Ch. 35: Key Pediatric Nursing Interventions
A 5-year-old boy is receiving an analgesic intravenously while in the hospital. What should the nurse do to determine whether the drug is being properly excreted from this child? Measure the child's respiration rate. Monitor the child's fluid intake and output. Assess the child's blood pressure level. Ask the child to describe his pain level.
Monitor the child's fluid intake and output. RATIONALE: Monitoring intake and output is important in children receiving drugs to be certain urine excretion or an outlet for drug metabolites is adequate. The other interventions listed are not typically used to determine whether drug excretion is occurring.
The nurse is preparing to administer an intramuscular immunization to a 5-year-old child. What statement to the child is appropriate for inclusion in the preadministration period? "This will help prevent you from getting sick." "This shot will help you." "I am going to give you an immunization." "If you don't hold still it will hurt more."
"This will help prevent you from getting sick." RATIONALE: When providing teaching to a child it is important to be open and honest and provide developmentally appropriate information. Explaining that this will prevent later illness is something a child can understand. Saying that pain may result if movement occurs is a scare tactic and counterproductive. Using the word "immunization" employs terminology that is too complex for a child. Using the word "shot" is scary for the child and should be avoided if possible.
The nurse is showing the student nurse how to flush a pediatric client's peripherally inserted central catheter (PICC) line. The nurse prepares a 3-ml normal saline flush using a 5-ml syringe. The student asks the nurse why the flush was prepared this way. What is the most accurate response by the nurse? "Using a larger-volume syringe exerts less pressure on the PICC line." "It is standard policy in our facility to use a 5-ml syringe for all PICC line flushes." "I like how the 5-ml syringe fits in my hand. I feel like I have a better grip on it than a smaller syringe." "The 5-ml syringe is what we have the most stock of so I just always use it."
"Using a larger-volume syringe exerts less pressure on the PICC line." RATIONALE: Using a larger-volume syringe (i.e., 5 mL or larger) exerts less pressure on the PICC, thereby reducing the risk of rupture.
A child who weighs 22 lb (10 kg) is to receive a blood transfusion. How many milliliters of blood should the nurse expect to transfuse in an hour?
100 RATIONALE: The recommended rate of infusion is 10 ml/kg/hour. A child who weighs 10 kg would receive 100 ml in an hour.
A nurse is providing care for a child diagnosed with beta-thalassemia. The child requires a blood transfusion of packed red blood cells (PRBCs). The health care provider has prescribed a transfusion volume of 10 ml/kg. The child weighs 37 lb (16.8 kg). How many milliliters should the nurse infuse?
168 RATIONALE: The nurse will use the client's weight in kilograms and multiply by the prescribed milliliters/kilogram 16.8 kg × 10 ml PRBCs = 168 mLl
A child with HIV, weighing 25 kg (55.1 lbs), is about to receive an infusion of IVIG. The recommended dose is 400 mg/kg/dose. The medication is available in a concentration of 50 mg/mL. What is the proper amount of infusion that the child will receive? 200 mL 1000 mL 2000 mL 100 mL
200 mL RATIONALE: The dose is calculated as 25 x 400 = 10,000 mg. Because the concentration is 50 mg/mL, calculate the volume as 10,000/50 = 200 mL.
The nurse is caring for a child who weighs 42 lb (19 kg). The medication prescribed for the child has a therapeutic dosage range of 33 mg/kg/day to 48 mg/kg/day. The medication prescribed is to be given 3 times per day. Which dosage would the nurse identify as being appropriate to administer to this child in one dose? 250 mg 30.4 mg 627 mg 62.7 mg
250 mg RATIONALE: Use the child's weight in kilograms. The low dose of this medication would be 19 kg × 33 mg/kg/day = 627 mg, divided by 3 times per day equals 209 mg per dose. The high dose of this medication would be 19 kg × 48 mg/kg/day = 912 mg/day divided by 3 times per day equals 304 mg per dose. Halfway between these two dosages (304 mg - 209 mg = 95 mg, 95 mg ÷ 2 = 47.5 mg), equates to a dose of 250 mg per dose being appropriate.
The nurse is caring for a 12-year-old post-appendectomy client who weighs 86 pounds. The child has a temperature of 38.5ºC (101.3ºF). The nurse prepares to give the client a dose of oral acetaminophen. The order reads "Tylenol 15mg/kg/dose every 4 to 6 hours PO PRN for fever or pain." How many milligrams of Tylenol should the nurse give the client? 147 milligrams 587 milligrams 1,290 milligrams 1.3 milligrams
587 milligrams RATIONALE: The child's weight must first be converted to kilograms by dividing 86 by 2.2. The result is 39.1 kilograms. Next, the 39.1 kilograms must be multiplied by 15 milligrams. This answer is 587 milligrams.
A health care provider has prescribed hydroxyurea 650 mg for a child diagnosed with sickle cell anemia. The child weighs 65 lb (29.5 kg). The normal recommended dose is 20 mg/kg/day. What action should the nurse take? Contact the health care provider to increase the dose. Administer the medication as prescribed. Contact the health care provider to lower the dose. Call the pharmacist to clarify the dosage.
Contact the health care provider to lower the dose. RATIONALE: The nurse should perform the needed calculations to check the dosage is correct for the client. The nurse will use the client's weight in kilograms and multiply by the prescribed milligrams per day. 29.5 kg x 20 mg = 590 mg Therefore, the nurse should contact the health care provider about lowering the dose.
A child is receiving intravenous fluids for dehydration. The nurse notes coarse breath sounds and increased pulse and blood pressure. What does the nurse do first? Assess intake, output, and weight. Contact the health care provider. Discontinue the IV infusion. Request a chest X-ray for evaluation.
Discontinue the IV infusion. RATIONALE: Signs of fluid overload are those of congestive heart failure and include coarse breath sounds, increased pulse rate, and increased blood pressure. These are not symptoms of extravasation because this would be swelling of fluid around the IV site. The nurse would need to stop the IV infusion, then assess weight, intake, and output. The nurse would then contact the health care provider.
The nurse is assessing a child who is receiving TPN. The nurse determines the TPN bag was hung 24 hours ago. What initial action by the nurse is indicated? Discontinue the TPN bag and notify the physician. Increase the rate of the TPN to complete the bag. Document the amount of solution left in the bag and continue the administration. Hang a new bag of TPN.
Hang a new bag of TPN. RATIONALE: TPN bags should not hang over 24 hours. The nurse should discontinue the current bag and hang a new one. There is no need to notify the physician. The rate of the TPN should never be changed without a physician's order.
A parent informs the nurse about having a hard time getting her 6-year-old child to take the liquid medication at home. Which would be the best suggestion for the nurse to offer the parent to help correct this concern? Tell the parent to say calmly, "Can you drink this for me?" Tell the parent to ask the child nicely, "Will you drink this for me?" Tell the parent to state firmly, "It's time for you to drink your medicine." Tell the parent to tell the child, "It tastes just like candy!"
Tell the parent to state firmly, "It's time for you to drink your medicine." RATIONALE: The best guideline for the parent to help in getting a child to take the liquid medication is to state firmly, "It's time to take your medication." Asking or pleading with the child does not work. Firmness is required. The child can be, however, allowed to choose what liquid to use to help swallow the medication. This helps with self-esteem and independence. The parent should also be honest about the taste of the medication. Adults also should never refer to medicine as candy. If a child happens to like a particular medicine, he or she may help themselves to it, and consuming too much can be fatal.
A school-age child is to receive insulin therapy via a subcutaneous infusion pump. When explaining this method of administration, the nurse would include which site as most likely to be used? upper chest abdomen antecubital space of the arm scalp
abdomen RATIONALE: With a subcutaneous infusion pump, the drug is delivered by the pump via a medicine-filled syringe. The site chosen is usually the abdomen because this both protects the pump and allows it to be out of sight. The other sites are used for other intravenous infusions.
The nurse is caring for a 7-year-old with a low-profile gastrostomy tube placed 6 months ago. Which is the priority intervention to prevent irritation of the skin at the insertion site? cleansing the skin around the site with an alcohol wipe after each feeding cleaning the surrounding skin with soap and water daily plus keeping the area dry cleaning under the external disc or bumper with diluted hydrogen peroxide rotating the gastrostomy tube or button daily
cleaning the surrounding skin with soap and water daily plus keeping the area dry RATIONALE: Daily cleansing with soap and water and keeping the area dry are essential. Moisture can create irritation and encourage the growth of organisms in the warm, moist climate created. Alcohol can sting if used on the area; in addition, it can remove protective skin oils and promoting excess drying, which can lead to skin breakdown. Cleaning under the bumper or disc with hydrogen peroxide is not recommended because it is irritating and damaging to skin cells. Rotating the gastrostomy tube or button daily is important to prevent adherence in the tract, but keeping the skin clean and dry is the priority.
The charge nurse is assisting the new graduate nurse in administering eye drops to a child. The charge nurse would stop the new graduate if which action was observed? administers drops into conjunctival sac positions the child supine on the bed allows the child to sit up after blinking a few times holds the eyelids apart for about 30 seconds
holds the eyelids apart for about 30 seconds RATIONALE: To prevent the conjunctiva from drying, the nurse should not hold the eyelids apart any longer than necessary. Therefore, the charge nurse would need to stop the new nurse. It is best to use the supine position. Instill the correct number of drops into the conjunctiva of the lower lid. Allow the eyelid to close. Avoid placing the drops directly on the cornea because that can be painful. To prevent the conjunctiva from drying, do not hold the eyelids apart any longer than necessary. After the child has blinked 2 or 3 times, allow the child to sit up.
A parent must administer a medication in syrup form to a 2-month-old infant. The nurse suggests: placing the syrup in an medicine syringe. placing the syrup in a small amount of oat cereal. using a measured medicine spoon. mixing the syrup in a small amount of formula.
placing the syrup in an medicine syringe. RATIONALE: The young infant should naturally and easily suck the medicine through a medicine syringe. Formula and oat cereal are essential foods for the infant and the desirability of them should not be altered by the taste of the medication. In addition, a 2-month-old infant is not developmentally ready for spoon feeding of oat cereal or medication from a medicine spoon.
The primary health care provider prescribed ketoconazole for a child with ringworm. Which statement by the parents indicates the nurse needs to provide additional teaching on the prescription? "I will wrap the skin tightly after applying the medication." "My child needs to take the full prescribed dosage." "I will wash my hands before and after I apply this medication." "If this medication gets in my child's eyes, I will rinse with water immediately."
"I will wrap the skin tightly after applying the medication." RATIONALE: Ketoconazole is an antifungal used to treat tinea infections. The nurse would teach to avoid covering treated skin areas with tightly. The area needs to allow for air to circulate to the skin in order to limit side effects. All other statements indicate correct understanding.
A neonate is to receive a hepatitis B vaccine within a few hours after birth. What is the best approach for the nurse to take when giving this medication? Administer the medication in the vastus lateralis with a 20-gauge needle. Administer the medication in the deltoid muscle with a 20-gauge needle. Administer the medication in the neonate's vastus lateralis with a 25-gauge needle. Administer the medication in the dorsogluteal with a 25-gauge needle.
Administer the medication in the neonate's vastus lateralis with a 25-gauge needle. RATIONALE: The vastus lateralis site is a safe choice for intramuscular (IM) injections in a neonate. A 22- to 25-gauge needle is recommended for neonates, but the nurse must assess the neonate's size before determining needle size to use. The 25-gauge needle is recommended for neonates. The dorsogluteal site should not be used until school age. Neither the deltoid muscle nor the dorsogluteal muscle are recommended IM sites for neonates. These muscles should not be used until toddler age or older. The volume of the medication should not exceed 0.5 ml per injection until the child is preschool age.
A child is reporting pain where an IV infiltrated his hand earlier in the shift. The doctor orders warm compresses to the right hand every 4 hours. What precautions would the nurse implement for this client? Have the parents apply the warm compresses if the nurse is tied up elsewhere. Limit treatments to 20 minutes at a time. Heat the moistened towels in the microwave. Use hot water on gauze for the warm compress.
Limit treatments to 20 minutes at a time. RATIONALE: Warm compresses are used to increase circulation to an area of the body and to promote pain relief. For a child having warm compresses, the length of each session is a maximum of 20 minutes to prevent skin damage. Towels used in warm compresses are never heated in a microwave because of uneven heating. Parents are not to apply compresses because the nurse needs to assess the skin before and after the treatment. Gauze is not a good material for compresses; it does not hold heat well.
The health care provider orders a urinalysis on a 15-month-old toddler. The mother states that the child is not potty-trained. What is the best way for the nurse to collect the specimen? Place a urine collection bag on the child after cleaning off the perineum. Observe the child for signs he needs to urinate and quickly pull the diaper down and catch the urine when he voids. Clean off the penis with a commercial cleaning pad and catheterize the client. Aspirate urine out of the diaper with a syringe and place it in a specimen cup.
Place a urine collection bag on the child after cleaning off the perineum. RATIONALE: In clients that are not potty-trained, the best method for collecting a urine specimen is to place a urine collection bag on the child and wait for them to void. The doctor did not order a urine culture, so a catheterized urinalysis is not needed and would be traumatic for the child. Trying to catch urine from a voiding toddler is nearly impossible. Aspirating urine out of the diaper is not the best approach or one that ensures the best results.
A child is having difficulty swallowing pills. What is the best action for the nurse to take to help this child swallow medications? Place the pills in a bite of ice cream or applesauce. Hold the medication and notify the health care provider. Crush all medications and dissolve in water. Obtain small round candy to practice swallowing techniques.
Place the pills in a bite of ice cream or applesauce. RATIONALE: The most useful technique when children cannot swallow pills is to put them into some ice cream or applesauce. This allows the medication to be administered in the original form. The nurse should not use candy for practice, because this may suggest to the child that medicine is the same as candy. The nurse should never crush medications which are enteric coated or time released. The nurse should always strive to administer a prescribed medication, even if doing so may be difficult.
The nurse is administering otic medication to a 22-month-old with a diagnosis of otitis media. Which nursing action ensures that the medication is distributed appropriately? Pull the pinna down and back. Place a cotton ball in the outer ear. Place in a side-lying position. Pull the pinna up and back.
Pull the pinna down and back. RATIONALE: By making sure that the ear canal is straight for the medication to progress to the tympanic membrane, the medication is distributed appropriately. It is also appropriate to place the child in a side-lying position. Some nurses place a cotton ball in the ear but that does not impact distribution of the medication. A child over 3 years of age needs the pinna pulled up and back.
A 1-year-old child with an abdominal wound is undergoing a dressing change. The child's parent is at the bedside. Which action would the nurse instruct the parent to do? Talk to the child in a quiet, soothing voice. Participate by holding the legs still during the treatment. Wait outside until the procedure is finished. Sit across from but directly in the view of the child.
Talk to the child in a quiet, soothing voice. RATIONALE: At the time of a procedure, the nurse should advocate for the parents to remain during procedures to offer support. The parental role should be supportive and comforting and not one that causes pain. The parent should be sitting next to the child in the same room, not across from the child. Some parents may ask to hold their child during a procedure that causes pain, but do not ask parents to restrain the child during such a procedure.
A preschool-age child who is receiving gastrostomy feedings occasionally vomits following a feeding. When the parent describes the feeding process, what does the nurse note as the likely cause of the vomiting? Bolus feedings are administered over a period of about 25 minutes. Caretakers omit flushing the tube at the conclusion of bolus feedings. The mother does not check gastric residual prior to feedings. A feeding pump is used to administer the feedings.
The mother does not check gastric residual prior to feedings. RATIONALE: Because gastric residual (amount left in the stomach from prior feeding) is not checked before feeding, there may be times the child's stomach is overfilled when the current nutritional material is added. Aspirating to measure residual would confirm this as well as provide data about how fast the child's stomach is emptying. The feeding plan may need to be modified. Not flushing the tube would not be related to vomiting. Using 25 minutes to administer a bolus feeding is an appropriate amount of time in most instances. A feeding pump would precisely control feeding rate and should not be the source of vomiting.
A medical/surgical nurse has been floated to the pediatric unit. Which action by the float nurse would require the pediatric nurse to intervene? scanning the child's barcode on the identification band requesting the pediatric nurse to double-check calculations asking the child his or her name prior to giving medications speaking to both the parents and child about medications
asking the child his or her name prior to giving medications RATIONALE: To prevent errors, the nurse should never ask children their names for identification. This action would require the pediatric nurse to intervenes. Instead, nurses must read or scan the bar code on clients' identification arm bands and compare them with the medication sheet or electronic record. It is important to include both the parents and child in teaching about a medication. Calculating pediatric doses is not something medical/surgical nurses do on a regular basis, so it would be appropriate for the float nurse to have a pediatric nurse double-check the calculations.
The nurse is caring for a pediatric client who requires vitamins, minerals, lipids and amino acids through the circulatory system instead of the gastrointestinal tract. Which type of intravenous therapy is anticipated for long-term therapy? intermittent fluids via a syringe pump central venous catheter infusions use of a short line catheter and volume control chamber peripheral venous catheter infusions
central venous catheter infusions RATIONALE: Total parenteral nutrition (TPN) is the administration of dextrose, lipids, amino acids, electrolytes, vitamins, minerals and trace elements through the circulatory system. It is anticipated that long-term therapy will be completed via a central venous access device. Peripheral devices and short catheters are for short-term therapy. Syringe pumps are for small amounts of fluid over a period of time. The volume control chamber prevents fluid overload from pump malfunction.
The site most often used when administering a medication using the intradermal route is the: thigh. forearm. deltoid. abdomen.
forearm. RATIONALE: Intradermal injections deposit medications just under the epidermis. They are most often used for tuberculosis screening and allergy testing. The forearm is the site most often used. The anterior thigh, lateral upper arms, and abdomen are the preferred sites for subcutaneous administration. The deltoid, vastus lateralis and the ventrogluteal are the preferred sited for intramuscular injections.
The floor nurse is making rounds on her clients and discovers that an 8-month-old admitted with pneumonia has an oxygen saturation of 91% on room air. The physician has standing orders to keep saturations at 96% or above. Which oxygen delivery system would the nurse choose for this client? oxygen tent nasal cannula non-rebreather mask face mask
nasal cannula RATIONALE: For infants and older children, the nasal cannula is the most appropriate oxygen delivery system for this oxygenation level. It is the least invasive and most comfortable for the infant. A face mask or a non-rebreather mask are used if the nasal cannula is not successful in keeping the infant's oxygen saturations within the set parameters. Oxygen tents are rarely used due to the difficulty in maintaining a constant O2 level in the tent.
When preparing to administer medication to an infant, the nurse should utilize which device? infant formula and bottle measured medication spoon medicine cup oral syringe without a needle
oral syringe without a needle RATIONALE: When administering medication to an infant, an oral syringe without a needle or a dropper may be used. Medication should not be mixed with the infant's formula. Toddlers and older children may use a measured medication spoon or cup.
The nurse has been caring for a 12-year-old boy during his 5-day hospitalization. The child's IV has infiltrated, and the care provider is getting ready to change the intravenous line site. Which statement made by the nurse would be appropriate in supporting the child? "The nurses on the unit know the client well, so maybe a nurse could start the IV." "I will be back after your IV is in place." "Would you like me to stay with you or are you OK alone?" "The client is left-handed and likes to draw; an IV site in his right arm would be best."
"The client is left-handed and likes to draw; an IV site in his right arm would be best." RATIONALE: The staff nurse may serve as the child's advocate when the care provider comes to start an infusion. The staff nurse who has cared for the child has the child's confidence and knows the child's preferences.
The nurse is caring for a 4-year-old child who requires a venipuncture. To prepare the child for the procedure, which explanation is most appropriate? "The doctor will look at your blood to see why you are sick." "The doctor needs to use a needle and a little container to get blood to see if you have strep." "The doctor needs to take your blood to see why you are sick." "The doctor wants to see if you have strep throat."
"The doctor will look at your blood to see why you are sick." RATIONALE: The nurse should provide a description of and reason for the procedure in age-appropriate language. The nurse should avoid the use of terms such as culture or strep throat, as it is not age-appropriate for a 4-year-old child. The nurse should also avoid confusing terms like "take your blood" that might be interpreted literally.
A young client has a temperature of 102℉ (38.9℃). In addition to the scheduled antipyretic the child received, the nurse is treating the fever with nonpharmacologic methods by removing the blanket that covers the child. What is the rationale for this action? The blanket soaks up the sweat, making the child warmer. The blanket adds heat to the child. Covering the child with a blanket leads to shivering, which will only generate more heat. Removing excess coverings allows for evaporation, which aids in cooling the child.
Removing excess coverings allows for evaporation, which aids in cooling the child. RATIONALE: Removing covering from a child when he or she is febrile aids in additional cooling by allowing evaporative heat loss. The rationale is not that the blanket warms the child further, or that it will soak up sweat. Nor will covering the child lead to shivering. Shivering occurs when the child is chilled by some intervention; shivering serves as a sign that the cooling procedure needs to be stopped.
A child is being discharged from the hospital and the nurse has completed discharge teaching regarding prescribed liquid medications. Which comments by the parent demonstrates understanding of discharge instructions for safe medication administration? Select all that apply. "I will only need one medicine dropper for both of the medications being prescribed." "I can probably pinch my child's nose to help in swallowing the medication. I do this when I don't want to taste a liquid medication." "I will be sure to not give too much of the liquid medication at one time." "I shouldn't use a liquid dropper from my kitchen because it may be a different measurement than one from the pharmacy." "I need to make sure to use the medicine dropper the pharmacy gives me instead of the syringe I use for my B12 injections."
"I will be sure to not give too much of the liquid medication at one time." "I shouldn't use a liquid dropper from my kitchen because it may be a different measurement than one from the pharmacy." "I need to make sure to use the medicine dropper the pharmacy gives me instead of the syringe I use for my B12 injections." RATIONALE: Only droppers given by the pharmacy for the specific medication should be used. Different syringes may have different measurements than pediatric oral syringes. Mixing medication syringes is avoided if a dropper is packaged with a certain medication since the drop size may vary from one dropper to another. Giving small amounts of liquid avoids aspiration. Pinching the child's nose increases the risk for aspiration and interferes with the development of a trusting relationship.
A child is undergoing a painful procedure and is upset. Which statement by the nurse would be the best approach in dealing with the child? "You were brave and good, so you get a sucker." "I know that this hurts some but you are being so strong. It is OK to cry." "Please don't bite or kick me; that would be very naughty." "If you hold still and be quiet, I will give you a popsicle."
"I know that this hurts some but you are being so strong. It is OK to cry." RATIONALE: Children should be given the right to cry and be verbally praised for cooperating. Pediatric clients should not routinely be rewarded for acting appropriately during a procedure or for being brave or good, but if they are given a small reward such as a sticker or small toy afterward, the child's memory of the experience is more positive. A nurse never tells a child to be quiet during a painful procedure nor tells the child that he/she is naughty for acting out in pain.
The nurse is teaching parents of a 12-year-old child how to administer otic medication. Which statement by the parent indicates a need for further education? "After removing the medication from the refrigerator, I need to roll it gently in my palms to warm it." "I will hold the dropper 0.5 in (1.25 cm) above the ear canal and be certain not to touch the ear with the dropper." "After administering the drops, I will ask my child to remain side-lying for several minutes." "I will pull the outer ear down and back before administering the medication."
"I will pull the outer ear down and back before administering the medication." RATIONALE: The proper technique to instill ear drops in a child older than 3 years of age involves pulling the pinna up and back. Otic medication should not be administered if it is cold. Cold medication may cause discomfort and produce vomiting or vertigo in the child. If an otic medication must be refrigerated, it should be warmed in the palms of the hands. Proper otic administration technique involves holding the dropper 0.5 in (1.25 cm) above the ear canal and being careful not to touch the dropper to the ear to prevent contamination of the dropper with microorganisms. The child should remain in a side-lying (or supine) position for several minutes after administration.
The nurse has finished completing a client education program for parents on proper medication administration to children. Which statement by a parent would indicate a need for further education? "If my toddler won't swallow her medication, I will hold her nose until she has to swallow." "When I give my toddler medication, I will make sure they are sitting up." "I will let my preschooler squirt his medication in his own mouth after I have measured it out." "I will put my daughter's pill in a small amount of applesauce to help her learn now to swallow it."
"If my toddler won't swallow her medication, I will hold her nose until she has to swallow." RATIONALE: Proper medication administration includes placing a pill in applesauce or ice cream to help a child learn how to swallow it. When giving medications to an infant or small child, always have them in an upright position to avoid aspiration. Allowing a toddler or preschooler to squirt medication into his or her own mouth is appropriate. You should never force medication into a child's mouth or pinch his or her nose. This increases the risk for aspiration and interferes with developing a trusting relationship.
The nurse is providing discharge education to the parents of a 2-year-old who will be taking amoxicillin orally at home. The nurse would include which statement in the teaching? "Use a dosing cap to measure the dosage." "Give the medication until your child has no symptoms." "Mixing the medication with milk will help." "Crush the pills and mix with applesauce when giving the medication."
"Use a dosing cap to measure the dosage." RATIONALE: When talking to parents about giving medicine, stress that if a medicine comes supplied with a dosing cap, it is best to use that to measure the correct dose (Pham et al., 2011). If there is no dosing cap, then an oral medicine syringe or dropper are the next best methods to measure liquid medicine because kitchen teaspoons are rarely exactly 5 ml. Antibiotics need to be taken for the full course, not until symptoms subside. Mixing the medication with a drink or in food makes it difficult to determine how much the child has taken if the child refuses to finish it all. Amoxicillin comes in a liquid form, so crushing the pills is not appropriate.
The nurse is preparing to administer an oral dose of metoclopramide to a 5-year-old child who weighs 40 lb (18.2 kg). The prescription reads metoclopramide 0.8 mg/kg/day to be given in 4 oral doses. How many milligrams of metoclopramide would the nurse give per dose? 3.65 mg per dose 18.20 kg per dose 8.00 mg per dose 14.60 mg per dose
3.65 mg per dose RATIONALE: To calculate the does, use the client's weight in kilograms. Multiply 0.8 mg by 18.2 kg, which equals 14.6 mg per day for the client's weight. Then, divide 14.6 mg by 4, the number of doses per day , to arrive at 3.65 mg per dose.
A child weighs 18 pounds. The nurse is making sure the intravenous (IV) infusion is flowing at the correct rate. After determining fluid requirements for this child for a 24-hour period, the nurse should be sure that the IV is infusing at how many milliliters per hour?
34 RATIONALE: The child's weight must be converted to kilograms (18 lb divided by 2.2 kg = 8.18 kg). This kilogram weight is multiplied by 100 (8.18 x 100 = 818.18 ml) to determine the 24-hour fluid requirement. The 24-hour fluid requirement is divided by 24 (hours)= 34.09 (34 ml/hr).
The nurse is preparing a toddler for a diagnostic test. Which nursing intervention is best? Provide a detailed explanation of the procedure an hour in advance. Ask the parents to provide information to the child to prevent fear. Allow the child to role play with a doll prior to the actual procedure. Prepare only the parents only because the child is too young to understand.
Allow the child to role play with a doll prior to the actual procedure. RATIONALE: Toddlers and preschool-age children resist any diagnostic testing that involves any degree of discomfort or pain or any procedure that is unfamiliar to them. Even though the toddler is young, it is still important to explain the procedure to the child. A long explanation an hour ahead gives too much information and too much time to worry. Give children of this age short explanations of what to expect close to the time of the procedure so that little time can be spent worrying. Try to associate any new equipment with things that they are familiar with, such as comparing an MRI to a giant cell phone camera. If possible, introduce any equipment that will be used in procedures (e.g., a nasogastric tube) in a play session with a doll so the child can handle the new object and see that the doll is not injured or does not resist having the tube inserted. It is not appropriate to expect parents to provide the information because this is the nurse's role.
A child has undergone a procedure requiring moderate sedation. The child asks the nurse, "I am thirsty; can I have something to drink?" Before giving the child something to drink, what will the nurse do first? Ask the child their name and birth date. Check the child's vital signs. Assess the child's level of consciousness. Check the child's gag reflex.
Check the child's gag reflex. RATIONALE: Although assessing vital signs and level of consciousness are important, the nurse should check the child's gag reflex to ensure it is intact before offering any fluids to drink to reduce the risk of aspiration. The key is to prevent aspiration. Asking the child's name and birth date would not be effective in preventing aspiration.
A child with extensive burns is receiving an intraosseous infusion into the right leg because there is no other site available for IV access. Which action is appropriate for the nurse to implement when caring for the child while receiving fluids and medication by this route? Assess pulses distal to the site every hour. Inspect the leg color every 8 hours. Change the infusion tubing every 24 hours. Change the site dressing every 12 hours.
Assess pulses distal to the site every hour. RATIONALE: Tubing and dressings must be changed as per protocol (approximately every 48 hours for the tubing and approximately every 24 hours for the dressing), to reduce the possibility of infection. The nurse will assess for a distal pulse and adequate temperature and color of the leg every hour throughout the infusion to ensure there is adequate circulation to the extremity.
The nurse is preparing to administer regular insulin to a nonverbal pediatric client. Which action will the nurse perform prior to administering the medication? Check the birth date and full name on the client's wristband with the medication administration record and have another nurse verify. Check the full name and room number on the client's wristband with the medication administration record. Check the full name and age on the client's wristband with the medication administration record and have the parent verbally confirm. Check the full name and birth date on the client's wristband with the medication administration record.
Check the full name and birth date on the client's wristband with the medication administration record. RATIONALE: When administering medications to a child, the nurse needs to use at minimum two client identifiers that are directly associated with the client and the medication to be given, such as full name, client ID number, and birth date. The nurse will take the medication administration record to the room to perform a "double-identifier" check. A client's identity must be verified with two acceptable identifiers, not just one. There is no need to have another nurse verify or have the parent state the client's information. A room number or a bed number is not an acceptable identifier.
The nurse is preparing to administer regular insulin to a nonverbal pediatric client. Which action will the nurse perform prior to administering the medication? Check the full name and room number on the client's wristband with the medication administration record. Check the full name and birth date on the client's wristband with the medication administration record. Check the full name and age on the client's wristband with the medication administration record and have the parent verbally confirm. Check the birth date and full name on the client's wristband with the medication administration record and have another nurse verify.
Check the full name and birth date on the client's wristband with the medication administration record. RATIONALE: When administering medications to a child, the nurse needs to use at minimum two client identifiers that are directly associated with the client and the medication to be given, such as full name, client ID number, and birth date. The nurse will take the medication administration record to the room to perform a "double-identifier" check. A client's identity must be verified with two acceptable identifiers, not just one. There is no need to have another nurse verify or have the parent state the client's information. A room number or a bed number is not an acceptable identifier.
A toddler requires 1.5 ml of an antibiotic given intramuscularly (IM). How will the nurse administer this medication? Divide the dose. Administer 0.75 ml IM in each vastus lateralis. Seek an order for an oral form of the antibiotic. Reduce the volume of the dose using less diluent than recommended to prepare the antibiotic for IM injection. Administer the antibiotic IM in the rectus femoris.
Divide the dose. Administer 0.75 ml IM in each vastus lateralis. RATIONALE: The recommended amount of solution a toddler should receive in one IM injection should not exceed 1 ml. Dividing the dose is necessary even though two injections will cause additional stress. These could be given simultaneously by two nurses. Seeking an oral route could be explored, but may not be feasible. The manufacturer's directions regarding the amount of diluent should be followed to ensure safety.
One of the 2030 National Health Goals is to reduce emergency visits for medication overdoses for children under 5 years old. What roles do nurses have in meeting this goal? Select all that apply. Educate parents about securing medication in locked cabinets outside the reach of children. Provide education for parents regarding how to measure doses and proper administration. Assist parents in developing a schedule to administer the prescribed medications for home use that optimize sleep Explain to parents that dosages are based on the weight of the child and should not be used for other children in the family. Stress that parents use dosing cups, syringes, or droppers with all medications administered to children. Educate parents about not using household tablespoons or teaspoons for medications as there is no uniform size
Educate parents about securing medication in locked cabinets outside the reach of children. Provide education for parents regarding how to measure doses and proper administration. Assist parents in developing a schedule to administer the prescribed medications for home use that optimize sleep Explain to parents that dosages are based on the weight of the child and should not be used for other children in the family. Stress that parents use dosing cups, syringes, or droppers with all medications administered to children. Educate parents about not using household tablespoons or teaspoons for medications as there is no uniform size RATIONALE: All of these options are correct, as nurses play a big role in educating parents on safe medication administration and storage. Compliance will help reduce the number of children under 5 years old coming to the emergency department with medication overdoses.
An 8-month old infant has a colostomy placed following abdominal surgery for removal of a section of bowel. The stoma is 2/3 full, draining liquid stool and the bag appears inflated. What actions would the nurse take in caring for this client? Select all that apply. Remove the stoma bag and discard it every day. Empty the bag and record the output. Examine the skin around the stoma site for redness or irritation. Remove the stoma bag and allow the stoma to remain open to air for 1 to 2 hours. Look at the infant's intake to determine if any foods could be causing gas.
Empty the bag and record the output. Examine the skin around the stoma site for redness or irritation. Remove the stoma bag and allow the stoma to remain open to air for 1 to 2 hours. RATIONALE: In caring for an infant with a colostomy, the nurse empties the contents of the bag on a regular basis, rinses it out, closes it again, but does not discard it each time it is emptied. The nurse also inspects the skin around the stoma for any redness or skin breakdown. Since the bag was inflated initially, the nurse should review the infant's intake to note if the infant is consuming any gas-causing foods and recommend limiting them. The bag is never left off for any length of time due to the constant stooling pattern of the infant.
The nurse administers an antipyretic rectal suppository. The child has a bowel movement 15 minutes later. What is the appropriate nursing action? Examine the stool for the presence of the suppository. Immediately notify the physician or nurse practitioner. Administer another suppository, and then hold the child's buttocks together. Wait to readminister the medication until the next scheduled dose. Recheck the child's temperature to determine if the suppository is needed.
Examine the stool for the presence of the suppository. RATIONALE: The stool should be examined for the suppository that may have been expelled with the bowel movement. If it is found, the physician or nurse practitioner can be notified to determine if the suppository should be repeated. The nurse should not administer another dose without examining the stool or contacting the physician or nurse practitioner. Rechecking the child's temperature would provide little useful information since only a very limited time has elapsed since the temperature was last checked.
The nurse has prepared an IM injection to give a 13-year-old child. After some searching, the nurse locates the child in the playroom in front of a video game. Which action is best for the nurse to take? Give the injection in the playroom since the child is distracted with the video game. Ask the child when the game will be over. Ask the child to take a break from the game and come back to the child's room to give the injection. Inform the child that it is time for an injection. Explain why the injection is needed and have the child move to the treatment room.
Inform the child that it is time for an injection. Explain why the injection is needed and have the child move to the treatment room. RATIONALE: Explaining the reason for a medication is appropriate for a 13-year-old child. The medication should not be given in the playroom. The playroom is a safe area for clients. Painful procedures should be done in a treatment room. Asking the child to take a break from the game sounds like the nurse is asking permission to give the medication. A child should not be given the opportunity to refuse a medicine.
The nurse is preparing to give a 4-month-old an oral medication. Which technique demonstrates the nurse's accurate knowledge of the infant's developmental level? Place the medication in a bottle with a small amount of the infant's formula and feed the bottle to the infant in an upright position. Position the infant supine in bed, and squirt the medication on the tongue toward the cheek. Position the infant upright, offer the infant a bottle of formula, remove the bottle and squirt the medication on the side of the tongue toward the cheek, then offer the infant the bottle again. Place the medication in a bottle with a small amount of juice, then feed the infant the bottle in an upright position.
Position the infant upright, offer the infant a bottle of formula, remove the bottle and squirt the medication on the side of the tongue toward the cheek, then offer the infant the bottle again. RATIONALE: Proper medication administration for an infant includes the following: Position the infant upright, present a pleasant- or neutral-tasting substance to ensure that the child is awake and swallowing, give the medication slowly enough to allow the child to swallow and prevent any risk of aspirating, and give a pleasant-tasting "chaser." An infant should not be placed supine since this would increase the risk of aspiration. Medications should not be placed in a client's staple food to avoid an aversion to the food in the future.
The nurse is administering otic medication to a 22-month-old with a diagnosis of otitis media. Which nursing action ensures that the medication is distributed appropriately? Pull the pinna down and back. Place in a side-lying position. Pull the pinna up and back. Place a cotton ball in the outer ear.
Pull the pinna down and back. RATIONALE: By making sure that the ear canal is straight for the medication to progress to the tympanic membrane, the medication is distributed appropriately. It is also appropriate to place the child in a side-lying position. Some nurses place a cotton ball in the ear but that does not impact distribution of the medication. A child over 3 years of age needs the pinna pulled up and back.
A child with gastroenteritis has been unable to keep oral medication down. What nursing intervention would be appropriate for this client? Request an intravenous form of the medication. Give an antiemetic prior to giving oral medications. Place the child on NPO status. Hold all medications until the vomiting stops.
Request an intravenous form of the medication. RATIONALE: Absorption is the transfer of the drug from its point of entry into the bloodstream, and vomiting and diarrhea interfere with absorption because the drug does not remain in the gastrointestinal tract long enough to be absorbed. Distribution is not affected by vomiting and diarrhea, as it involves movement of the drug through the bloodstream. Metabolism involves conversion of the drug into an active or inactive form, and is unaffected by gastroenteritis. Excretion is the elimination of the drug from the body, usually through the kidneys. This is also unaffected by vomiting and diarrhea.
The nurse is administering a gavage feeding through a nasogastric feeding tube. Which nursing intervention is the highest priority? The nurse positions the child in a sitting position. The nurse replaces stomach content that has been aspirated. The nurse verifies the position of the feeding tube. The nurse documents how the child tolerated the feeding.
The nurse verifies the position of the feeding tube. RATIONALE: Verifying the position of the tube to ensure that the tube is in the stomach by aspirating stomach contents is the highest priority. This is a top priority because of the danger of aspiration if the tube is not in the stomach but rather in the esophagus or the lung.
The nurse has brought a 3-year-old's oral medications into the room for administration. Upon approaching the child, the nurse said, "I have your medication. Would you rather have me hand it to you or Mommy?" In critiquing the nurse's actions, which is most accurate? The nurse's behavior is incorrect. The mother did not prepare the medication and should not have administered the medication. The nurse's behavior is correct. Children are afraid of the nurse. The nurse's behavior is incorrect. The nurse should have been firm in expecting the child to take the medication. The nurse's behavior is correct. The nurse provided the child a choice between two acceptable options with the outcome of taking the medication.
The nurse's behavior is correct. The nurse provided the child a choice between two acceptable options with the outcome of taking the medication. RATIONALE: The nurse is correct to offer a choice to the preschooler and then for the mother to administer the medication, if chosen. This meets the developmental level of autonomy. The nurse prepared the medication and the medication remained with the nurse until handing it to the mother, who handed it to the child. The nurse witnessed the medication administration and documents it. The nurse firmly requires the medication to be taken but found a way for the child to take it that was acceptable to the child and accomplished the goal.
The nursing student identifies which technique as the correct one to use when giving oral medications to an infant? Use a dropper and slowly inject the liquid into the side of the infant's mouth. Use a dropper and squirt the liquid quickly into the back of the infant's mouth. Allow the child to lay flat while giving the liquid medication to relax the child. Use a dropper and let it rest on the infant's tongue when squirting the medicine.
Use a dropper and slowly inject the liquid into the side of the infant's mouth. RATIONALE: When giving liquid medication to an infant or child, the nurse should never administer it while the child is flat. Doing so could cause a child to aspirate. The nurse uses the dropper by placing it so the fluid flows slowly into the side of the child's mouth. The nurse should make sure the end of the syringe rests at the side of the infant's mouth to help prevent aspiration as well.
The nurse is preparing an intravenous solution of D5 ¼ NS @ 20 ml/hour for a 6-month-old client. Which safety device will be added to protect against fluid overload? a volume control device pediatric IV tubing a secondary line a syringe pump
a volume control device RATIONALE: A volume control device (also called buretrol) is designed to deliver only the amount of medication placed in the chamber. The nurse places no more than 2 hours of fluid within the device. Should the pump fail, the client will receive only the fluid amount in the chamber, thus preventing fluid overload.
A 4-year-old child is admitted to the hospital for surgery. Before the nurse administers medicine, the best way to identify the child would be to: tell the child to state his or her nickname. read the child's armband. call the child's name and see if he or she answers. ask the child to state his or her name.
read the child's armband. RATIONALE: A child may answer to the wrong name or deny his or her identity to avoid an unpleasant situation or if scared of the unknown. If the child is avoiding the situation he or she may fail to answer. Using the child's nickname is okay in conversation but it is not a legal identification of the child. To verify the correct identity the nurse should verify the child's armband and the correct name with the child's caregiver. Bar code scanning the child's armband would also be a correct method of identification.
