PrepU 26. Emergency Care
The nurse is caring for a 4-year-old boy who is receiving mechanical ventilation. Which intervention is the priority when moving this child?
Checking the CO2 monitor for a yellow display Exhaled CO2 monitoring is recommended when a child has been intubated. It provides quick, visual assurance that the tracheal tube remains in place and that the child is being adequately ventilated.
Assessment of a child reveals a tension pneumothorax. The nurse would prepare the child for:
needle thoracotomy. A needle thoracotomy is indicated for tension pneumothorax to relieve the air collected in the space.
A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. What is the priority intervention?
Administer 100% oxygen by mask.
When assessing a client in an emergency situation, to guide the assessment the nurse should be aware that most pediatric cardio-pulmonary arrests stem from what cause?
Airway and breathing problems
The nurse is caring for a child who has had an endotracheal tube placed and is hooked to a ventilator. When assessing the child, the nurse notes that they child is exhibiting signs of poor oxygenation. What should the nurse do? Select all that apply.
Assess tracheal tube placement. Assess for the presence of decreased breath sounds on one side of the chest. Assess for tracheal tube obstruction. Assess the ventilator equipment, checking to see that all tubing is connected correctly.
Which medication is used for symptomatic bradycardia unresponsive to ventilation and oxygenation?
Atropine
The nurse is caring for a child who has recently been intubated. The nurse notes that the tracheal tube has an end-tidal CO2 monitoring device that is purple in color. What is the first intervention by the nurse?
Auscultate the chest to determine breath sounds Colors on the end-tidal CO2 device correspond with tracheal tube placement. Purple indicated little or no CO2 detected. Colorimetric end-tidal CO2 devices may at times fail to detect the presences of exhaled carbon dioxide, so the nurse should assess the client to determine if the endotracheal tube is still in place. The first step in determining tube placement is to auscultate the chest to determine the presence of bilateral breath sounds.
Which assessment finding would indicate to the health care team the child would need to be re-intubated due to improper placement of the endotracheal tube?
Breath sounds heard over the abdominal area
When a poison has been ingested by a child, what should the parents do first?
Call the local poison control center. Not all poisons should be vomited. Strong acids, for example, could cause as much destruction of tissue being vomited as being swallowed. The poison control center will provide the most accurate information on the next steps for the client.
The nurse must calculate the adolescent's cardiac output. The child's heart rate is 76 beats per minute and the stroke volume is 75 mL. Calculate the child's cardiac output. Record your answer using a whole number.
Cardiac output (CO) is equal to heart rate (HR) times ventricular stroke volume (SV). That is, CO = HR x SV 76 beats per minute x 75 mL = 5,700
The condition of an 11-year-old boy who is on mechanical ventilation begins to deteriorate. What action would the nurse do next?
Check to see if the tracheal tube is displaced.
Administration of which medication reverses the histamine release and hypotension that are seen in anaphylaxis?
Epinephrine
The off-duty nurse is in the park and is present when a child collapses. Which step should be performed first?
Implement head tilt-chin lift maneuver.
The nurse is caring for a child brought to the emergency room by the babysitter. The babysitter reports the child was playing and acting "fine" but started to be "sick and get worse" all of a sudden after lunch. The babysitter denies any obvious reason or situation leading to the child's decline. What would the nurse further assess for?
Ingestion of a toxin
When attempting to locate the pulse of child found in a state of collapse, how much time should be taken?
No more than 10 seconds
The nurse is mentoring a newly licensed nurse collecting a sample for a urinalysis on an 11-year-old female. Which actions by the newly licensed nurse would require the nurse to intervene?
Obtaining the specimen via indwelling catheter Educating the parent the urinalysis will determine if the child has been taking illicit substances
The parents of a preschool child are distraught as they carry their limp child into the emergency room. The parents report the child fell approximately 10 foot from a large slide and hit his head "hard enough to knock him out." What is the nurse's next action?
Perform a jaw-thrust technique to assess the patency of the airway
The nurse provides frequent and ongoing assessments for the child who is intubated and on mechanical ventilation. What assessment findings would be concerning for the nurse?
The child's pulse oximeter ranges from 85% to 90% The breath sounds are greater on the right side
The health care team prepares to intubate the pediatric child. What is the advantage of premedicating the child prior to intubation?
Reduces the risk of increased intracranial pressure in the child
Which nursing diagnosis would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub?
Risk for suffocation
The nurse is ventilating a 9-year-old girl with a bag valve mask. Which action would most likely reduce the effectiveness of ventilation?
Setting the oxygen flow rate at 15 L/minute An adolescent, not a 9-year-old, would most likely require an oxygen flow rate of 15 L/minute for effective ventilation.
The nurse is participating in performing cardiopulmonary resuscitation for an 8-year-old child. Which findings indicate the need to review and modify the technique being used? Select all that apply.
The chest is rising on the right side and not on the left side. The abdomen begins to distend.
The nurse prepares to defibrillate a child weighing 38 pounds. The nurse would plan to administer how many joules of energy initially?
The nurse would plan to administer 2 joules/kg. 38 pounds/2.2 = 17.27 kg x 2 = 35 joules
The child's physician requests that the nurse should notify her if the child's urine output is less than 1 mL/kg of body weight each hour. The child weighs 56 lb (25.46 kg). Calculate the minimum amount of urine output the child should produce each hour. Record your answer using a whole number.
Urine output should be calculated using weight in kilograms. 25.46 kg x 1 mL/kg = 25.46 mL/hour The child must produce 25 mL/hour
The child presents to the emergency department via ambulance in uncompensated SVT at a rate of 262 beats per minute. The nurse receives an order to administer adenosine IV. In addition to adenosine, what would the nurse bring to the bedside in preparation to administer the adenosine?
A generous saline flush to follow the IV medication
The nurse is preparing to insert an oropharyngeal airway. Which action would be most appropriate to determine the proper size?
Placing the airway next to the cheek with tip pointing down The nurse determines the correct size by placing it next to the child's cheek with the tip pointing down. An airway that is too large will extend past the angle of the child's mandible and can obstruct the glottic opening when inserted. Measuring the distance from the end of the nose to the tragus of the ear is appropriate for a nasopharyngeal airway. Looking at the child's fifth digit reflects the approximate diameter of the nasopharyngeal airway. Measuring from the tip of the nose to the earlobe to the middle area between the xiphoid process and umbilicus is used to determine the length of a nasogastric tube.
The nurse is assessing a child in the pediatric inpatient unit and notes mottling of the child's lower extremities. Which nursing actions would be appropriate? Select all that apply.
Monitor the child's oxygen saturation via pulse oximetry. Assess for signs of hypothermia and monitor the child's temperature. Provide simple, short explanations in order to decrease the child's anxiety level. The child may appear mottled (mark with spots or smears of color.) in response to poor oxygenation, hypothermia and stress
The nurse is preparing to assess and intubate a school-aged child who presents via ambulance to the emergency department. The child has been manually ventilated prior to arrival. The nurse obtains a nasogastric tube in preparation to care for the child for what reason?
The nasogastric tube will alleviate the air that may have accumulation of air in the stomach
A nurse manager is debriefing a group of co-workers who had just finished carding for a child who suffered a cardiac arrest. One of the co-workers stated, "Why did they let the family stay while we were working on the child?" What is the best response by the nurse?
"Allowing the family to stay during the resuscitation may assist the family in coping."
The nurse is collecting a brief health history from the parents of a 3-year-old child brought to the emergency department experiencing a cardiac emergency. What questions are appropriate for inclusion? Select all that apply.
"Has your child had any recent illnesses?" "What foods or drugs is your child allergic to?" "Tell me about any coughing or wheezing you may have noticed when your child has been playing lately."
The nurse has completed teaching a CPR course for a local day care. Which statement by a participant indicates a need for further education?
"I will place the heel of my hand on the sternum of a 9-month-old when performing CPR."
The nurse is assessing a 5-year-old. The child's blood pressure is 84/42. The child's mother asks if this is normal. What is the best response by the nurse?
"It's fine. The lowest acceptable top number of a blood pressure for a 5-year-old is 80." According to PALS, the minimum acceptable systolic BP is 60 for the neonate, 70 for the infant aged 1 to 12 months, and 70 + twice the age in years for children aged 1 to 10 years. For this child a minimum systolic BP would be 80 (70 + (5 x 2) = 80.
The nurse is assisting with the intubation of a 6-year-old child and is gathering the necessary equipment. The nurse determines that the child needs which size tracheal tube?
5.5 To determine tracheal tube size, divide the child's age by 4 and add 4. The resulting number will indicate the size of the tracheal tube in millimeters. For this child, 6/4 + 4 = 5.5.
A 6-year-old girl in shock is receiving dobutamine. What would the nurse most likely do?
Monitor for ventricular arrhythmias.
The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of:
respiratory failure.
The school-aged child presents to the emergency room with suspected sepsis. What labs would the nurse expect the health care provider to order? Select all that apply.
Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) Spinal fluid culture Urine culture
A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which action should the nurse take first?
Establish a suitable IV site.
The nurse is assessing a 6-month-old boy in the emergency room after the parents report the child fell off the parents' bed, hitting his head. Which assessment findings would alert the nurse to neurological compromise in the infant?
Right pupil is dilated, unreactive to light No spontaneous movement of the legs or arms
After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next?
Assess level of consciousness. Once the ABCs are completed, the nurse's next step is to assess the child's level of consciousness or disability. This would be followed by removing the child's clothing and diaper (exposure) to assess for underlying signs of illness or injury. Next, full vital signs are taken while facilitating the family presence, followed by giving comfort by managing pain and providing emotional support. The acronym ABCDEFG is a useful reminder of the order of assessment: airway, breathing, circulation, disability, exposure, full vital signs and facilitating family, and giving comfort.
The nurse has administered IV adenosine as ordered to a child with supraventricular tachycardia. Which action would the nurse do next?
Administer a rapid generous saline flush. Administration of IV adenosine should be followed immediately by a rapid generous saline flush. Adenosine is given rapidly over 1 to 2 seconds and repeated every 1 to 2 minutes to a maximum dose of 0.3 mg/kg. Five positive-pressure ventilations are given after atropine, which is diluted with 3 to 5 mL of normal saline, is given via the tracheal route.
The nurse receives shift report from the previous shift on several pediatric clients. For which child would the nurse further assess the electrolyte levels immediately following report?
The 15-year-old who had a resolved episode of ventricular tachycardia the previous shift Abnormalities of potassium, and hypokalemia have been associated with the development of ventricular tachycardia in children.
