Chapter 40: Nursing Care of the Child With an Alteration in Gas Exchange/Respiratory Disorder

A client asks the nurse why a healthy newborn would be at risk for hypoxemia. How should the nurse reply?

"A newborn only has half of the number of alveoli developed, placing the newborn at risk." Alveoli begin developing in the fetus at 24 weeks' gestation. In a healthy newborn born at term, there are approximately 150 million alveoli present. The number of alveoli duplicate until the adult number of 300 million are present somewhere between 3 and 8 years of age. The smaller numbers of alveoli place the newborn at a higher risk for hypoxemia and carbon dioxide retention because this is where gas exchange occurs. This is also more pronounced if the newborn is premature. Newborns consume twice as much oxygen (6 to 8 L) as adults (3 to 4 L). This is due to higher metabolic and resting respiratory rates. The shape of the chest and smaller airways contribute to adequate oxygenation for the size of the newborn. They do not place the newborn at high risk for hypoxemia. Newborns do have smaller lung volumes, but these volumes are adequate for the size and grow as the newborn grows.

A 4-year-old with bronchiolitis has been admitted to the hospital with respiratory compromise. The father asks the nurse why the physician won't prescribe an antibiotic, "My child just keeps getting worse." What is the best response by the nurse?

"Bronchiolitis is almost always caused by the respiratory syncytial virus (RSV). Unfortunately, antibiotics don't work on viruses." Bronchiolitis is an acute inflammatory process of the bronchioles and small bronchi. Nearly always caused by a viral pathogen, respiratory syncytial virus (RSV) accounts for the majority of cases of bronchiolitis; therefore, antibiotic therapy is not warranted.

A 4-week-old infant is diagnosed with acute bronchiolitis. The parent states, "I do not know how the baby got this!" How should the nurse respond?

"Has your infant been around any crowds?" Acute bronchiolitis is caused by a viral infection, most often, respiratory syncytial virus. Viruses are often spread between groups of people in close contact. Hereditary and environmental complications do not relate to this disorder.

A child with asthma has been monitoring his peak expiratory flow rate (PEFR) and has been maintaining it within 90% of his personal best. Today, the child is experiencing symptoms and his PEFR is at 40% of his personal best. The child's mother calls the office and asks the nurse what she should do. What would the nurse instruct the mother to do first?

"Have him use his short-acting bronchodilator right away." The child's symptoms and drop in PEFR suggest a medical alert or "red" situation, indicating the need for the short-acting bronchodilator and then a trip to the office or emergency department. The child should use his short-acting bronchodilator first and then go to the physician's or nurse practitioner's office or emergency room. Waiting for a greater drop in his PEFR readings would be inappropriate because the child is experiencing an acute condition that warrants immediate attention. The child is experiencing an acute situation and requires immediate attention. A low-dose steroid inhaler would not be appropriate because it would not help his bronchospasm.

The nurse is caring for a 10-year-old girl with cystic fibrosis who receives pancreatic enzymes. Which comment by a parent demonstrates understanding of the instructions regarding the medication?

"I should give the enzymes before each meal or snack." The enzymes are necessary for appropriate digestion and absorption of food and nutrients. There is no interaction between enzymes and antibiotics. Large, malodorous stools are a sign of no pancreatic enzyme activity. Pancreatic enzymes must be given each time the child eats, usually in smaller doses for snacks than for meals.

The nurse is auscultating the lungs of a lethargic, irritable 6-year-old boy and hears wheezing. The nurse will most likely include which teaching point if the child is suspected of having asthma?

"I'm going to have this hospital worker take a picture of your lungs." The nurse should teach the child using terms a 6-year-old will understand. A chest x-ray is usually ordered for the assessment of asthma to check for hyperventilation. A sputum culture is indicated for pneumonia, cystic fibrosis, and tuberculosis; fluoroscopy is used to identify masses or abscesses as with pneumonia; and the sweat chloride test is indicated for cystic fibrosis.

The nurse is providing education to a client newly diagnosed with asthma. Which statement by the parents indicates additional teaching is needed?

"It is okay for our child to do chores such as sweeping the floor." Sweeping the floor can trigger a child's asthma by making environmental allergens and irritants airborne, causing upper respiratory infections. The nurse will intervene if the parents make this statement. An inhaler should be with the child at all times in case of an asthma attack. Smoke and pet allergens can trigger an attack and exposure should be avoided. Other triggers are exercise, weather changes, air pollution, foods, and certain medications.

The nurse working at the child community clinic must administer the influenza vaccine to the high-risk children first. Which child would she choose first?

23-month-old client who had heart surgery as an infant for a defect Children who are considered high risk and could benefit from the influenza vaccine are: immunocompromised have a chronic pulmonary disease have had a congenital abnormality chronic renal or metabolic disease sickle-cell disease HIV any type of neurological disorder (seizures) The other choices would be considered normal and the child is not at high risk.

The nurse notes a 3-year-old child is restless, has a respiratory rate of 55 breaths/minute, and has an oxygen saturation of 90%. Which action will the nurse take first?

Apply oxygen via a facemask. Oxygen is the most indicated treatment and is needed to increase low partial pressure of oxygen (PaO2) levels in the blood. The child is showing signs of hypoxemia and needs oxygen. The nurse will notify the health care provider after administering oxygen. Respiratory therapy and breathing treatments may be needed based on the child's response to oxygen.

Pancreatic enzymes are part of the treatment in cystic fibrosis. When should the nurse administer the enzymes?

Before meals and snacks with milk Enzymes should be administered before all meals and snacks to help in normal absorption of nutrients from the food. The other choices do not promote absorption of foods or are not taken with food.

The nurse is caring for a 14-month-old boy with cystic fibrosis. Which sign of ineffective family coping requires urgent and immediate intervention?

Compliance with therapy is diminished. Until the family adjusts to the demands of the disease, they can become overwhelmed and exhausted, leading to noncompliance, resulting in worsening of symptoms. Typical challenges to the family are becoming overvigilant, the child feeling fearful and isolated, and the siblings being jealous or worried, but these are not a priority over the noncompliance.

An 8-year-old with cystic fibrosis has had a noted decline on the growth chart. Which nursing intervention is best for maintaining adequate nutrition?

Encourage high calorie, high protein snacks. The best nursing intervention is a high calorie, high protein snack. Calories can be obtained from non-nutritious foods. It is not only that the client needs calories for energy, but nutrition needs to be present. Pancreatic enzymes aid in digestion so they need to be available for foods; thus they are given prior to ingestion. Sodium is encouraged due to the high sodium loss.

During a class for caregivers of children with asthma, a caregiver asks the nurse the following question when medications are being discussed. "They told me about a plastic device my child can hold in his a hand which will give him a premeasured and exact amount of his corticosteroid." The nurse recognizes that the caregiver is most likely referring to which device?

Metered-dose inhaler In the treatment of asthma, corticosteroids are most often delivered by metered-dose inhaler ([MDI], which is a hand-held plastic device that delivers a premeasured dose). The medication cup and needleless syringe may deliver PO medications, but most often corticosteroids are not given PO in the treatment of asthma, and those would not be premeasured and an exact dosage like a metered-dose inhaler would be. Corticosteroids are not administered by nebulizer.

A child presents to the health clinic with a temperature of 101.8°F (38.8°C), dysphagia, headache, and a sore, erythematous throat. Which collaborative intervention will the nurse complete first?

Obtain a throat culture. A child presenting with fever, dysphagia, headache, and a sore, erythematous throat may have viral or bacterial pharyngitis. The nurse's first action should be to obtain a throat culture to determine if the child has a bacterial or viral infection. If the throat culture is negative, the child will not require antibiotics. If the culture is positive, the child will need antibiotics. Saltwater gargles will help relieve pain, but this is not a priority. Children with streptococcal pharyngitis may develop a sandpaper rash, but this information alone is not conclusive, and a throat culture should be obtained prior to administering antibiotics.

The nurse is caring for a 7-year-old boy who has just had a tonsillectomy. Which intervention is least appropriate for this child?

Providing fluids by straw Providing fluids by straw may cause trauma to the surgical site and should be avoided. Applying an ice collar, if ordered, helps relieve pain. Placing the child on his side, until he is fully awake, facilitates safe drainage of secretions. The child should be discouraged from coughing, clearing his throat, and blowing his nose to avoid trauma to the surgical site.

During an assessment, a child exhibits an audible high-pitched inspiratory noise, a tripod stance and intercostal retractions. Using SBAR communication, the nurse notifies the health care provider and states which breath sounds that are congruent with the clinical presentation of the child?

Respiratory stridor Stridor is a high-pitched, readily audible inspiration noise that indicates an upper airway obstruction. The child presents in severe respiratory compromise and struggles to breathe. A wheeze is a high-pitched sound heard on auscultation, usually on expiration. It is due to obstruction in the lower trachea or bronchioles. Rales are crackling sounds heard on auscultation when the alveoli become fluid filled. Rhonchi is a snoring sound heard throughout the lung field when inflammation occurs.

Which electrolyte does the client with cystic fibrosis need in abundance?

Sodium Dietary intake of sodium is encouraged due to increased sodium losses. Clients are especially encouraged to eat salty pretzels, potato chips, etc. during hot weather or when sodium losses are anticipated.

The nurse is caring for a child who has been admitted with a possible diagnosis of cystic fibrosis. Which laboratory/diagnostic tools would most likely be used to help determine the diagnosis of this child?

Sweat sodium chloride test Sweat sodium chloride tests are used for determining the diagnosis of cystic fibrosis. Purified protein derivative tests are used to detect TB. Blood culture and sensitivity is done to determine the causative agent as well as the anti-infective needed to treat an infection. Pulmonary function tests are diagnostic tools for the child with asthma and indicate the amount of obstruction in the bronchial airways, especially in the smallest airways of the lungs.

The nurse is taking a health history for a 3-year-old girl suspected of having pneumonia who presents with a fever, chest pain, and cough. Which information places the child at risk for pneumonia?

The child attends day care. Attending day care is a known risk factor for pneumonia. Being a triplet is a factor for bronchiolitis. Prematurity rather than postmaturity is a risk factor for pneumonia. Diabetes is a risk factor for influenza.

The nurse has assessed a 6-year-old child as having respiratory distress due to swelling of the epiglottis and surrounding structures. Which signs and symptoms would support this assessment?

The child is in tripod position. Inflammation and swelling of the epiglottis and surrounding structures are common in children ages 2 to 7 years. The child will attempt to improve his/her airway by sitting forward and extending the neck forward with the jaw up, in a "sniffing position" (tripod position). Being pale, vomiting, and having elevated patches on the skin are not associated with epiglottis. Stridor, tachycardia, and the rapid onset are classical signs of epiglottitis.

A nurse is caring for an infant admitted with a diagnosis of bronchiolitis. After completing an assessment, the nurse creates a plan of care for the infant. Which client goal would be priority in the plan of care?

The infant's airway will remain clear and free of mucus. Keeping the infant's airway clear is the top priority. An O2 saturation of 90% on room air is minimally acceptable. It is important that the infant's breathing be less labored and that there is decreased nasal stuffiness, but having the airway clear and free of mucus is most important.

The nurse is taking a respiratory history of a newly admitted child. While documenting the symptoms the child has, what other item is important to document when taking a history on an altered respiratory status?

The triggers in the environment When assessing a respiratory history, it is very important for the nurse to find out what in the environment worsens the child's symptoms. These are called "triggers." The other choices would be part of a general health history.

The nurse at a camp for children with asthma is teaching these children about the medications they are taking and how to properly take them. The nurse recognizes that many medications used on a daily basis for the treatment of asthma are given by which method?

Using a nebulizer Many of these drugs used in the treatment of asthma can be given either by a nebulizer (tube attached to a wall unit or cylinder that delivers moist air via a face mask) or a metered-dose inhaler ([MDI], which is a hand-held plastic device that delivers a premeasured dose). Emergency medications are given intravenously. Most children do not have a gastrostomy tube, and medications sprinkled on foods are given with cystic fibrosis.

The nurse has administered an intradermal injection of 0.1 ml of purified protein derivative. During which time frame will the nurse evaluate the site for reactions?

Within 48 to 72 hours Clients who have had a tuberculin skin test will need to return to the facility to have the site evaluated for a reaction within 48 to 72 hours. Redness, swelling, induration, and itching are signs of a positive reaction.

The student nurse is collecting data on a child diagnosed with cystic fibrosis and notes the child has a barrel chest and clubbing of the fingers. In explaining this manifestation of the disease, the staff nurse explains the cause of this symptom to be:

chronic lack of oxygen. In the child with cystic fibrosis the development of a barrel chest and clubbing of fingers indicate chronic lack of oxygen. Impaired digestive activity may occur due to a lack of pancreatic enzymes. The high sodium concentration makes the child taste salty, but is not related to the barrel chest and clubbing of the fingers. Respiratory issues are a concern, but the barrel chest and clubbing of the fingers are not because of the child's respiratory capacity.

The nurse is collecting data on a child admitted with a respiratory concern. The nurse notes that the child is anxious and sitting forward with the neck extended to breathe. The signs the nurse noted indicate the child likely has:

epiglottitis. The child with epiglottitis is very anxious and prefers to breathe by sitting forward with the neck extended. Immediate emergency attention is necessary. The child with asthma would have wheezing and distress trying to breathe. The child with cystic fibrosis would not have respiratory distress unless ill with respiratory infection. The drooling, leaning forward, and appearing distressed are not manifestations of TB.

What is a symptom of bacterial pharyngitis?

fever Bacterial pharyngitis is most often caused by group A streptococcus. Fever is a symptom of bacterial pharyngitis. Other symptoms are an elevated WBC count, abrupt onset, headache, sore throat, abdominal discomfort, enlargement of tonsils, and firm cervical lymph nodes. It must be treated with an antibiotic. Penicillin is the drug of choice. Symptoms of rhinitis, a normal WBC count, and slow onset are indicative of viral pharyngitis.

A nurse is providing supplemental oxygen therapy to a young child. Based on the nurse's understanding of oxygen delivery methods, what would the nurse expect to be used to deliver the highest concentration of oxygen to the child?

nonrebreather (face) mask A nonrebreather (face) mask provides 95% oxygen concentration. An oxygen hood provides up to 80% to 90% oxygen concentration. This delivery method is used only for infants. A partial rebreather mask provides 50% to 60% oxygen concentration. A Venturi mask provides 24% to 50% oxygen concentration.

What is a complication of cystic fibrosis?

pneumothorax Cystic fibrosis (CF) is a genetic disorder causing thickened tenacious secretions of the sweat glands, gastrointestinal tract, pancreas, respiratory tract and exocrine tissues. The treatment is aimed at minimizing pulmonary complications, maximizing lung function, preventing infection, and facilitating growth. A pneumothorax is a complication of CF. A rupture of the subpleural blebs through the visceral pleura takes place. There is also a high reoccurrence rate and incidence increases with age. Crohn disease is a gastrointestinal disorder that is not associated with cystic fibrosis. Urinary tract infection and kidney disease are also not associated with CF. Most of the problems and complications associated with CF relate to the respiratory system, the gastrointestinal system, and infectious disorders.

The nurse has received morning report on a group of pediatric clients. For which pediatric client should the nurse prioritize care?

school-aged child with dysphagia, drooling, and a hoarse voice The school-aged child shows signs and symptoms of epiglottitis and should be seen first because epiglottitis is an emergency that can quickly cause airway obstruction. The infant exhibits signs of bronchiolitis and an oxygen saturation of 92%. The infant is more stable than the child with epiglottitis, as is the toddler with signs of croup and the preschool-aged child with signs and symptoms of pneumonia.

After teaching the parents of an 8-year-old girl with asthma about common allergens their child should avoid, the nurse determines that the parents need additional teaching when they identify what as a common allergen for asthma?

shellfish Eating shellfish is not a typical asthma trigger. Allergic reactions can occur with shellfish, but usually not an exacerbation of asthma. Indoor molds, pet dander, and dust mites are common asthma triggers.

The nurse is assessing a 7-year-old boy with pharyngitis. What assessment finding would suggest the child has developed a peritonsillar abscess?

shifting uvula Peritonsillar abscess may be noted by asymmetric swelling of the tonsils and shifting of the uvula to one side. Difficulty swallowing, sore throat, and headache are consistent with pharyngitis, as is the rash, which would be fine, red, and sandpaper-like (called scarlatiniform) but do not indicate a peritonsillar abscess.

An 8-year-old client is suffering from allergic rhinitis (hay fever). Which statement will the nurse include when providing education to the client's caregiver?

"Pollen is a cause of these symptoms. Allergy medicine may help your child." The allergens that usually cause allergic rhinitis (hay fever) are pollens or molds rather than foods or drugs. Over-the-counter or prescription allergy medications may help provide relief for these clients when taken. Peanuts and soap are not associated with allergic rhinitis. Antibiotics are used to treat bacterial infections, not allergic responses in clients.

A 3-year-old child with asthma and a respiratory tract infection is prescribed an antibiotic and a bronchodilator. The nurse notes the following during assessment: oral temperature 100.2°F (37.9°C), respirations 52 breaths/minute, heart rate 90 beats/minute, O2 saturation 95% on room air. Which action will the nurse take first?

Administer the bronchodilator via a nebulizer. The nurse would first administer the bronchodilator to open the child's airway and facilitate breathing. Once the airway was open, the nurse could administer oxygen, if indicated. At this time, the child's saturation level is normal but it should be monitored. The nurse would then administer the antibiotic medication. The heart rate is within normal range for a child of this age (65 to 110 beats/minute); therefore, a cardiac monitor is not needed at this time.

The nurse notices that a child is spitting up small amounts of blood in the immediate postoperative period after a tonsillectomy. What would be the best intervention?

Continue to assess for bleeding. Children will have a small amount of blood mixed with saliva following a tonsillectomy. Suctioning or coughing could irritate the surgical site and cause hemorrhage.

What is the most common debilitating disease of childhood among those of European descent?

Cystic fibrosis Cystic fibrosis is the most common debilitating disease of childhood among those of European descent. Medical advances in recent years have greatly increased the length and quality of life for affected children, with median age for survival being the late 30s.

Which clinical manifestation of acute nasopharyngitis is more of a concern for the infant than the older child?

Nasal congestion The infant has smaller airways, making it more difficult to breathe when nasal congestion occurs. The older child can tolerate the congestion better than the infant with smaller airways. Depending upon the age of the child, younger infants are afebrile. Vomiting and diarrhea can occur at any age as the mucus from the nasal drainage enters the gastrointestinal tract.

Upon providing discharge instructions home after a tonsillectomy and adenoidectomy, which is most important?

Note any frequent swallowing. A complication of a tonsillectomy and adenoidectomy is bleeding. If the child is bleeding he or she must be brought to the emergency room immediately. To determine if a child is bleeding, the parents must assess for frequent swallowing. All of the other discharge instructions are appropriate, but noting any frequent swallowing is the priority.

The nurse is caring for a 6-week-old with symptoms of irritability, nasal stuffiness, difficulty drinking and occasional vomiting. Which assessment finding produces important information regarding the medical and nursing treatment plan?

Obtain testing for respiratory syncytial virus. The symptoms presented are of acute nasopharyngitis. Many times this is viral in nature and can be common in the very young from respiratory syncytial virus (RSV). RSV is tested by obtaining nasal secretions and sending to the lab. A 6-week-old may rub his/her face but is too young for the "allergic salute," which is done to relieve itching and open nasal pathways. Vital signs can be helpful to note the beginning of an infectious process.

The nurse is administering medications to a child with cystic fibrosis. Which method would the nurse most likely use to give medications to treat the pancreatic involvement seen in this disease?

Open capsule and sprinkle on food. Pancreatic enzymes should be administered at all meals and snacks to promote adequate digestion and absorption of nutrients. They are supplied in capsule form. For the infant and young child, they can be opened and sprinkled on foods such cereal, pudding, or applesauce. They also can be swallowed whole. They are not supplied in liquid form, so the child could not take them in a medication cup. They are not supplied for injection or inhalation, only oral use.

The nurse is reinforcing teaching about medications with the parents of a 2-year-old who has cystic fibrosis. The nurse suggests that pancreatic enzymes may be given by which method?

Sprinkled onto the food Pancreatic enzymes are used in the treatment of cystic fibrosis and are given by opening the capsule and sprinkling the medication on the child's food. If the child with cystic fibrosis has an infection, IV medications may be given, but this is not on a daily basis. Most children do not have a gastrostomy tube. Many of these drugs used in the treatment of asthma can be given either by a nebulizer (tube attached to a wall unit or cylinder that delivers moist air via a face mask) or a metered-dose inhaler [MDI], which is a hand-held plastic device that delivers a premeasured dose.

The nurse sees a 3-year-old child in the ambulatory setting for localized wheezing on auscultation. Which statement by the parent would be most important to report to the health care provider?

The child was eating peanuts yesterday. Aspiration can cause airway mucosal inflammation. When aspiration from a small object occurs, the child may cough and gasp for a few seconds to a few minutes. Following that, the child may not be symptomatic for a day or longer. The aspiration of a foreign body may mimic an asthma attack, but an asthma attack would have generalized wheezing. Localized wheezing suggests only a small portion of a lung is involved, such as occurs following aspiration. Allergic situations cause early symptoms such as rash development and are generally not genetic or inherited in nature. The US Centers for Disease Control and Prevention recommends children receive pneumococcal vaccine series before 2 years of age, usually at 2, 4, and 6 months.

The caregivers of an 8-year-old bring their child to the pediatrician and report that the child has not had breathing problems before, but since taking up lacrosse the child has been coughing and wheezing at the end of every practice and game. Their friend's child has often been hospitalized for asthma; they are concerned that their child has a similar illness. The nurse knows that because the problems seem to be directly related to exercise, it is likely that the child will be able to be treated with:

a bronchodilator and mast cell stabilizers. Mast cell stabilizers are used to help decrease wheezing and exercise-induced asthma attacks. A bronchodilator often is given to open up the airways just before the mast cell stabilizer is used. Corticosteroids are anti-inflammatory drugs used to control severe or chronic cases of asthma. Leukotriene inhibitors are given by mouth along with other asthma medications for long-term control and prevention of mild, persistent asthma.

A group of nursing students are reviewing information about variations in the anatomy of a child's respiratory tract structures in comparison to adults. The students demonstrate an understanding of the information when they describe the shape of the larynx in infants as:

funnel. In infants and children (younger than the age of 10 years), the cricoid cartilage is underdeveloped, resulting in laryngeal narrowing and a funnel-shaped larynx. In teenagers and adults, the larynx is cylindrical and fairly uniform in width.

The mother of a child with asthma tells the nurse that she occasionally gives her child the steroid medicine she takes for her rheumatoid arthritis when the child has a "flare-up" of asthma. "It's easier than going to the hospital or doctor every time a flare-up happens," the mother says. What is the best response by the nurse?

"I'm sure it must be difficult to cope with the flare-ups, but there are many side effects from steroid use and the physician needs to monitor your child's asthma symptoms." Showing empathy for the parent is important when explaining the possibility of the steroid's side effects and the importance of the physician monitoring the child's asthma. Just listing all of the side effects of the steroid is not therapeutic communication and doesn't address the need for the child to be seen by the physician. Scolding the parent by telling her that she should never give her child her medication does not encourage good rapport. Giving the child the mother's medication even "occasionally" is not advisable.

A nurse is caring for an infant diagnosed with bronchiolitis due to respiratory syncytial virus (RSV) infection. The infant is scheduled to be discharged home and the nurse is preparing discharge instructions for the parents. What information should the nurse include in the instructions? Select all that apply.

-Be aware that your infant may continue to cough for up to 2 weeks. -It is important for all family members to wash their hands frequently. -Contact the health care provider if you notice signs of worsening disease. Good hand hygiene, notifying the health care provider of signs of a worsening condition, and the possibility that the infant may have a cough for up to 2 weeks are all important to include in the discharge instructions. Follow-up with the health care provider should be within 48 hours of discharge, not 2 weeks. There is no need to isolate the infant at home for 2 weeks.

A 5-year-old girl who was already admitted to the hospital for an unrelated condition suddenly becomes irritable, restless and anxious. These may be early signs of respiratory distress in a child if accompanied by:

tachypnea. Restlessness, irritability, and anxiety result from difficulty in securing adequate oxygen. These might be very early signs of respiratory distress, especially if accompanied by tachypnea (an increased respiratory rate). Retractions can be a sign of airway obstruction but occur more commonly in newborns and infants than in older children. Cyanosis (a blue tinge to the skin) indicates hypoxia, which may be a sign of airway obstruction but would not be the first. Children with chronic respiratory illnesses often develop clubbing of the fingers, a change in the angle between the fingernail and nailbed because of increased capillary growth in the fingertips. Clubbing would not occur in an acute airway obstruction, as is indicated in the scenario above.

The caregivers of a child report that their child had a cold and complained of a sore throat. When interviewed further they report that the child has a high fever, is very anxious, and is breathing by sitting up and leaning forward with the mouth open and the tongue out. The nurse recognizes these symptoms as those seen with which disorder?

Epiglottitis The child with epiglottitis may have had a mild upper respiratory infection before the development of a sore throat, and then became anxious and prefers to breathe by sitting up and leaning forward with the mouth open and the tongue out. The child with tonsillitis may have a fever, sore throat, difficulty swallowing, hypertrophied tonsils, and erythema of the soft palate. Exudate may be visible on the tonsils. The child with acute laryngotracheobronchitis develops hoarseness and a barking cough with a fever, cyanosis, heart failure; acute respiratory embarrassment can also result.

The nurse caring for a school-aged client with cystic fibrosis aims to have the client meet the goal of adequate nutritional intake to compensate for decreased absorption of nutrients. What is the best indication that this is met?

The client is within the 20th percentile for height and weight. The client demonstrates adequate nutritional intake to compensate for decrease absorption of nutrients by remaining within normal limits on the growth chart and in the 20th percentile. A growth chart displays long-term trends in growth, making that method of assessment preferred over one visit. Intellectually, there are no deficits in a school-aged child with cystic fibrosis. Subjective data of being full at the end of meals is not an indicator of nutrients being absorbed.

The nurse has assessed four clients. Which assessment finding warrants immediate action?

1-week old newborn with nasal congestion Until 4 weeks of age, newborns are obligatory nose breathers and breathe only through their mouths when they are crying. The newborn cannot automatically open the mouth to breathe if the nose is obstructed; therefore, a newborn with nasal congestion needs immediate action. Also, the newborn and young infant have very small nasal passages, so when excess mucus is present, airway obstruction is more likely. Mouth breathing may occur when a large amount of nasal congestion is present. Although this finding is abnormal and warrants follow up, in a 6-year-old child this finding does not warrant immediate action. Through early school-age, children tend to have enlarged tonsillar and adenoidal tissue even in the absence of illness; therefore, this finding is normal in a 4-year-old child and does not warrant immediate follow up. The frontal sinuses and the sphenoid sinuses develop by age 6 to 8 years; therefore a 10-year-old child may develop a sinus infection. Although these symptoms warrant follow up, immediate action is not necessary.

Which nursing diagnosis would best apply to a child with allergic rhinitis?

Pain related to sinus edema and headache Many children with allergic rhinitis develop sinus headaches from edema of the upper airway. In younger children the maxillary and ethmoid sinuses are involved. In children aged 10 years and older the frontal sinuses are also involved. The pain comes from mucosal swelling, decreased ciliary movement and a thickened nasal discharge. Nosebleeds are not common with either allergic rhinitis or sinusitis nor are either of these inherited. The eustachian tubes would cause symptoms of otitis, not of the nasal passage.

The caregivers of a child who was diagnosed with cystic fibrosis 5 months ago report that they have been following all of the suggested guidelines for nutrition, fluid intake, and exercise, but the child has been having bouts of constipation and diarrhea. The nurse tells the caregiver to increase the amount of which substance in the child's diet?

Pancreatic enzymes Adequate nutrition helps the child resist infections. Pancreatic enzymes must be administered with all meals and snacks. If the child has bouts of diarrhea or constipation, the dosage of enzymes may need to be adjusted. The child's diet should be high in carbohydrates and protein with no restriction of fats. The child may need 1.5 to 2 times the normal caloric intake to promote growth. Low-fat products can be selected if desired. The child also may require additional salt in the diet. Increased caloric intake compensates for impaired absorption.

The nurse is caring for a child with thickened pulmonary secretions. Which action(s) would the nurse use to assist the child breathe with less effort? Select all that apply.

-Perform chest physiotherapy -Encourage oral fluids Thickened pulmonary secretions occur with many respiratory disorders and illnesses. Encouraging oral liquids helps to thin the secretions so the child can easily cough them out. Chest physiotherapy is done to mobilize the secretions; therefore, the secretions are easier for the child to expectorate (spit out). Oxygen, if in use, should be humidified to avoid drying out the mucosa. The child should be observed for cyanosis and have pulse oximetry readings taken more frequently than every 12 or 24 hours. Often, the child is observed hourly or more.

A 4-year-old child has been admitted to the hospital with a diagnosis of pneumococcal pneumonia. The parents are extremely distraught over the child's condition and the fact that the child has not wanted to eat anything for the past 2 days. Which nursing approach would be most important to take to help alleviate the high anxiety level of the parents?

Allow the parents to remain with the child as much as possible. Pneumonia may be caused by many reasons: bacteria, viruses, fungus, and aspiration. If the child has mild symptoms (no respiratory distress) he or she may be treated at home. Hospitalization is required if the child has oxygen requirements, shows signs of respiratory distress, has poor oral intake, and has lethargy. Oxygen supplementation, IV fluids, and antibiotics will be necessary. It is very frightening for the parents to see their child so ill, and it is very frightening for the child to be so sick and be in a strange environment. The parents should be allowed to remain with their child at all times and their concerns should be addressed. The nurse should explain that not eating is part of the illness, but the child is being hydrated with IV fluids and will start eating as the illness improves. Telling the parents the child is receiving the best care possible does not address their concern of not eating. Parents should be educated on all aspects of the child's condition and prognosis.

Which measure would be most effective in aiding bronchodilation in a child with laryngotracheobronchitis?

Assisting with racemic epinephrine nebulizer therapy Croup is a viral infection that causes inflammation and edema of the larynx, trachea, and bronchi. One form of treatment is the use of nebulized racemic epinephrine. Racemic epinephrine is an alpha adrenergic agent. It works on the mucosal vasoconstriction to reduce the edema. This increases the lumen of airways, allowing for better intake of air. A child in respiratory distress is unable to take slow, deep breaths. The child should not be offered fluids because this is an aspiration risk and analgesics will not reduce swelling.

A 2-year-old toddler is seen for acute laryngotracheobronchitis. What observation would lead the nurse to suspect airway occlusion?

The respiratory rate is gradually increasing. Acute laryngotracheobronchitis is also know as croup. It produces edema of the larynx, trachea, and bronchi. An increasing respiratory rate, retractions, and nasal flaring are signs of major respiratory distress and occlusion. The toddler is breathing faster because less air is received with each breath. Nasal discharge is generally not seen with croup. The cough of croup is due to the inflammation in the larynx and trachea and it is a barking cough (sounds like a seal). A 2-year-old toddler will become tired and fall asleep or be irritable and unable to fall asleep. This age group is unable to verbalize being tired and wanting to sleep.

The nurse is planning care for a child with a pneumothorax. The nurse adds the nursing diagnosis, "Risk for injury related to potential dislodgement of chest tube" to the care plan. When writing the care plan, what should the nurse be sure to include as interventions?

-Ensure a pair of hemostats are at the bedside. -Monitor pulse oximetry readings. -Assess lungs as directed by the physician or as the client's condition warrants. -Maintain chest tube bottle in an upright position and below the level of the chest. If the tube becomes dislodged from the child's chest, the nurse must apply Vaseline gauze and an occlusive dressing to prevent air leakage into the pleural space. A pair of hemostats should be kept at the bedside to clamp the tube should it become dislodged from the drainage container. Pulse oximetry and lung assessments help ensure proper placement of the chest tube. To maintain proper drainage, the bottle must be kept upright and below the level of the chest.

The nurse is caring for a 5-year-old client and notes respiratory rate of 45 breaths per minute, blood pressure 100/70 mm Hg, heart rate 115, temperature 101°F (38.3°C), and oxygen saturation 86%. Which diagnostic test is priority for the nurse to complete?

Arterial blood gas (ABG) The most useful diagnostic test in respiratory distress is an ABG. Knowing normal blood gas values for children is very important for evaluation and proper treatment. A CBC is a blood test used to test for disorders including anemia, infection, and leukemia. An EEG is a test used to find problems related to electrical activity of the brain. A pulmonary function test is performed to evaluate the respiratory system. Based on the findings, the child is experiencing respiratory distress and has an elevated temperature. Airway and breathing are priority over an elevated temperature. The child's blood pressure is within normal range for this age.

A worried mother calls the nurse and tells her that her son has developed a horrible croup cough and is having trouble breathing. What would be the best intervention for the nurse to recommend to the mother?

Run a hot shower to fill the bathroom with steam and have the boy stay there. One emergency method of relieving croup symptoms is for a parent to run the shower or hot water tap in a bathroom until the room fills with steam, then keep the child in this warm, moist environment as this relaxes the airway tissues and widens the bronchi lumens. If this does not relieve symptoms, parents should bring the child to an emergency department for further evaluation and care. Caution parents not to give cough syrup routinely to children as many produce little effect and the risk of overdose, incorrect dosing, and adverse events is greater than the benefit of the syrup. An analgesic might help alleviate pain due to inflammation and irritation of the throat from coughing, but it is not the priority intervention in this case. Drinking would likely be painful for this child and would not provide lasting benefit.

A 9-year-old female child was brought to the emergency department after experiencing wheezing and shortness of breath while playing soccer. The parents administered two puffs of albuterol metered dose inhaler (MDI) with little effect, and 911 was notified. Paramedics applied oxygen 2 liters by nasal cannula for oxygen saturation of 90% on room air, and administered an albuterol nebulizer treatment. Audible wheezing was heard, and a 20-gauge intravenous (IV) catheter was inserted. Vital signs upon arrival at the emergency room: temperature, 98.8°F (37.1°C); heart rate, 125 beats/min; blood pressure, 88/50 mm Hg; respiratory rate, 32 breaths/min; oxygen saturation, 92% on simple face mask. Child appears anxious. The emergency room nurse should first ___________ then ___________.

The nurse should assess the child's airway first. Assessment should always be prioritized using the ABCs (airway, breathing, and circulation).Intravenous (IV) methylprednisolone should be administered promptly to decrease inflammation in the lungs, which will improve air flow. Circulation would be assessed after airway and breathing.Level of consciousness is simultaneously checked with ABCs (airway, breathing, and circulation), but the nurse must first perform a focused respiratory assessment and implement interventions promptly to prevent respiratory arrest.Metered-dose inhalers would not be used in status asthmaticus. Aerosol nebulizer treatments would be administered.Because the child is in severe respiratory distress, the nurse would not perform peak flow meter instruction at this time.

The nurse is preparing to administer albuterol to a 14-year-old client for the first time. Prior to administration, which adverse reaction is priority for the nurse to educate the client?

tachycardia Adverse reactions of albuterol, a bronchodilator, include tachycardia, nervousness, tremors, hyperactivity, malaise, palpitations, increased appetite, hypokalemia, and muscle cramps. The expected action of albuterol is to relax bronchial, uterine, and vascular smooth muscle by stimulating beta-2 receptors. While tachycardia and increased appetite are both adverse reactions, tachycardia happens abruptly following the first dose and can be alarming for clients. It is a priority for the nurse to provide education on this over a slower, less concerning change.