Chapter 38 Medication Administration and Safety for Infants and Children

1. What is the 24-hour maintenance fluid requirement for a child weighing 8.5 kg?

ANS: 850 ml The formula for calculating daily fluid requirements is 0 to 10 kg: 100 mL/kg/day; 10 to 20 kg: 1000 mL for the first 10 kg of body weight plus 50 mL/kg/day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24: 8.5 kg ´ 100 mL = 850 mL/24 hr.

11. What is the main purpose for using a volume-control device, such as a Buretrol or an infusion pump, to administer intravenous fluids to children? a. To avoid fluid overload b. To aid in measuring intake c. To administer antibiotics d. To ensure adequate intravenous fluid intake

ANS: A Feedback A A volume-control device such as a Buretrol or an infusion pump allows the nurse to set a specific volume of fluid to be given in a specific period of time (usually 1 hour) and decreases the risk of inadvertently administering a large amount of fluid. B Although the use of a volume-control device allows for accurate measurement of intake, the primary purpose for using this equipment is to prevent fluid overload. C Medications such as antibiotics can be administered with a volume-control device; however, this equipment is used primarily to minimize the risk of fluid overload. D The risk of fluid overload is the primary reason for using a volume-control device.

13. When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration? a. Administer the medication with a syringe (without needle) placed along the side of the infant's tongue. b. Administer the medication as rapidly as possible with the infant securely restrained. c. Mix the medication with the infant's regular formula or juice and administer by bottle. d. Keep the child upright with the nasal passages blocked for a minute after administrat

ANS: A Feedback A Administer the medication with a syringe without a needle placed alongside of the infant's tongue. The contents are administered slowly in small amounts, allowing the child to swallow between deposits. B Medications should be given slowly to avoid aspiration. C The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking/eating, it is difficult to determine how much medication was consumed. Essential foods also should not be used. D Holding the child's nasal passages will increase the risk of aspiration.

8. The nurse administering an IV piggyback medication to a preschool child should a. Use a "Smart" pump if available. b. Flush the IV tubing before and after the infusion with normal saline solution. c. Inject the medication into the IV catheter using the port closest to the child. d. Inject the medication into the IV tubing in the direction away from the child.

ANS: A Feedback A Programmable infusion pumps are frequently used to facilitate safe intermittent infusion of IV medications for children via the piggyback method. Some hospitals use previously used "Smart" pumps with preprogrammed drug libraries to assist in the prevention of medication errors. B When administering medications by IV piggyback, the nurse flushes the tubing after the medication has infused. C The nurse is using the IV push method when injecting medication into the IV tubing using the port closest to the child. D The IV retrograde method involves clamping the IV tubing below the injection port and injecting medication into the tubing in a direction away from the child, causing it to flow into the tubing above the injection port.

9. What parameter should guide the nurse when administering a subcutaneous injection to a school-age child with cellulitis? a. Do not to give injections in edematous areas. b. Attach a clean 1-inch needle to the syringe. c. The maximum volume injected into one site is 2 mL. d. Do not pinch up tissue before inserting the needle.

ANS: A Feedback A Subcutaneous injections should never be given in areas of edema because absorption is unreliable. B A short (no more than 1/2- to 5/8-inch) needle should be used to deposit medication into subcutaneous tissue. C Volumes for subcutaneous injections are small, usually averaging 0.5 mL. D The skin is pinched up for a subcutaneous injection to raise the fatty tissue away from the muscle.

21. When teaching a mother how to administer eye drops, where should the nurse tell her to place them? a. In the conjunctival sac that is formed when the lower lid is pulled down b. Carefully under the eye lid while it is gently pulled upward c. On the sclera while the child looks to the side d. Anywhere as long as drops contact the eye's surface

ANS: A Feedback A The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. B The medication should not be administered directly onto the eyeball. C The medication should not be administered directly onto the eyeball. D The medication should not be administered directly onto the eyeball.

17. A child is receiving intravenous fluids. How frequently should the nurse assess and document the condition of the child's intravenous site? a. Every hour b. Every 2 hours c. Every 4 hours d. Every shift

ANS: A Feedback A The nurse assesses and documents an IV site at least every hour for signs and symptoms of infiltration and phlebitis. B The nurse should assess a child's IV site more frequently than every 2 hours. C The nurse should assess a child's IV site more frequently than every 4 hours. Serious complications could occur during this time interval. D The nurse should assess a child's IV site more frequently than every shift.

1. What should the nurse use to prepare liquid medication in volumes less than 5 mL? a. Calibrated syringe b. Paper measuring cup c. Plastic measuring cup d. Household teaspoon

ANS: A Feedback A To ensure accuracy, a calibrated syringe without a needle should be used to prepare a liquid dosage less than 5 mL. B Paper measuring cups are not calibrated for liquid volumes less than 5 mL. C A liquid volume less than 5 mL cannot be measured accurately in a plastic measuring cup. D A household teaspoon is not accurate enough to measure small amounts of medication.

20. What is the best action for the nurse to take when giving medications to a 3-year-old child? a. Tell the child to take the medication "right now." b. Tell the child to take the medication or he will have to get a shot. c. Allow the child to choose fruit punch or apple juice when giving the medication. d. Tell the child that another child his age just took his medication like a "good boy."

ANS: C Feedback A Direct confrontation typically results in a "no" response. B Threatening a child with a shot is inappropriate. C Realistic choices allow the child to feel some control. D Comparisons are not helpful in getting a child to cooperate.

4. Which factor should the nurse remember when administering topical medication to an infant as compared with an adolescent? a. Infants require a larger dosage because of a greater body surface area. b. Infants have a thinner stratum corneum that absorbs more medication. c. Infants have a smaller percentage of muscle mass. d. The skin of infants is less sensitive to allergic reactions.

ANS: B Feedback A A similar dose of a topical medication administered to an infant compared with an adult is approximately three times greater in the infant because of the greater body surface area. B Infants and young children have a thinner outer skin layer (stratum corneum), which increases the absorption of topical medication. C The smaller muscle mass in infants affects site selection for injected medications, but should not affect administration of topical medications. D The young child's skin is more prone to irritation, making contact dermatitis and other allergic reactions more common.

5. What is the appropriate nursing response to a parent who asks, "What should I do if my child cannot take a tablet?" a. "You can crush the tablet and put it in some food." b. "Find out if the medication is available in a liquid form." c. "If the child can't swallow the tablet, tell the child to chew it." d. "Let me show you how to get your child to swallow tablets."

ANS: B Feedback A A tablet should not be crushed until it is determined that it will not alter the effectiveness of the medication. B A tablet should not be crushed without knowing whether it will alter the absorption, effectiveness, release time, or taste. Therefore telling the parent to find out whether the medication is available in liquid form is the most appropriate response. C A chewed tablet may have an offensive taste, and chewing it may alter its absorption, effectiveness, or release time. D Forcing a child, or anyone, to swallow a tablet is not acceptable and may be dangerous.

2. Which food is appropriate to mix with medication? a. Formula or milk b. Applesauce c. Syrup d. Orange juice

ANS: B Feedback A Formula and milk are essential foods in a child's diet. Medications may alter their flavor and cause the child to avoid them in the future. B To prevent the child from developing a negative association with an essential food, a nonessential food such as applesauce is best for mixing with medications. C Syrup is not used to mix with medications because of its high sugar content. D Orange juice is considered an essential food; therefore the nurse should not mix medications with it.

19. What nursing action is indicated when a child receiving a unit of packed red blood cells complains of chills, headache, and nausea? a. Continue the infusion and take the child's vital signs. b. Stop the infusion immediately and notify the physician. c. Slow the infusion and assess for cessation of symptoms. d. Start a dextrose solution and stay with the child.

ANS: B Feedback A If the child is displaying signs of a transfusion reaction, the transfusion cannot continue. B If a reaction is suspected, as in this case, the transfusion is stopped immediately and the physician is notified. C If the child is displaying signs of a transfusion reaction, the transfusion cannot continue. D Dextrose solutions are never infused with blood products because the dextrose causes hemolysis. This action does not address the blood infusion. If the child is displaying signs of a transfusion reaction, the transfusion is stopped immediately.

14. Guidelines for intramuscular administration of medication in school-age children include a. Inject medication as rapidly as possible. b. Insert needle quickly, using a dart-like motion. c. Penetrate skin immediately after cleansing site, before skin has dried. d. Have child stand, if possible, and if child is cooperative.

ANS: B Feedback A Inject medications slowly. B The needle should be inserted quickly in a dart-like motion at a 90-degree angle unless contraindicated. C Allow skin preparation to dry completely before skin is penetrated. D Place child in lying or sitting position.

10. What action is correct when administering eardrops to a 2-year-old child? a. Administer the eardrops straight from the refrigerator. b. Pull the pinna of the ear back and down. c. Massage the pinna after administering the medication. d. Pull the pinna of the ear back and up.

ANS: B Feedback A Medication should be at room temperature because cold solutions in the ear will cause pain. B For children younger than 3 years, the pinna, or lower lobe, of the ear should be pulled back and down to straighten the ear canal. C The tragus, not the pinna, of the ear should be massaged to ensure that the drops reach the tympanic membrane. D For children younger than 3 years, the pinna of the ear should be pulled back and down to straighten the ear canal. For a child 3 years or older, the pinna is pulled up and back.

18. What is the hourly maintenance fluid rate for an intravenous infusion in a child weighing 19.5 kg? a. 19 mL b. 61 mL c. 195 mL d. 1475 mL

ANS: B Feedback A The formula for calculating daily fluid requirements is 0 to 10 kg: 100 mL/kg/day; 10 to 20 kg: 1000 mL for the first 10 kg of body weight plus 50 mL/kg/day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. B The formula for calculating daily fluid requirements is 0 to 10 kg: 100 mL/kg/day; 10 to 20 kg: 1000 mL for the first 10 kg of body weight plus 50 mL/kg/day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. Calculations: Child weighs 19.5 kg. Therefore the child requires 1000 mL; plus 50 mL ´ 9.5 kg = 475 mL. Next add calculated amounts: 1000 + 475 = 1475 mL, and divide by 24 hours to equal 61.45 mL per hour. This rounds down to 61 mL/hr. C The formula for calculating daily fluid requirements is 0 to 10 kg: 100 mL/kg/day; 10 to 20 kg: 1000 mL for the first 10 kg of body weight plus 50 mL/kg/day for each kilogram between 10 and 20. To determine

6. What is the maximum safe volume that a neonate can receive in an intramuscular injection? a. 0.5 mL b. 1.0 mL c. 1.5 mL d. 2 mL

ANS: B Feedback A This is an acceptable volume to inject; however, it is not the maximum. B The maximum volume of medication for an intramuscular injection to a neonate is 1.0 mL. C This volume is appropriate for an intramuscular injection to an infant or older child, not a neonate. D This volume is not appropriate for a neonate.

1. What nursing actions are correct when administering heparin subcutaneously? Select all that apply. a. Insert the needle with the bevel up at a 15-degree angle. b. Insert the needle at a 45- to 90-degree angle. c. Insert the needle into the tissue on the upper back. d. Insert the needle into the abdominal tissue. e. Massage the injection site when the injection is complete.

ANS: B, D Feedback Correct For this subcutaneous injection, the nurse inserts the needle at a 45- to 90-degree angle and injects into the subcutaneous abdominal tissue. Incorrect This technique is used for an intradermal injection. The upper back is used for intradermal injections. The nurse should not massage the site after administering heparin.

2. A nurse should routinely ask a colleague to double-check a medication calculation and the actual medication before administering which medications? Select all that apply. a. Antibiotics b. Insulin c. Anticonvulsants d. Anticoagulants e. Narcotics

ANS: B, D, E Feedback Correct The nurse should ask another nurse to check the dosage calculation and the medication before administering the following: insulin, narcotics, chemotherapy, digoxin or other inotropic drugs, anticoagulants, and K+ and Ca++ salts. Institutions may require two nurses to check other medications also to prevent medication error. Incorrect The nurse always double-checks a dosage calculation, but it is not necessary to have a second nurse check the medication before administering antibiotics.The nurse always double-checks a dosage calculation, but it is not necessary to have a second nurse check the medication before administering anticonvulsant medications.

12. What is the most important nursing action before discharge for a mother who is apprehensive about giving her child insulin? a. Review the side effects of insulin with the mother. b. Have the mother verbalize that she knows the importance of follow-up care. c. Observe the mother while she administers an insulin injection. d. Help the mother devise a rotation schedule for injections.

ANS: C Feedback A Although reviewing side effects is important, this could be done over the phone or by the pharmacist when the medication is picked up. B This is important but not directly relevant to the mother's concern. C It is important that the nurse evaluate the mother's ability to give the insulin injection before discharge. Watching her give the injection to the child will give the nurse an opportunity to offer assistance and correct any errors. D This is important, but not as important as having the mother demonstrate the procedure.

15. What action indicates that a school-age child is using a metered-dose inhaler correctly? a. The child uses his inhaled steroid before the bronchodilator. b. The child exhales forcefully as he squeezes the inhaler. c. The child holds his breath for 10 seconds after the first puff. d. The child waits 10 minutes before taking a second puff.

ANS: C Feedback A If one of the child's medications is an inhaled steroid, it should be administered last. B The child should inhale slowly as the inhaler is squeezed or depressed. C After a puff, the child should hold his breath for about 10 seconds or until he counts slowly to 5. D The child does not need to wait this long to take a second puff of medication. He can take a second puff after holding his breath for 10 seconds.

16. What action is appropriate when using an EMLA cream before intravenous catheter insertion? a. Rub a liberal amount of cream into the skin thoroughly. b. Cover the skin with a gauze dressing after applying the cream. c. Leave the cream on the skin for 1 to 2 hours before the procedure. d. Use the smallest amount of cream necessary to numb the skin surface.

ANS: C Feedback A The EMLA cream should not be rubbed into the skin. B After the cream is applied to the skin surface, it is covered with a transparent occlusive dressing. C The cream should be left in place for a minimum of 1 hour and no more than 2 hours. D The nurse should use a liberal amount of EMLA cream.

3. Which physiologic difference affects the absorption of oral medications administered to a 3-month-old infant? a. More rapid peristaltic activity b. More acidic gastric secretions c. Usually more rapid gastric emptying d. Variable pancreatic enzyme activity

ANS: D Feedback A Infants up to 8 months of age tend to have prolonged motility. The longer the intestinal transit time, the more medication is absorbed. B The gastric secretions of infants are less acidic than in older children or adults. C Gastric emptying is usually slower in infants. D Pancreatic enzyme activity is variable in infants for the first 3 months of life as the gastrointestinal system matures. Medications that require specific enzymes for dissolution and absorption might not be digested to a form suitable for intestinal action.

7. In which muscle should the nurse select to give a 6-month-old infant an intramuscular injection? a. Deltoid b. Ventrogluteal c. Dorsogluteal d. Vastus lateralis

ANS: D Feedback A The deltoid muscle is not used for intramuscular injections in young children. B The ventrogluteal muscle is safe for intramuscular injections for children older than 18 months. C The dorsogluteal muscle does not develop until a child has been walking for at least 1 year. D The vastus lateralis is not located near any vital nerves or blood vessels. It is the best choice for intramuscular injections for children younger than 3 years of age.

1. A student nurse on the pediatric unit is preparing gentamicin to administer intravenously. The student understands that she must apply the "five rights" when administering medications. Is this statement true or false?

ANS: F The student must adhere to the "six rights" of medication administration. This includes the right patient, rights drug, right dose, right time, right route, and right documentation.

2. The mucous membranes inside the nose allow for fairly rapid systemic absorption of overriding of a variety of medications. Antidiuretic hormone (DDAVP) is an appropriate medication to administer intranasally. Is this statement true or false?

ANS: T This is correct. Other medications that can be given by this route include fentanyl, ketamine, versed, and lorazepam. Otherwise, nose drops and sprays are used for localized treatment of the nasal passages.