PrepU Vsim-Pediatric Case: Sabina Vasquez (Core) Pre/Post

While observing a patient demonstrating proper use of a peak flow meter, the nurse would expect the patient to demonstrate the following steps in which order?

1) Shake the arrow down to "0." 2) Stand up straight and take a deep breath. 3) Close lips tightly around mouthpiece. 4) Blow out hard and fast. 5) Note the number the arrow moves to. 6) Repeat two more times and record the highest reading. Rationale:A peak flow meter is used to determine a patient's lung capacity. Patients should obtain their "personal best" peak flow meter reading when they are feeling well and their asthma is under good control. The reading will be used as a baseline to compare future peak flow measurements and serves as a guide when planning treatment.

The nurse is educating the patient on how to use a metered-dose inhaler with a spacer properly. Place the following tasks in the appropriate order.

1) Shake the inhaler and remove the cap. 2) Attach the inhaler to the spacer. 3) Put spacer mouthpiece in the mouth. 4) Compress the inhaler and breathe in slowly. 5) Hold breath while counting to 10. Rationale:A spacer is recommended for use with metered-dose inhalers to increase the bioavailability of the medications within the lungs. For young children, a spacer with a mask can be used in place of the mouthpiece to increase compliance and effectiveness.

When teaching Sabina and her mother proper use of a peak flow meter, what is the best way for the nurse to determine whether the teaching has been effective?

Have Sabina demonstrate use of the peak flow meter with help from her mother Rationale:Return demonstration of equipment use is the most effective way to ensure that patients and families know how to use the equipment properly. Remediation

What is the best position in which to place a 5-year-old patient who is alert and experiencing respiratory distress to promote optimal respiratory function?

High Fowler's Rationale:Many patients in respiratory distress are most comfortable sitting upright, as this position allows for better diaphragmatic expansion and decreases the work of breathing. If the patient is unable to maintain his or her airway or has a decreased level of consciousness, supine positioning may be required to facilitate airway positioning for manual ventilation and intubation.

Which statement by Sabina's mother best indicates her understanding of controlling allergens as a component of asthma management?

I will replace the carpet in Sabina's room with hardwood flooring and mop weekly. Rationale:When possible, carpets should be replaced with solid-surface flooring, and the flooring should be mopped each week. If pet dander is an asthma trigger for the child, pets should be removed from the home permanently. If pets cannot be removed, it is important to keep them out of the bedroom and off the carpet and upholstered furniture to reduce exposure to pet dander. Patients with asthma should avoid going outdoors when mold, pollen counts, and pollution levels are high. It is important to avoid exposure to tobacco smoke. If the parents smoke and cannot quit, they should not smoke inside the house or car.

Which statement by a patient with severe persistent asthma indicates proper understanding of the use of controller medications? (Select all that apply.)

I will rinse my mouth out after using my corticosteroid inhaler., I will take my long-acting bronchodilator at the same time daily using a spacer. Rationale:Controller medications must be taken daily in order for them to be effective. Corticosteroids are not for treatment of acute shortness of breath or wheezing. A rescue medication such as a short-acting β2-agonist should be taken when experiencing symptoms of an asthma exacerbation including shortness of breath. Patients with severe persistent asthma are prescribed both a long-acting bronchodilator and inhaled corticosteroid. It is important to take the bronchodilator first prior to taking the steroid as it will help to open up the airways, allowing the second medication to better reach the lower airways to increase effectiveness. Rinsing the mouth after using inhaled corticosteroids helps to reduce the incidence of oral thrush.

A nurse is working with a patient who is having an acute asthma exacerbation. Which of the following would be the priority nursing diagnosis for the patient?

Ineffective airway clearance related to inflammation Rationale:The priority when caring for a patient in respiratory distress is to assess and maintain airway patency. The other diagnoses would be appropriate for a patient with an acute asthma exacerbation and respiratory distress, but they are not the priority.

A pediatric patient is brought to the clinic in respiratory distress. Upon assessment, the nurse notes that the patient is drowsy and pale and can only speak in short sentences. The pulse oximeter reading shows oxygen saturations of 88%. What action should the nurse take first?

Administer oxygen at 10 L/min via nonrebreather mask Rationale:The patient is showing signs of moderate to severe respiratory distress. Based on the symptoms, the patient needs a higher concentration of oxygen, and a nonrebreather mask can deliver up to 95% oxygen concentration with a liter flow rate of 10 to 12 L/min. A nasal cannula provides a low oxygen concentration of 22% to 44% with a maximum flow rate of 4 L/min in children. A short-acting β2-agonist (albuterol) and an anticholinergic (ipratropium) may be administered together to help produce bronchodilation of the airways, but the immediate priority is oxygenation. Furthermore, it would be difficult for the patient to receive an inhaled medication while experiencing respiratory distress.

A nurse is providing instruction to the parent of child with asthma regarding the effects of the medication the child has been prescribed. Which of the following correctly describes the mechanism of action of a short-acting β2-agonist?

Causes smooth muscle relaxation resulting in bronchodilation Rationale:Short-acting β2-agonists (i.e., albuterol, levalbuterol) cause bronchodilation by relaxing smooth muscles of the airway and are used to treat wheezing and bronchospasm in patients with asthma. Mast cell stabilizers, which prevent the release of histamine from sensitized mast cells, and oral corticosteroids, which suppress inflammation and normal immune response, are also used to treat symptoms associated with asthma. Expectorants, which reduce the viscosity of thickened secretions, are not used to treat asthma and can cause further airway irritation and constriction when used during an exacerbation.

A patient with mild intermittent asthma arrives at the clinic with a several-day history of upper respiratory infection and audible wheezing. What is the priority action for the nurse to take at this time?

Check the patient's airway for patency and complete a focused respiratory assessment. Rationale:The priority action is to assess the patient's airway and overall respiratory status. Although the other answers listed are appropriate actions to take with this patient, none is as important as checking the patient's airway for patency and completing a focused respiratory assessment as it is the most urgent.

A patient received a short-acting β2-agonist (albuterol) via metered-dose inhaler (MDI) for wheezing. Before the treatment, the patient's heart rate was 100, but now it is 125. The other vital signs are within normal limits. The patient reports feeling "a little shaky," but is otherwise fine. What is the most appropriate nursing action at this time?

Document the patient's response to treatment and explain it to the patient and family Rationale:Tachycardia and nervousness are common side effects of albuterol and in the absence of other symptoms are not a cause for alarm. The patient is not in distress and the side effects are short in duration.

The nurse is assessing a 5-year-old patient with suspected asthma. Which factors from the health history suggest asthma or a risk for asthma? (Select all that apply.)

Dyspnea with exercise Cough, especially at night Seasonal pollen allergies Rationale:Air pollution, allergens, family history, and viral infections all play a role in asthma. Many children with asthma also have gastroesophageal disease, but the relationship between the two diseases is not clearly understood. If the parent is a former smoker who quit 6 years ago, then the child would not have been exposed to second-hand smoke in utero or after birth.

During assessment, the patient reports shortness of breath every day that requires the use of a rescue inhaler, along with nighttime coughing and trouble sleeping a few nights per week. The patient would be classified as having which of the following levels of asthma severity?

Moderate persistent Rationale:Asthma severity is classified based on: the type and frequency of symptoms reported daily/nightly, lung function, interference with normal activities of daily living, and frequency of use of short-acting β2-agonist for symptom control. Patients with moderate persistent asthma experience daily symptoms and nighttime symptoms more than once a week, but not nightly. Forced expiratory volume is 60% to 80% of predicted values. There are some limitations with normal activity, and patients use short-acting β2-agonists daily for symptom control.

Several months later, Sabina is brought back to the clinic for an acute asthma exacerbation that occurred while playing soccer. Which statement by her mother indicates that teaching has been effective? (Select all that apply.)

Next time, I will be sure to give her the bronchodilator before soccer.,I need to make sure that she has her rescue inhaler with her at all times.,Her asthma was caused by her playing soccer. Rationale:Exercise-induced bronchospasm may occur in any patient with asthma regardless of severity and can be the only symptom in a patient with mild intermittent asthma. To prevent bronchospasm during exercise, patients may use a longer warm-up period and inhale a short-acting bronchodilator just prior to exercise as needed. Inhaled corticosteroids do not relieve the symptoms of an acute asthma attack. Quitting the soccer team is not necessary.

When teaching Sabina about asthma management, which developmentally appropriate interventions would the nurse include to promote self-care? (Select all that apply.)

Provide her with both a spacer with a mouthpiece and one with a mask,Allow her to prepare the meter and obtain peak flow with supervision Rationale:It is important to allow the patient some control and involvement in decision-making and daily care activities. At this age, most children are able to sequence so they have the ability to learn the steps involved in a process. Offer choices whenever possible, as in choosing which type of spacer the patient is more comfortable using, but don't offer choices when there are no alternatives, such as which medication to take first when medications need to be taken in a specific order. Developmentally, a 5-year-old would not be able to understand or calculate percentages to determine what zone he or she is in.

A nurse is assessing a 5-year-old who is experiencing respiratory difficulty. Which of the following are early signs of respiratory distress in infants and children?

Restlessness and tachypnea Rationale:Restlessness, irritability, and anxiety result from inadequate oxygenation and are early signs of respiratory distress, especially when accompanied by tachypnea. Nasal flaring can occur early on and indicates an effort to increase oxygenation. It is important to note the location and severity of retractions. Lethargy, bradypnea, and apnea are late signs that signal impending respiratory failure. Cyanosis indicates hypoxia but not necessarily respiratory distress

The nurse is caring for a patient in respiratory distress. Fifteen minutes ago, the nurse heard audible wheezing and intervened by raising the head of the bed and applying 100% oxygen at 10 L/min via a nonrebreather mask. On reassessment, which findings are most concerning?

Tripod position and absence of wheezing with diminished breath sounds throughout Rationale:Signs of respiratory distress, including the tripod position, with sudden absence of associated wheezing and diminished breath sounds, is indicative of impending respiratory failure. With severe airway obstruction, air movement can be so poor that wheezes might not be heard upon auscultation. The other findings are typical of asthma and respiratory distress, which, while significant, are not as urgent as impending respiratory failure, which is life threatening.

When caring for Sabina, whose mother speaks Spanish and has limited proficiency in English, what is the best method for the nurse to use when communicating medical information to the mother?

Use a medical interpretation service for communication Rationale:An interpreter can help to ensure that the patient and parent can read and understand all written and translated materials. Written materials may need to be provided in both English and the primary language of the patient or parent. Although it is important to face the patient and parent and speak slowly, the parent may still be unable to understand all communications, especially medical terminology. Children should never be used as interpreters.

The nurse has just explained the asthma action plan to a school-aged child. Which statement by the patient best indicates understanding of the asthma action plan?

When I am in the red zone, I will take my rescue medication and call or see my doctor. Rationale:When in the green zone (80% to 100% of personal best), the patient should take his or her regular medications for asthma control and maintenance. When in the yellow zone (50% to 80% of personal best), the patient should continue to take regular medications in addition to quick-relief or rescue medications. The red zone (less than 50% of personal best) means that the patient needs to take quick-relief medication and seek further medical help immediately. The patient should avoid asthma triggers at all times, not just when in the red or yellow zones.