Chapter 30: Procedures and Treatments

A nurse is caring for a 14-year-old with a gastrostomy tube. The girl has skin breakdown and irritation at the insertion site. What would be the most appropriate method to clean and secure the gastrostomy tube?

If any drainage is present, use a presplit 2 × 2 and place it loosely around the site. Skin around the gastrostomy or jejunostomy insertion site may become irritated from movement of the tube, moisture, leakage of stomach or intestinal contents, or the adhesive device holding the tube in place. Keeping the skin clean and dry is important and will help prevent most of these problems. If any drainage is present, a presplit 2 × 2 can be placed loosely around the site and changed when soiled. If no drainage is present, the nurse should not place a dressing as it can cause undue pressure and trap moisture, leading to skin irritation. Preventing movement of the tube helps reduce skin irritation; however, the tube should be able to move slightly in and out of the child's stomach.

A nurse has just received an order to apply an ice bag to a client's groin. Which of the following intervals for placement of the ice bag does the nurse plan to use?

20 minutes As with heat, a provider must order the use of cold applications. Intervals of 20 minutes are recommended for both dry and moist cold.

After inserting a nasogastric tube (NG) into a young child, how will the nurse tape the tube in place?

Below nose and to cheek The nurse will tape the tube below the nose and to the side of the cheek to avoid pressure on the naris, as also happens when taping to the forehead is done. Taping to the cheek and behind the ear will not stabilize the tube adequately. It will not be taped to the side of the mouth. A nasogastric tube enters the nose.

The nurse needs to provide instructions to a school-aged girl about how to obtain a clean catch midstream urine specimen. Which instructions are best?

Clean the labia from front to back, then void a small amount into the toilet before collecting in the cup. For girls, clean the labia from front to back using a cleansing pad or cotton balls saturated with the agency's designated cleaning solution. During the child's voiding, ask the parent to collect a "midstream" sample into a sterile container provided. It is unnecessary to catheterize a school age child to get a clean catch urine specimen. Urinating into the cup is part of the process, but it follows cleaning the labia and voiding a small amount in the toilet. A urine collection bag is used for infants, not school age children.

A 6-year-old has just returned to his room after a spinal tap. What could the nurse do to make this unpleasant procedure less memorable for the child?

Give him a little toy that he has been wanting. Children given a treat or small toy after an uncomfortable procedure tend to remember the experience as not totally bad. The nurse should never say that any patient will not have to go through an uncomfortable experience again. Saying the child was brave when maybe he was not could foster mistrust in the nurse.

A child has returned to the unit after having a lumbar puncture. Which instructions are important for the nurse to provide the parents and child?

The child will need to remain flat to prevent a headache. After a lumbar puncture, remind children to remain quiet and with their head flat to help prevent a postdural puncture (spinal) headache. Typically, children will not be fearful of staff nor will the child be up ambulating until later. The procedure should not need to be repeated in 24 hours.

How will the nurse measure urine output in the hospitalized toddler who is partially potty trained?

Weigh the wet pull-up or diaper and subtract the weight of a dry diaper A toddler who is partially potty trained is likely to regress during the stress of hospitalization and need diapering. Subtracting dry weight in grams from wet weight reveals the number of milliliters of urine excreted. The other output measurement methods will not be accurate.

The nurse is administering a prescribed bolus gavage feeding. Which action would be incorrect in performing this procedure?

Verify placement by auscultating for sounds in the stomach when air is inserted. Auscultating for sounds when air is injected into the stomach is no longer considered recommended for verifying tube placement because it has been found unreliable as a confirmation of position.

How will the nurse determine the length of orogastric tubing needed to gavage the 14-month-old infant?

Measure from nose tip to earlobe to end of sternum Measuring from the tip of the infant's nose to the earlobe and then to the end of the sternum determines how far the orogastric and nasogastric tubes should be inserted for an infant over age 12 months. Measuring bridge of nose to xiphoid or mouth to umbilicus is not an accurate way to determine length of tube insertion. The tip of the nose to the earlobe to halfway between the end of the sternum and the umbilicus is used for infants younger than 12 months of age.

The nurse instructs the mother of a preschool-aged child on the use of ibuprofen prescribed for a temperature. Which statement indicates that the teaching has been effective?

"I should give this medication with food." Because ibuprofen can cause gastrointestinal irritation, it should be given with food or fluids. The medication dosage should be measured by using the device supplied with the medication and not using a kitchen spoon. Fluids should be encouraged when taking this medication because renal failure can occur if the child becomes dehydrated. If the child complains of a stomachache while taking this medication, notify the health care provider. This could be an indication of an adverse effect.

A 7-year-old boy has been admitted to the hospital with a diagnosis of fever of unknown origin. He has numerous tests ordered for diagnosis. When preparing him for the blood tests ordered, the best explanation would be:

"The doctor needs to look at your blood to see why you are sick; it will hurt for a second." Using the term "drawing blood" implies you are suggesting a game, not a momentary painful procedure. Being honest about pain allows the child to trust you.

A parent calls the nurse in the emergency department and reports giving a tepid bath to decrease temperature in a feverish child. The parent states the child is shivering and wants to know if this means the bath was effective. What is the best response by the nurse?

"Shivering means the child is chilling, which will cause the body temperature to increase." If a child begins to shiver, whatever method is being used to lower the temperature should be stopped. Shivering indicates the child is chilling, which will cause the body temperature to increase.

How will the nurse properly collect and care for the child's 24-hour urine specimen?

Empty each void into a designated container that keeps the urine cool The 24-hour urine collection is cumulative over this time period and is sent to the laboratory when complete. The urine is kept cool to keep the bacterial count to a minimum. Sterile collection procedures are not needed. Hydration of the child should reflect the youngster's norm. Pushing clear fluids is not necessary.

The nurse is reinforcing teaching with a group of caregivers regarding steps that can be taken to lower a child's elevated temperature. Which action would the nurse include in the discussion? Select all that apply.

Encourage fluids. Administer acetaminophen. Lower the room temperature. Methods used to reduce fever include maintaining hydration by encouraging fluids and administering acetaminophen. Keep room environment cool. Dress the child in lightweight clothing. Because of their ineffectiveness in reducing fever and the discomfort they cause, tepid or lukewarm sponge baths are no longer recommended for reducing fever.

What action should the nurse take after collecting a stool specimen for ova and parasites from a preschool-aged child?

Have the specimen taken to the laboratory immediately. If a stool specimen is for ova and parasites, do not refrigerate it because refrigeration destroys the organisms to be analyzed. The specimen needs to arrive in the laboratory in less than 1 hour after collection so the parasites can be readily detected. Alcohol should not be added to the specimen container. The color of the stool sample is of no consequence.

A nurse is preparing to apply heat therapy to a client who has a back abscess. Heat has which of the following benefits? Select all that apply.

Increases circulation Causes vasodilation Promotes muscle relaxation Local application of heat increases circulation by vasodilation and promotes muscle relaxation, thereby relieving pain and congestion. It also speeds the formation and drainage of superficial abscesses.

The nurse is caring for an 11-year-old admitted with a respiratory condition. The child requires occasional administration of low-flow oxygen. Which of the following methods of oxygen administration would likely be used for this child?

Nasal prongs Depending on the child's age and oxygen needs, many different methods are used to deliver oxygen. Nasal prongs or a nasal cannula are used appropriately for an 11-year-old child, especially if the child has modest needs for supplementation.

Parents asks the nurse why their premature infant is receiving a feeding through the mouth rather than the nose. What is the best explanation by the nurse?

Newborns are obligate nose breathers so nasogastric may obstruct their breathing. Whether enteral catheters should be passed through the nares or the mouth is controversial. Because newborns are obligate nasal breathers, passing a catheter through the nose may obstruct their breathing space, and repeated insertion of a nasogastric tube can cause inflammation and obstruction of the nose; thus most tubes are inserted orally in small infants. Orogastric insertion can also decrease the possibility of striking the vagal nerve in the back of the throat and causing bradycardia, whereas nasogastric tubes increase the possibility of striking the vagal nerve.

If a urine specimen for analysis is ordered for an 8-month-old girl, which intervention would you use?

Place a urine collector on her just prior to feeding. Most infants void following a feeding, so placing a urine collector just before a feeding will usually allow a urine specimen to be obtained.

A pediatric client is having difficulty breathing. Which nursing intervention is appropriate for this client?

Provide oxygen as needed to maintain oxygen saturation above 93% The nurse would provide oxygen to increase oxygen saturation as needed for this child. A decrease in oxygen saturation will cause the child to have an increase in the work of breathing. The positioning does not promote an open airway. Having family members leave the room could increase the child's anxiety, which would worsen the respiratory status. Continuing to monitor the child provides no assistance or relief.

Colin, age 1, has been admitted for an injury on his head that requires sutures to be placed. He is crying and trying to sit up when he is placed on the examining table. To keep him safe during the procedure, the nurse would choose which method to restrain him?

Restrain him with a mummy restraint and release it as soon as the procedure is completed. Restraints often are needed to protect a child from injury during a procedure or an examination, or to ensure the infant's or child's safety and comfort. A mummy restraint can be used for an infant or small child during a procedure. This device is a snug wrap that is effective when performing a scalp venipuncture, inserting a nasogastric tube, or performing other procedures that involve only the head or neck.

The nurse aspirates stomach contents before administering a nasogastric (NG) tube feeding. How will the nurse manage the aspirate? Select all that apply.

Return the aspirate to the stomach Determine the pH of the aspirate Record the amount of the aspirate Discarding the aspirate would deprive the child of both electrolytes and nutrients. The aspirate should not be discarded. The other measures are the ones to be used.

The nurse notes that parents accompanying their child for a procedure appear tense and nervous. What intervention by the nurse will best assist the young child to relax?

Use measures to reduce the parents' anxiety. Reducing the parents' anxiety will also reduce the child's anxiety. Anxious parents transmit their anxiety to the child and are less effective in providing support. The other nursing interventions are helpful, but relaxed parents are the key.

A pediatric nurse wants to determine an accurate amount of urine output for a diapered baby. Which is the most effective method?

Weigh a diaper before use and mark with weight, then weigh after and subtract the weight of the diaper. Diapers can be readily used as a method of measuring urine output. Weigh a diaper before it is placed on an infant and record this weight conspicuously (e.g., mark it on the front of the plastic covering with a ballpoint pen). Reweigh the diaper after it is wet and subtract the difference to determine the amount of urine present. This difference will be in grams, but because 1 g = 1 ml, the amount can be recorded in milliliters. This is the most accurate measure of output for an infant. This knowledge makes the answer that measuring output is impossible an incorrect answer. For just everyday intake and output, counting the number of wet diapers is adequate. Using a urine collection device is not always accurate because many times urine leaks around the bag.

While teaching parents how to effectively reduce the child's fever, the nurse should emphasize avoiding which intervention?

acetylsalicylic acid Caution parents to never give acetylsalicylic acid (aspirin) to children with fever because aspirin is associated with Reye syndrome, a severe neurologic disorder. Acetaminophen is safe for children, and cool cloths and dressing lightly will help reduce fever.

A pediatric nurse is preparing to use a jacket restraint with a client. After making sure it is the correct size and applying the jacket, the nurse will secure the ties to which of the following?

bed frame Jacket restraints are used to secure the child from climbing out of bed or a chair. Ties must be secured to the bed frame, not the side rails, so that the jacket is not pulled when the side rails are moved up and down.

A new graduate nurse is asking the nurse preceptor about enemas in pediatrics. The preceptor explains that the use of enemas in children is warranted under which circumstances? Select all that apply.

fecal impaction Hirschsprung disease preparation for surgery preparation for a colonoscopy Enemas are rarely used with children unless they are used as therapy for fecal impaction, Hirschsprung disease, a part of preparation for surgery, or a diagnostic test. Enemas would not be used for bloating or constipation.

A child is to receive an IV. The nurse knows that the first step in initiating the procedure is to:

verify the physician's order. The first step before beginning the procedure is to verify the physician's order. The other steps are necessary but are not the first step.

A nurse is teaching a parent ways to reduce fever in a child. What statement made by the parent would require further education?

"I will give my child a tepid sponge bath to reduce the fever." Because of their ineffectiveness in reducing fever and associated discomfort, tepid sponge baths are no longer recommended for reducing fever.

A nursing student is learning how to insert and administer enteral feedings through a nasogastric (NG) tube. The student identifies the best way to check placement before each feeding as which of the following?

Aspirating stomach contents and checking pH Confirmation of placement by radiologic examination is the most accurate method of verifying placement and position of a feeding tube. Because of the risks of repeated radiation exposure, however, this procedure cannot be used before each feeding. The nurse should verify placement of the tube by aspirating stomach contents and checking the pH. Verifying position by inserting air into the feeding tube and listening for sounds in the stomach is now considered an unreliable method of checking for tube placement.

Following the repair of a cleft palate, the nurse places an 18-month-old child in restraints. The caregivers are with the child and will stay in the room at all times. Which type of restraints would the nurse most likely use for this child?

Elbow restraint An elbow restraint prevents the child from being able to bend the elbows and thus prevents the child from reaching or touching the face or head areas.

A nurse working with a patient who has an elevated temperature notices that the child is beginning to shiver. Which of the following should the nurse do immediately?

Stop whatever intervention is being done to lower the temperature. Removing clothing and excess covering from a child with a fever permits additional cooling through evaporation. If a child starts to shiver, whatever method is being used to lower the temperature should be stopped. Shivering indicates the child is chilling, which will cause the body temperature to increase.

The nurse is caring for a client needing oxygen. Many forms of oxygen delivery can be used. Which of the following is the most difficult to manage the oxygen concentration?

Oxygen tent It is most difficult to manage the oxygen concentration in a tent because it is opened frequently.

The nurse needs to transport her preschool client to radiology for a chest X-Ray. Which transportation device would be most appropriate?

Wagon When transporting a child off the floor, the nurse needs to select the correct means of transportation based upon the child's age and developmental level. For a preschooler, a wagon would be the best choice for both safety and for enjoyment. A stretcher or wheelchair are both too large for such a young child and a crib is too small for them.

The nurse is caring for a breastfed infant hospitalized for gastroenteritis. Which method can be used to most accurately measure intake?

Weigh the infant before and after feeding and subtract weight. Intake in breast-fed infants is generally recorded as "breast-fed for X minutes." If it is necessary to estimate the amount more closely than this, an infant can be weighed before and after a feeding. The difference in weight (measured in grams) is calculated to establish the number of milliliters of breast milk ingested (1 g = 1 ml). Weighing the infant before and after feeding is the most accurate method for strict intake. Comparing to a bottle-fed infant is inaccurate and therefore not correct.

A 4-year-old child is being prepared to undergo a bronchoscopy to remove an aspirated pea. The nurse knows that the parents need additional teaching based on which statement?

"We will be able to take our child home immediately after the procedure is completed." The child will not leave immediately. Procedural complications are not common but may include compromise to the airway such as hemorrhage, pneumothorax, and airway edema. After the procedure, the nurse will need to continue to assess the child's respiratory function and airway patency. Postprocedure complications may include bronchospasm, stridor, desaturation, or respiratory distress. The nurse will observe children carefully the first time they drink after the procedure to assess that the gag reflex is intact and they do not choke. All of the other options are correct.

An infant is scheduled to have a painful procedure performed. Which nursing action provides the best support for the parents and infant?

Allow the parents to hold the infant during the procedure. It is important for the nurse to advocate for parents to remain in the procedure room to provide support to the infant. The parent may choose to hold the infant during a painful procedure, but it is best that the parent not restrain the infant during the procedure. Their role should be supportive and comforting, not one that causes pain. Having the parents remain outside the room leaves the infant without needed support. Infants experience pain but express it differently than adults.

A nurse is starting an intravenous (IV) line in the antecubital fossa of a small child. What restraint would be best for the nurse to use to maintain patency of the IV?

Elbow restraint Elbow restraints are wrapped around the child's arm and tied securely to prevent the child from bending the elbow. They are often made of muslin or other materials in two layers. Pockets wide enough to hold tongue depressors are placed vertically in the width of the fabric. The top flap folds over to close the pockets. Care must be taken to ensure that the elbow restraints fit the child properly.

A nurse receives a physician's order to collect a specimen for the diagnosis of respiratory syncytial virus. How should the nurse collect this specimen?

Obtain a nasal washing. To diagnose respiratory syncytial virus, a nasal washing may be done. A small amount of saline is instilled into the nose; then the fluid is aspirated and placed into a sterile specimen container.

When an infant is scheduled for a painful procedure, what is the most important action by the nurse?

Help to soothe and comfort the baby before and after the procedure. Infants undergoing procedures can experience pain. Thus, the important action is to help soothe and comfort the child before and after the procedure. The nurse should explain everything to the care provider, but the patient's comfort in this case is the highest priority.

A preschool-aged child has not been able to eat for several days until all diagnostic tests are complete to determine the cause of chronic diarrhea. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time?

Imbalanced nutrition, less than body requirements, related to food restriction for procedures Because the child has not been able to eat for several days, the risk for imbalanced nutrition is high. This is the appropriate diagnosis for the nurse to select at this time. There is no enough information to determine if the child is at risk for injury, fearful of procedure rooms, or experiencing a deficiency in diversionary activities.

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?

Limit treatments to 20 minutes at a time. 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 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?

Nasal cannula For infants and older children, the nasal cannula is the most appropriate oxygen delivery system for this oxygenation level. It is the less 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.

A child is receiving continuous tube feedings via a gastrostomy tube. The nurse needs to administer medication via the tube. After preparing the medication, what action should the nurse take next?

Pause or stop the feeding. Administering medications via a gastrostomy tube when continuous feedings are running requires the feeding pump to be paused or stopped. If not, the medications will be pushed into the formula tubing and not into the stomach. This means the medication will only be delivered at the rate the feeding is running. The medication could take several hours to completely enter the stomach. Checking for placement with pH paper and checking the amount of residual is important but not the first action. The tubing should be flushed with water prior to the medication administration, but this not the first action.

The doctor 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. In patients 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 and aspirating urine out of the diaper is not the best approach or one that ensures the best results.

The nurse is caring for a comatose school-age child receiving gastrostomy tube feedings. The nurse aspirates 15 ml of stomach contents prior to administering a feeding. What is the appropriate action by the nurse?

Replace the stomach contents and continue with the feedings as prescribed. The nurse should always aspirate nasogastric or gastrostomy tubes for stomach contents to check for tube placement and assess gastric residual amounts prior to administering feedings. The nurse will return any amount of stomach residue aspirated so the child does not lose large amounts of stomach acid. 15 ml is a very small amount of gastric contents and should not interfere with feedings.

The nurse is preparing a 7-year-old child for surgery. Which nursing action is the highest priority?

The nurse should follow the facility's policies. It is important to follow the facility's policies to ensure that legal requirements and safety precautions are met. Explaining the prognosis or risks and benefits of surgery is not normally the role of the nurse. The child does not likely need teaching about the detailed approach to pain management postoperatively.

A preschool child has been admitted to the hospital. Which prescription should the nurse question?

tap water enema 500 ml Tap water is not used in enemas with children because, as it is not isotonic, it causes a rapid shift of fluid in body compartments, possibly leading to water intoxication. The nurse would want to question the health care provider about the prescription for a large tap water enema. The other prescriptions could be completed safely for a preschool-age child.