." "Hanging an IV bag would cause the infusion to flow too quickly." "Your child is too young to receive IV fluids by that method."
"I need to administer small amounts of fluid as quickly as possible." Explanation: Children who require fluid resuscitation should receive several small boluses over short periods of time (20 ml/kg over 5 to 10 minutes). Infusing the fluid via gravity would be too slow for resuscitation purposes. Children are not too young to receive IV infusions via a more traditional method. Children may need less fluid overall than adults but that is not the rationale for using a syringe for fluid resuscitation.
When a child suffers a head injury, the nurse does an emergency assessment. Which is included in the assessment technique? Select all that apply. Reaction of pupils Level of consciousness Motor ability Blood glucose level Pulse and respiratory rates Temperature
Reaction of pupils Level of consciousness Motor ability Pulse and respiratory rates Temperature All children with head trauma need to have a neurological assessment and examination of the pupillary reaction, level of consciousness, pulse and respiratory rates, and temperature. A blood sugar level would only be necessary if the child was known to have diabetes.
The nurse is attempting to establish peripheral vascular access in a child requiring pediatric advanced life support. The decision to use the intraosseous route would be made if the nurse were unsuccessful after how many attempts within 90 seconds? two three four five
three Explanation: No more than three attempts should be made within 90 seconds to obtain peripheral vascular access.
A child is exhibiting symptomatic bradycardia that has been unresponsive to ventilation and oxygenation. Which of the following would the nurse expect to be administered? atropine sodium bicarbonate naloxone calcium carbonate
atropine Explanation: Atropine is used for symptomatic bradycardia unresponsive to ventilation and oxygenation. Sodium bicarbonate is used for metabolic acidosis. Naloxone reverses the effect of opioids. Calcium carbonate is used for documented or suspected hypocalcemia, hyperkalemia, hypermagnesemia, and calcium channel blocker overdose.
The nurse is caring for a child who will be given activated charcoal due to an unintentional poisoning. Which statement by a parent indicates a need for further education? "My child will drink the charcoal; it will be mixed with water and some sweet syrup." "The charcoal will help to deactivate the poison that is in my child's system." "I need to check my child's stools for the next few days; if they are black, that means there is blood in the stool." "If she can't drink the charcoal, the nurse will put a tube down my child's throat into the stomach and put the medication in it."
"I need to check my child's stools for the next few days; if they are black, that means there is blood in the stool." Explanation: Activated charcoal is excreted through the bowel over the next 3 days; stools may appear black, which can be misinterpreted as blood in the stool. The charcoal can deactivate a swallowed poison. The child can either drink the charcoal, or if the child is unable to swallow it, it can be administered via an NG tube. The charcoal can be mixed with water and a sweet syrup to make it more palatable for the child.
The nurse is preparing to present an educational session on pediatric cardiopulmonary arrests. The nurse will include which statement in the teaching? "Most pediatric arrests stem from airway and breathing issues." "Obtaining an automated external defibrillator (AED) is vital to survival." "Activate the emergency response system first in an unwitnessed event." "Start cardiopulmonary resuscitation (CPR) in an infant if the heart rate is below 75 beats per minute."
"Most pediatric arrests stem from airway and breathing issues." Explanation: Most pediatric arrests are related primarily to airway and breathing, and usually only secondarily to the heart issues. This information guides the nurse to always assess the airway first in case of an emergency involving cardiopulmonary arrest. While obtaining an AED is important, pediatric arrests are more often respiratory related instead of cardiac. In an unwitnessed event, CPR should be started first. The emergency response system is first activated when the event is witnessed. CPR should be started when an infant's heart rate is less than 60 beats per minute.
A nurse witnesses a child get hit by a car while riding a bike. The child is lying motionless in the street. What action should the nurse take next? Assess the level of consciousness. Check the vital signs. Ensure a safe environment. Check for visible injuries.
Ensure a safe environment. Explanation: The nurse should ensure that the area is safe before approaching the child. The nurse can then assess the child's cardiac status, breathing, other vital signs, disability, and stabilize the cervical spine.
The off-duty nurse is in the park and is present when a child collapses. Which step should be performed first? Initiate rescue breathing. Activate the EMS. Initiate chest compressions. Implement head tilt-chin lift maneuver.
Implement head tilt-chin lift maneuver. Explanation: When initiating rescue care to a child, implementation of CPR is indicated before activation of the EMS. The first step in the rescue is the establishment of a patent airway. The head tilt-chin lift is used in children.
When the nurse is caring for a child presenting with a traumatic injury, which action is priority? Perform a primary assessment Notify the primary health care provider Ensure the code cart is available Apply an oxygen saturation monitor
Perform a primary assessment Explanation: The nurse would perform a primary assessment. When assessing a child with a traumatic injury, airway (A), breathing (B), and circulation (C) are assessed first: assess the patency of the airway and establish the effectiveness of breathing, examining the child's respiratory effort, breath sounds, and color; evaluate the circulation, noting pulse rate and quality and observing the color, skin temperature, and perfusion. Once this is accomplished, the nurse would notify the health care provider and apply monitors as needed. The nurse should ensure a code cart is available before the start of the shift.
A 7-year-old girl is in the intensive care unit following a bicycle accident. Which would be most helpful in providing support to the girl's parents? Providing honest answers in a reassuring manner Giving them brief explanations of procedures Describing the treatment plan for their daughter Encouraging them to read to their daughter
Providing honest answers in a reassuring manner Explanation: Providing honest answers to the parents' questions and concerns in a reassuring manner will provide the most support. Procedures and treatment plans should be explained in terms they can understand and repeated patiently, if need be. Encouraging the parents to read to their daughter will involve them in their child's care and help normalize the situation for the child.
When creating a care plan for a child with a head injury, the nurse uses the nursing diagnosis of Risk for excess fluid volume related to administration of hypertonic solution. Which is an appropriated outcome evaluation for this diagnosis? The child's lungs remain clear to auscultation. The child's urine specific gravity is between 1.030 and 1.033. The child shows no evidence of any altered thought process. The child's parents state an understanding of treatment of increased intracranial pressure.
The child's lungs remain clear to auscultation. Explanation: Appropriate outcomes for the diagnosis of Risk for excess fluid volume related to administration of hypertonic solution include lungs are clear to auscultation, respiratory rate, heart rate, and blood pressure remain normal for age of child, and urine specific gravity of 1.003 to 1.030, not 1.030 to 1.033. Although the child's parents should understand the child's treatment, this is not an appropriate outcome for this nursing diagnosis.
The nurse is preparing to assess and intubate a school-aged child who presents via ambulance to the emergency department. The child has been manually ventilated prior to arrival. The nurse obtains a nasogastric tube in preparation to care for the child for what reason? A nasogastric tube will permit the endotracheal tube to be secured properly The child will be restricted from eating or drinking while the endotracheal tube is in place In order to intubate the child quickly, the nasogastric tube must be inserted before intubation The nasogastric tube will alleviate any accumulation of air in the stomach
The nasogastric tube will alleviate any accumulation of air in the stomach Explanation: Children who are manually ventilated typically have some abdominal distention as some air passes into the stomach. The nasogastric tube will not assist the ET to be secured properly or allow a quick intubation. The child will be NPO while intubated and may require a nasogastric tube for feeding in the future, but the purpose of the emergency need is to alleviate the accumulation of air.
Administration of which medication reverses the histamine release and hypotension that are seen in anaphylaxis? diphenhydramine atropine epinephrine cimetidine
epinephrine Explanation: Epinephrine reverses histamine release and hypotension due to anaphylaxis. It increases the heart rate and systemic vascular resistance. Diphenhydramine and cimetidine are histamine blockers. They are used for milder forms of allergic reactions. Atropine is an anticholinergic. It causes tachycardia, inhibits secretions, and relaxes smooth muscle.
The nurse is assessing an 8-year-old child in the emergency department. Which assessment finding would be a priority and alert the nurse to intervene immediately? a pleural fiction rub expiratory wheezing systolic blood pressure of 86 minimal air movement in the lung fields
minimal air movement in the lung fields Explanation: The nurse must immediately intervene when there is minimal air movement in the lung fields. The child is severely compromised at this time. The assessment findings of a pleural friction rub and an expiratory wheeze would require further assessment but are not as high of priority as minimal air movement. The systolic blood pressure of 86 is a normal finding for an 8-year-old child (70 + twice the age in years would be 70 + 16).
A 9-year-old boy nearly drowned when he fell through the ice while skating on a pond. The child is exhibiting bradycardia. What would the nurse expect to implement to resolve the child's bradycardia? using a convective air warming blanket providing 100% oxygen via face mask administering epinephrine as ordered giving intravenous isotonic fluids
using a convective air warming blanket Explanation: Bradycardia may be resolved by addressing the underlying condition—in this case by relieving hypothermia with a convective air warming blanket. Providing 100% oxygen and then administering epinephrine are primary and secondary treatments for arrhythmias. Giving fluids is an intervention for collapsed rhythms and hypovolemic shock.
The nurse is caring for a 9-month-old infant in the emergency department following a traumatic injury. The infant weighs 21.5 pounds. In order to provide adequate fluid resuscitation, the nurse plans to infuse 20 ml/kg of lactated Ringer's as an IV fluid bolus. How many ml will the nurse administer? (Round your answer to the nearest whole number.) _________
195 Explanation: The infant older than 1 month would receive 20 ml/kg of normal saline or LR for fluid resuscitation via a large bore IV. The infant weighs 9.77 kg (21.5/2.2) so 9.77 x 20 ml = 195.4545 ml rounded to 195 ml.
A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which treatment is most likely appropriate in the immediate treatment of the girl's poisoning? Administration of activated charcoal Inducing vomiting Gastric lavage Intravenous rehydration
Administration of activated charcoal Explanation: Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl's poisoning.
The nurse is caring for a client who is having an acute attack of asthma that is not responding to standard asthma treatment. Which medication does the nurse anticipate administering? ketamine lidocaine fentanyl citrate rocuronium
ketamine Explanation: The client is demonstrating symptoms of status asthmaticus. Ketamine is an anesthetic agent that improves BP and cause bronchodilation for status asthmaticus. The other medications are not recommended for this situation.
The nurse is examining a 10-month-old infant who has fallen from the back porch. Which nursing action has priority? palpating the anterior fontanel (fontanelle) assessing skin color and perfusion assessing neurological status maintaining an adequate airway
maintaining an adequate airway Explanation: The highest priority nursing action in the management of an infant with an injury is to establish and maintain an adequate airway. Observing skin color and perfusion is part of evaluating circulation. Once the ABCs have been evaluated, the nurse will move on to "D" and assess for disability by palpating the anterior fontanel (fontanelle) for signs of increased intracranial pressure and assessing neurological status.
When attempting to locate the pulse of child found in a state of collapse, how much time should be taken? 5 to 10 seconds no more than 10 seconds 15 to 30 seconds no more than 30 seconds
no more than 10 seconds Explanation: When assessing for the pulse rate for a child found in a state of collapse, no more than 10 seconds should be taken.
The nurse receives shift report from the previous shift on several pediatric clients. For which child would the nurse further assess the electrolyte levels immediately following report? the 18-month-old experiencing unrelenting pain from a fractured femur the 5-year-old post-op day #3 following repair of a traumatic injury to her spleen the 10-year-old preparing for discharge following a near-drowning 4 days ago the 15-year-old who had a resolved episode of ventricular tachycardia the previous shift
the 15-year-old who had a resolved episode of ventricular tachycardia the previous shift Explanation: Abnormalities of potassium and hypokalemia have been associated with the development of ventricular tachycardia in children. The other clients' electrolyte levels would require monitoring but there would be no expected deviation.
The nurse is caring for a newborn in the newborn intensive care unit. The nurse notes the newborn's cardiac monitor alarms, showing a heart rate of 244. What would be the nurse's next action? Assess the oxygen saturation. Notify the physician of the pulse rate. Assess the blood pressure. Verify the pulse rate via the femoral pulse.
Verify the pulse rate via the femoral pulse. Explanation: The nurse has the responsibility of first assessing the child before assuring the alarms on the equipment are working properly. The most appropriate pulse side in an infant is the femoral pulse (the brachial pulse is often difficult to assess). The nurse would assess the child's oxygen saturation and blood pressure and notify the physician if it is determined the infant's heart rate is accurate per the monitor. Repositioning the child would not be a priority at this time.
The nurse notes tachycardia on the cardiac monitor of the pediatric client. What would the nurse further assess for this child? Select all that apply. pain body temperature constipation oxygen saturation fluid volume status
pain body temperature oxygen saturation fluid volume status Explanation: Pain, fever, hypoxia, and hypovolemia are common reasons for the child to be tachycardic. Diarrhea, not constipation, would lead to increased fluid loss and thus be considered as a reason for tachycardia.
The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern? Inspection shows a sluggish pupillary reaction. Palpation of the head reveals a closed posterior fontanel (fontanelle). The child is crying and looking around fearfully. The child's eyes remain closed unless she is spoken to.
Inspection shows a sluggish pupillary reaction. Explanation: A sluggish pupillary reaction may occur with increased intracranial pressure, which would be cause for concern. A closed posterior fontanel (fontanelle) in an 11-month-old would be a normal finding. Crying and looking around are encouraging signs indicating improved neurologic status. Opening the eyes when being spoken to is an encouraging sign.
The child's physician requests that the nurse should notify her if the child's urine output is less than 1 ml/kg of body weight each hour. The child weighs 56 lb (25.46 kg). Calculate the minimum amount of urine output the child should produce each hour. Record your answer using a whole number.
25 Explanation: Urine output should be calculated using weight in kilograms. 25.46 kg x 1 ml/kg = 25.46 ml/hour. The child must produce 25 ml/hour
The nurse is caring for a child who has recently been intubated. The nurse notes that the tracheal tube has an end-tidal CO2 monitoring device that is purple in color. What is the first intervention by the nurse? Auscultate the chest to determine breath sounds. Observe for cyanosis. Notify the physician. Prepare the client for a stat chest x-ray.
Auscultate the chest to determine breath sounds. Explanation: Colors on the end-tidal CO2 device correspond with tracheal tube placement. Purple indicated little or no CO2 detected. Colorimetric end-tidal CO2 devices may at times fail to detect the presence of exhaled carbon dioxide, so the nurse should assess the client to determine if the endotracheal tube is still in place. The first step in determining tube placement is to auscultate the chest to determine the presence of bilateral breath sounds. Observing for cyanosis does not help to determine ET tube placement. Notifying the physician and preparing the client for a chest x-ray will need to be completed, but they are not the first steps to be taken.
The health care team is performing cardiopulmonary resuscitation on a child following a suspected poisoning. Which action by the nurse would indicate that CPR is warranted? The child is assessed for injury before applying the cardiac monitor. The nurse assesses the child's neurological status following chest compressions. The child is monitored for respiratory complications such as pneumonia. The nurse assesses the child's heart rate at 45 and begins chest compressions.
The nurse assesses the child's heart rate at 45 and begins chest compressions. Explanation: The child with a pulse of less than 60 beats per minute should receive chest compressions to maintain adequate perfusion and circulation. The nurse would assess for injuries, the child's neurologic status, and respiratory complications after CPR has stabilized the child.
Which assessment finding would indicate to the health care team that a child would need to be reintubated due to improper placement of the endotracheal tube? Symmetrical chest rise is observed. There's water vapor on the inside of the tube. Breath sounds are heard over the abdominal area. Oxygen saturation rises from 78% to 93% after intubation.
Breath sounds are heard over the abdominal area. Explanation: Indications the tube is accidentally inserted into the esophagus include auscultation of breath sounds over the abdominal region. Indications the tracheal tube is correctly placed include symmetrical chest rise, water vapor on the inside of the tube, and a rise in oxygen saturation.
The nursing instructor is observing a student nurse care for a child who suffered a skull fracture with cerebrospinal fluid (CSF) leaking from the child's nose. What action by the student nurse would indicate a need for intervention by the nursing instructor? coating the child's upper lip with petrolatum ointment placing the child in a semi-Fowler position assisting the child to place tissue in the nose to halt the drainage administrating an antibiotic as prescribed
assisting the child to place tissue in the nose to halt the drainage Explanation: Therapeutic management for a child with CSF draining from a nose or ear is to keep the child in a semi-Fowler position and make certain the child does not hold the nose or pack it so the amount of fluid draining can be observed. If the drainage is excoriating, an ointment such as petrolatum may be applied to the child's lip. An antibiotic may be prescribed to reduce the risk of meningitis.
The nurse is assessing a 6-week-old infant in the home setting. The nurse notes the infant has a regular breathing pattern with brief periods of apnea followed by a respiratory rate of 40. What would the nurse further assess in the infant? birth weight and Apgar scores skin color and heart rate anterior lung fields blood pressure
skin color and heart rate Explanation: Infants less than 2 months (or premature) may display periodic breathing. The infant who is experiencing period breathing looks pink and has a normal heart rate and the nurse would not need to intervene further. The infant's birth weight, Apgar scores, lung fields, and blood pressure are important to assess, but not specifically to the infant with period breathing.
The nurse is caring for a child who has had an endotracheal tube placed and is hooked to a ventilator. When assessing the child, the nurse notes that they child is exhibiting signs of poor oxygenation. What should the nurse do? Select all that apply. Assess tracheal tube placement. Assess for the presence of decreased breath sounds on one side of the chest. Assess for tracheal tube obstruction. Assess the ventilator equipment, checking to see that all tubing is connected correctly. Assess for decreased body temperature.
Assess tracheal tube placement. Assess for the presence of decreased breath sounds on one side of the chest. Assess for tracheal tube obstruction. Assess the ventilator equipment, checking to see that all tubing is connected correctly.
Assessment of a child reveals a tension pneumothorax. The nurse would prepare the child for: needle thoracotomy. intubation. suctioning. defibrillation.
needle thoracotomy. Explanation: A needle thoracotomy is indicated for tension pneumothorax to relieve the air collected in the space. Intubation is indicated for apnea and in situations in which the airway cannot be maintained. Suctioning would be indicated for excessive airway secretions that influence airway patency. Defibrillation is used to stimulate or alter the heart's electrical rhythm.
The nurse is caring for a child who presented with supraventricular tachycardia (SVT). The nurse is preparing to administer IV adenosine. How should the nurse administer this medication? over 1 to 2 seconds over 30 to 60 seconds over 2 to 3 minutes over 3 to 5 minutes
over 1 to 2 seconds Explanation: Adenosine should be given rapidly over 1 to 2 seconds followed with a rapid saline flush.
The nurse is planning to provide education on injury prevention to caregivers of toddlers. Which information will the nurse include in the session? Select all that apply. car seat safety burn prevention water safety poisoning prevention sports safety
car seat safety burn prevention water safety poisoning prevention Explanation: Common causes of unintentional injuries and death in the toddler age group include motor vehicle crashes, drowning, burns, and poisoning. Sports safety and the use of protective equipment are more important for older children.
The school-aged child presents to the emergency room with suspected sepsis. What labs would the nurse expect the health care provider to order? Select all that apply. erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) spinal fluid culture amylase and lipase urine culture
erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) spinal fluid culture urine culture Explanation: The child suspected of having sepsis would likely have an ESR, a C-reactive protein, and cultures of the urine and spinal fluid completed to determine the source and presence of the causative infection and pathogen. Amylase and lipase would be ordered if trauma to the abdominal cavity were suspected.
The nurse is caring for a child. Upon assessing the child, the nurse notes a heart rate of 235, abnormal P waves, weak peripheral pulses, and a decreased level of consciousness. The nurse is aware that this child is presenting in which cardiac arrhythmia? compensated SVT uncompensated SVT ventricular tachycardia ventricular fibrillation
uncompensated SVT Explanation: Signs and symptoms for uncompensated supraventricular tachycardia include a heart rate >220 bpm, abnormal P waves, and signs of shock such as altered level of consciousness, poor perfusion, and weak pulses. Compensated SVT signs and symptoms include a heart rate of >220 with an alert, well-perfused child. Ventricular tachycardia includes wide QRS complexes with no P waves, with or without a pulse. Ventricular fibrillation signs and symptoms include chaotic ventricular activity with no P, QRS, or T waves present.
The nursing student correctly identifies the major cause of death in the 1- to 4-year-old age group to be which of the following? cancer immunosuppressive disorders accidents congenital disorders
Explanation: Unintentional injuries are the leading cause of death among children. In the younger age child, falls are the highest cause. For the older adolescent, automobile wrecks are the highest cause. Drowning is the second leading cause of death in children and adolescents worldwide. Cancer follows injuries in the number of deaths, especially in children under 14 years of age. Congenital defects produce the second leading cause of death in infants. It is second only to prematurity. Immunosuppressive disease has a lower mortality rate. One reason is the availability of HIV drugs and treating the mother during pregnancy.
The parents of a 7-month-old boy with a broken arm agree on how the accident happened. Which account would lead the nurse to suspect child abuse (child maltreatment)? "He was climbing out of his crib and fell." "He fell out of a shopping cart in the store." "Mom turned and he fell from changing table." "The gate was open and he fell down three steps."
"He was climbing out of his crib and fell." Explanation: The nurse would be suspicious of a 7-month-old climbing out of his crib, since it is not consistent with his developmental stage. Other areas of concern are if the parents have different accounts of the accident and if the injury is not consistent with the type of accident.
A child is to undergo synchronized cardioversion. The child weighs 44 lb (20 kg). The nurse would expect how many joules to be delivered? 10 to 20 joules 2 to 4 joules 5 to 10 joules 30 to 40 joules
10 to 20 joules Explanation: Energy for cardioversion is delivered at 0.5 to 1 joule/kg. The child weighs 44 lb or 20 kg. Therefore, the child would receive 10 to 20 joules.
A community health nurse is planning a class on water safety for families. What information is important for the nurse to include in the class? Select all that apply. Small inflatable wading pools are safe options for toddlers. It is important for adult supervision at poolside at all times. Children who have learned to swim require less supervision. The family needs to maintain fencing around pools to deter unsupervised swimming. Personal floatation devices are recommended for children riding in boats.
It is important for adult supervision at poolside at all times. The family needs to maintain fencing around pools to deter unsupervised swimming. Personal floatation devices are recommended for children riding in boats. Explanation: Information that is important for the nurse to include in a water safety class includes the importance of adult supervision for children at poolside, maintaining fencing around pools, and the use of personal floatation devices for children riding in boats. Toddlers can easily drown in a few inches of water so inflatable wading pools can be as hazardous as a full sized pool. Parents and children sometimes misjudge the child's swimming abilities, so children will still require supervision.
Which nursing diagnosis would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub? Noncompliance Risk for suffocation Risk for falls Risk for imbalanced body temperature
Risk for suffocation Explanation: Death from drowning occurs from suffocation. Nearly half of all drowning victims are children under the age of 5. Most drowning deaths in young children occur because of inadequate supervision of a bathtub or pool.
A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. Which of the following would be the priority? Administer 100% oxygen by mask. Have the child sit up straight in a chair. Check his capillary refill time. Provide sedation as ordered.
Administer 100% oxygen by mask. Explanation: Management of the near-drowning victim focuses on assessing the ABCs and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the child assume his own most comfortable position. Checking capillary refill time helps determine ineffective tissue perfusion. Providing sedation is an intervention for pain that will be assessed after effective breathing is established.
The nurse is called into a toddler's room. The toddler's parent says "My toddler is having trouble breathing." What should the nurse do first? Assess patency of the airway. Place on 100% oxygen. Notify the health care provider. Apply a pulse oximeter to monitor oxygen levels.
Assess patency of the airway. Explanation: The first step in airway evaluation and management is assessing the patency of the toddler's airway. Depending on the assessment findings, the nurse may place oxygen and a pulse oximeter on the toddler. Notification of the health care provider needs to occur, but the nurse must assess the toddler first.
The nurse is assessing the neurologic status of an infant. What would the nurse identify as an abnormal finding? Lack of interest in surroundings Vigorous crying Making eye contact with the nurse Soft, flat anterior fontanel (fontanelle)
Lack of interest in surroundings Explanation: An infant who is not interested in the environment is a cause for concern. Vigorous crying is a reassuring sign. Making eye contact with the nurse is a reassuring finding. A normal anterior fontanel (fontanelle) is soft and flat and would be considered a reassuring finding.
The nurse is caring for a 2-year-old that has been rushed to the urgent care clinic immediately after swallowing an unknown number of acetaminophen tablets. Which of the following would the nurse expect to implement first? Perform a gastric lavage. Administer N-acetylcysteine. Initiate chelation therapy. Start IV fluid replacement.
Perform a gastric lavage. Explanation: If the child ingested the pills within the last 60 minutes, a gastric lavage and administration of activated charcoal would be the preferred treatment. Once the acetaminophen is in the blood stream, N-acetylcysteine may be administered. Chelation therapy is used for metal poisoning. IV fluid replacement is used to treat hypovolemic shock.
The nurse is caring for a 2-year-old toddler who swallowed an unknown number of acetaminophen tablets and was rushed to the clinic, arriving 45 minutes after the ingestion. Which is the priority intervention? Administer N-acetylcysteine. Initiate chelation therapy. Start IV fluid replacement. Perform a gastric lavage.
Perform a gastric lavage. Explanation: If the toddler ingested the pills within the last 60 minutes, a gastric lavage and administration of activated charcoal would be the preferred treatment. If the acetaminophen is in the bloodstream, N-acetylcysteine may be administered. Chelation therapy is meant for metal poisoning. IV fluid replacement is used to treat hypovolemic shock.
A 3-year-old child has sustained injuries from a fall. Once the airway is secured, which of the following interventions would be done next? Checking mouth for debris. Administering 100% oxygen. Stabilizing the cervical spine. Establishing antecubital IV access.
Stabilizing the cervical spine. Explanation: If head or spine injuries are suspected, then after the airway is opened, the cervical spine must be stabilized to prevent damage. Checking the mouth for debris is part of securing an airway. Administering oxygen and establishing IV access would be done after the C-spine is stabilized.
A 3-year-old girl had a near-drowning incident when she fell into a wading pool. Which intervention is the highest priority? Suction the upper airway to ensure airway patency. Insert a nasogastric tube to decompress the stomach. Cover the child with warming blankets. Assure the child stays still during an X-ray.
Suction the upper airway to ensure airway patency. Explanation: Due to the potentially devastating effects of drowning-related hypoxia on a child's brain, airway interventions must be initiated immediately. The child's airway should be suctioned to ensure patency. Other interventions such as covering the child with blankets, inserting a nasogastric tube, and assuring that the child remains still during an x-ray are interventions that are appropriate once airway patency is achieved and maintained.
A child is hospitalized with suspected sepsis. The health care provider has prescribed an intravenous fluid bolus of lactated Ringer's solution 15 ml/kg to infuse over 20 minutes. The child weighs 52 lb (23.6 kg). How much fluid should the nurse administer? Record your answer using a whole number.
354 Explanation: The nurse will multiply the client's weight in kilograms by the prescribed amount of fluid. 23.6 kg × 15 ml/kg = 354 ml
An emergency department nurse is caring for a 5-year-old child who was just brought in by ambulance with partial-thickness (second-degree) and full-thickness (third-degree) burns to their face, neck, and chest. The client is awake and alert. Vital signs: temperature, 97.2°F (36.2°C); heart rate, 148 beats/min; blood pressure, 68/39 mm Hg; respiratory rate, 32 breaths/min; oxygen saturation, 90% on 2 liters by nasal cannula. The nurse receives prescriptions for the client. Click to highlight the prescription(s) that requires immediate implementation. Prescriptions: Apply oxygen to maintain oxygen saturations 95% or greater. Administer 100 mcg/kg morphine via intravenous push (IVP) for pain prn q4 hour. Initiate fluid resuscitation per Lund and Browder chart using Parkland formula with 0.9% saline. Administer acetaminophen by mouth (PO) 325 mg q6h prn for fever. Initiate a regular diet as tolerated.
Apply oxygen to maintain oxygen saturations 95% or greater. Administer 100 mcg/kg morphine via intravenous push (IVP) for pain prn q4 hour. Initiate fluid resuscitation per Lund and Browder chart using Parkland formula with 0.9% saline. Explanation: The nurse applies oxygen to maintain an oxygen saturation of 95% or greater. The nurse will need to monitor the child's airway closely because the burns are on the chest and neck.Partial-thickness (second-degree) burns are very painful. The nurse administers 100 mcg/kg morphine via intravenous push (IVP) for pain prn q4 hours.Fluid resuscitation is implemented promptly to prevent shock. Fluid resuscitation for children is determined using the Lund and Browder chart and Parkland formula. Because the child sustained burns to the neck and chest, the nurse would not administer anything by mouth including medications such as acetaminophen PO 325 mg q6h prn for fever or a regular diet as tolerated.
The nurse is caring for a child in an emergency situation. When placing a cardiac monitor on the child, the nurse notes wide QRS complexes with no P waves. The child does not have a pulse. What interventions should be performed on this child? Select all that apply. CPR defibrillation atropine epinephrine adenosine
CPR defibrillation epinephrine Explanation: A child presenting with no pulse and an ECG monitor showing wide QRS complexes with no P waves is in pulseless ventricular tachycardia. Treatment for this arrhythmia includes CPR, defibrillation, epinephrine, and treatment of the underlying cause. Atropine is used to treat bradycardias. Adenosine is used to treat supraventricular tachycardias.
A nurse is providing discharge teaching to the parent of a child hospitalized after experiencing respiratory arrest. The parent expresses concerns about the child's well-being. Which action(s) is appropriate for the nurse take? Select all that apply. Reassure the parent that the child's infection has been cured. Reinforce when the health care provider should be called. Encourage the parent to discuss specific concerns about the child. Tell the parent that the child's provider will address any concerns during the follow-up visit. Review signs and symptoms of respiratory distress with the parent.
Reinforce when the health care provider should be called. Encourage the parent to discuss specific concerns about the child. Review signs and symptoms of respiratory distress with the parent. Explanation: The most appropriate actions would be for the nurse to reinforce signs and symptoms of respiratory distress, and when the health care provider or 911 should be called. The nurse should also encourage the parent to share specific concerns about the child and address them at that moment instead of delaying until the follow-up visit. Providing reassurance that the respiratory infection has been cured does not address the parent's expressed concerns.
The child's ability to perfuse is poor due to inadequate circulation. The physician writes an order for the child to receive 20 ml of normal saline for each kilogram of body weight. The child will receive the normal saline as a bolus through a central intravenous line. The child weighs 78 lb (35.46 kg). Calculate the amount of normal saline the nurse should administer as a bolus. Record your answer using a whole number.
709 Explanation: Dose should be calculated using weight in kilograms. 35.456 kg x 20 ml/kg = 709.1 ml. When rounded to the nearest whole number = 709 ml.
The nurse is assessing a child with a suspected head injury. The child opens the eyes only in response to the nurse placing pressure in the child's nail bed. What score on the Glasgow coma scale for eye opening should the nurse assign based on this assessment finding? 4 3 2 1
2 Explanation: In the eye opening section of the Glasgow coma scale, eye opening only in response to painful stimuli would be a score of 2. Spontaneous eye opening is a 4, opening in response to speech is a 3, and no eye opening in response to painful stimuli is a 1.
The parents of a preschool child are distraught as they carry their limp child into the emergency room. The parents report the child fell approximately 10 feet from a large slide and hit his head "hard enough to knock him out." What is the nurse's next action? Apply a cervical collar and request a cervical exam. Assess the child's breathing by using a pulse oximeter. Ask the child to rate the pain from 0-10 or use a picture scale. Perform a jaw-thrust technique to assess the patency of the airway.
Perform a jaw-thrust technique to assess the patency of the airway. Explanation: The nurse would first evaluate the airway, assessing its patency. Position the airway in a manner that promotes good air flow. Since cervical spine injury is a possibility, do not use the head tilt-chin lift maneuver; use only the jaw-thrust technique for opening the airway. The description of the injury would be suspicious for cervical injury. The nurse would evaluate the child's airway before evaluating pain scale and managing cervical concerns, although the nurse is managing cervical concerns by not performing a head tilt-child lift maneuver. A pulse oximeter measurement would not be the priority.
The nurse is participating in performing cardiopulmonary resuscitation for a child. Which finding(s) indicate the need to review and modify the technique being used? Select all that apply. The chest is rising bilaterally. The chest is rising on the right side and not on the left side. The child begins to regurgitate. The child's facial color begins to change from a dusky pallor to pale pink. The abdomen begins to distend.
The chest is rising on the right side and not on the left side. The abdomen begins to distend. Explanation: When cardiopulmonary resuscitation (CPR) is being performed, the chest should be observed for expansion. Expansion should be equal on both the right and left sides of the chest. Regurgitation may occur in CPR and does not necessarily signal a problem with the technique being employed. Improvements in the client's color signal the condition is improving. The nurse should monitor for distention of the abdomen as it may cause problems.
During the assessment of a child, the nurse notes weak distal peripheral pulses, wheezing in all lung fields upon auscultation, pulse oximeter level 88%, tachycardia, and short shallow respirations with tachypnea. Which nursing diagnosis does the nurse identify related to these assessment findings? Select all that apply. Impaired gas exchange Ineffective breathing pattern Decreased cardiac output Ineffective tissue perfusion (peripheral) Deficient fluid volume
Impaired gas exchange Ineffective breathing pattern Decreased cardiac output Ineffective tissue perfusion (peripheral) All of these nursing diagnoses are supported by the client's signs and symptoms except Deficient fluid volume. Impaired gas exchange (wheezing, oxygen saturation 88%), Ineffective breathing pattern (short shallow respirations with tachypnea), Ineffective tissue perfusion, and Decreased cardiac output (weak peripheral pulses oxygen saturation 88%, and tachycardia) are all applicable here.
The nursing instructor is speaking with a group of nursing students about medication used in rapid sequence intubation. Which statement by a student indicates a need for further education? "Atropine is used to help decrease the risk of bradycardia." "Succinylcholine is used to induce short-term paralysis during intubation." "Ketamine is the anesthetic typically used for children who have suffered head trauma and need to be intubated." "When midazolam is used with other opioids, we need to be aware to watch for respiratory depression."
"Ketamine is the anesthetic typically used for children who have suffered head trauma and need to be intubated." Explanation: Ketamine can cause increased intracranial pressure and should not be used in children who have suffered head trauma. Atropine can reduce the risk of bradycardia. Succinylcholine is the gold standard drug used during intubation. Combining midazolam with other opioids can increase the risk of respiratory depression.
The nursing instructor is speaking with a group of nursing students about rapid cardiopulmonary assessment. Which statement by a student would indicate a need for further education? "I will place the child on a cardiac monitor. I will use this to assess the child's heart rate." "If a child receiving 100% oxygen by mask does not improve, I will need to perform assisted ventilation with a bag-valve-mask device." "For an infant, I use the brachial artery to check for a pulse." "An interosseous needle will need to be inserted if a peripheral IV access cannot be obtained within 90 seconds in a child."
"I will place the child on a cardiac monitor. I will use this to assess the child's heart rate." Explanation: Always evaluate the presence of a heart rate by auscultation of the heart or by palpation of central pulses. Never use the cardiac monitor to determine if the child has a heart rate. The presence of a cardiac rhythm is not a reliable method for evaluation of the ability to perfuse the body. If a child does not improve with 100% oxygen, the next step is to administer oxygen via a bag-valve-mask. The brachial artery is the correct place to check for a pulse in an infant. Establishment of IO access should be attempted if a peripheral IV is not able to be obtained within 3 attempts or 90 seconds.
A child's parent calls the clinic nurse and states, "My child just drank an unknown amount of a cleaning solution. What should I do?" Which statement by the nurse is best? "You need to give your child ipecac syrup to induce vomiting." "Immediately take your child to your local emergency facility." "You need to hang up with me and call the poison control center now." "Monitor your child's breathing and heart rate closely for the next 24 hours."
"You need to hang up with me and call the poison control center now." Explanation: The nurse would tell the parent to call a poison control center to receive information of how to best treat the child. A poison control center will provide the most accurate information on the next steps for the client. The nurse would not recommend ipecac syrup, which induces vomiting. Not all poisons should be vomited. Strong acids, for example, could cause as much destruction of tissue being vomited as being swallowed. The child can be brought to the local emergency facility; however, calling a poison control center is best. Health care professionals should be the ones to monitor the child, not the parents or caregivers in this situation.
A nurse is preparing discharge instructions for a child treated for ingestion of an unknown amount of ibuprofen. The child was treated with an activated charcoal gastric lavage. Which piece of information should the nurse include to provide anticipatory guidance to the parent? Blood tests will be needed to check liver function. The child will continue taking the chelating agent. The mouth sores will heal over several weeks. Stools will be black in color for the next few days.
Stools will be black in color for the next few days. Explanation: Activated charcoal is a gritty black substance that binds with the ingested substance in the bowel and is excreted in the stools. It is important to give parents this information so they do not mistake the color for tarry stools, which indicate blood. The child would return for liver function tests if acetaminophen had been ingested. A chelating agent is treatment for lead poisoning and is not associated with ibuprofen ingestion or treatment with activated charcoal. Mouth sores are not associated with ibuprofen ingestion or activated charcoal. However, they are associated with the ingestion of corrosive agents such as batteries and some household cleaners.
The nurse notes absent breath sounds in the right upper, middle, and lower lung fields of a 24-month-child. What question by the nurse to the parents of the child would be most appropriate? "Has your child been diagnosed with asthma?" "Is your child allergic to environmental allergens?" "Was your child playing with a toy with small parts?" "When did your child last receive immunizations?"
"Was your child playing with a toy with small parts?" Explanation: Breath sounds that are absent on one side only are indicative of a pneumothorax or foreign body aspiration. The nurse would further assess the child for choking hazards. The nurse would ask the parent about asthma, allergies, and immunizations, but not specifically in relationship to an absent breath sound on one side (unilateral absent breath sound).
A child is brought to the emergency department in severe respiratory distress. As the nurse begins an assessment, the child becomes unresponsive and stops breathing. The nurse calls for help and the health care team begins resuscitative measures. The nurse attempts to escort the child's parent from the room but the parent refuses to leave. Which is the best action for the nurse to take? -Gently take the parent by the hand and lead him or her from the room. -Tell the parent that family members are not allowed in the room during resuscitation. -Ask someone from pastoral care to take the parent to the waiting room. -Allow the parent to stay in the room but remain at the parent's side for support.
Allow the parent to stay in the room but remain at the parent's side for support. Explanation: The best action for the nurse to take would be to allow the parent to remain in the room but the nurse (or another designated team member such as pastoral care) should stay with the parent to be a resource for questions and provide support. Research has shown that parents who are present during resuscitation of their child were able to cope better with the situation than parents who were not present during resuscitation. If the parent is refusing to leave the room, taking the parent by the hand to lead him or her from the room, asking pastoral care to take the parent to the waiting room or telling the parent that family is not allowed during a resuscitation will not be very effective. These options could cause the parent to become more upset and agitated.
A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which of the following would the nurse do first? Begin hyperventilation. Establish a suitable IV site. Provide oral analgesics as ordered. Draw blood for type and crossmatch.
Establish a suitable IV site. Explanation: The goal of treating shock is to restore circulating blood volume. This requires that vascular access be obtained to administer fluids and vasoactive drugs. Hyperventilation is reserved for temporary treatment of severe intracranial pressure. Analgesics should not be administered prior to neurologic and cardiovascular examination being performed. Drawing blood for type and crossmatch would be once vascular access is obtained and fluid and drug therapy has been initiated.
A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 bpm. Which intervention is priority? Give three doses of epinephrine. Administer two consecutive defibrillator shocks. Initiate cardiac compressions. Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR).
Initiate cardiac compressions. Explanation: The American Heart Association (AHA) emphasizes the importance of cardiac compressions in pulseless clients with arrhythmias, making this the priority intervention in this situation. Current AHA recommendations are for defibrillation to be administered once followed by five cycles of CPR. The AHA now recommends against using multiple doses of epinephrine because they have not been shown to be helpful and may actually cause harm to the child.
The nurse is assisting with endotracheal intubation of a 3-year-old child. Once the child is intubated, which assessments should be done? Select all that apply. Observe for symmetry in the rise and fall of the chest. Observe for symmetry in the abdomen. Ensure O2 saturation of 89%. Observe for the presence of water vapor inside the tracheal tube. Ensure the heart rate is at least 120 beats per minute.
Observe for symmetry in the rise and fall of the chest. Observe for the presence of water vapor inside the tracheal tube. Explanation: To assess for correct placement once the tracheal tube is inserted, observe for symmetric chest rise and auscultate over the lung fields for equal breath sounds. Inspect the tracheal tube for the presence of water vapor on the inside, indicating that the tube is in the trachea. To rule out accidental esophageal intubation, auscultate over the abdomen while the child is being ventilated: there should not be breath sounds in the abdomen. Note improvement in the oxygen saturation level via pulse oximetry.
The nurse is caring for a 7-year-old client who suffered extensive burns from a house fire. Which finding in the client's history most concerns the nurse? The child appears withdrawn and frightened. The child's clothing was burned when exiting the home. The child was home alone when the fire started. The child was trapped in a burning bedroom.
The child was trapped in a burning bedroom. Explanation: When a child is confined in a closed space during a fire, the child can inhale a great deal of smoke, causing respiratory tract burns or irritation. This would lead the nurse to further assess for respiratory complications, which is a priority at this time. Burned clothing could indicate burns of the child's body and requires further assessment. However, this is not a priority over assessing the client's airway and ability to breathe. The client appearing withdrawn and frightened and being home alone at such a young age would be concerning to the nurse and warrant follow-up once the client is determined to be stable.
The nurse is providing staff education regarding the use of the BroselowTM tape for pediatric emergencies. What would the nurse include in the education plan? The tape is ideal for estimating the child's age when the information is needed quickly. One disadvantage is the tape doesn't include medication dose information. The tape is useful to estimate the child's weight based on the length. The child should be measured while in a sitting position.
The tape is useful to estimate the child's weight based on the length. Explanation: The BroselowTM tape provides an estimate of the child's weight (not age) based on the child's length. The tape does include estimated mediation doses. The tape is based on the child's length therefore the sitting position is not accurate.
The child presents to the emergency department via ambulance in uncompensated SVT at a rate of 262 beats per minute. The nurse receives an order to administer adenosine IV. In addition to adenosine, what would the nurse bring to the bedside in preparation to administer the adenosine? a blood pressure cuff in the appropriate size a consent form for the child or parent to sign an emesis basin for the child to use if vomiting a generous saline flush to follow the IV medication
a generous saline flush to follow the IV medication Explanation: Adenosine IV is given rapidly (over 1 or 2 seconds) and is followed by a generous saline flush followed by a rapid (to ensure the medication has entered the vessel). The nurse would assess the child's blood pressure but not specifically in relation to the administration of adenosine. The parents would not sign a consent form for this medication. Vomiting is not a side effect of adenosine.
The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of: lethal arrhythmia. underlying heart disease. respiratory failure. neurologic trauma.
respiratory failure. Explanation: Cardiopulmonary arrest in infants and children typically results from disorders that lead to respiratory failure and shock. In adults, the most common causes of cardiopulmonary arrest are lethal arrhythmias secondary to heart disease. Although neurologic trauma can lead to respiratory failure, it alone is not the most likely factor.
