Respiratory Pediatrics
What must the nurse check before giving potassium in an infant?
Make sure the baby is voiding by checking I and O before giving potassium.
The nurse is providing instructions to the parent of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which statement made by the parent indicates a need for further teaching? "I need to place a steam vaporizer in my child's room." 2"I will take my child out into the cool, humid night air." 3"I could place a cool-mist humidifier in my child's room. "4"I will have my child inhale the steam from warm running water."
"I need to place a steam vaporizer in my child's room." Steam from running water in a closed bathroom will assist in keeping secretions thin so that they can be easily expectorated. Steam from a vaporizer however can present a danger of scald burns because of the more direct effect than that provided from steam from running water. A cool mist from a bedside humidifier may be effective in reducing mucosal edema. Cool-mist humidifiers are recommended over steam vaporizers. Taking the child out into the cool, humid night air may also relieve mucosal swelling.
A parent calls the primary health care provider's office, requesting an appointment for an 8-year-old child. The parent states that the child has asthma and that the child reports having trouble breathing last night and does not want to go to school. In triaging this child, which is the most importantquestion to initially ask the parent? "Is your child crying and irritable?" 2"Does your child have a productive cough?" 3"Did your child have a temperature last night of greater than 100° F (37.8° C)?" 4"Is your child telling you at this time about having trouble breathing?"
"Is your child telling you at this time about having trouble breathing?" Airway is always the most important indicator to determine whether the child can be seen in the primary health care provider's office or needs to be taken to the emergency department. Although all the assessment questions address manifestations of asthma, asking the child about difficulty breathing specifically addresses airway.
What is the pathophysiology of RSV?
1. Epithelial cells swell, protrude into the lumen and cause a loss of cilia leading to poor airway clearance
The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding? 1. Frequent swallowing 2. A decreased pulse rate 3. Complaints of discomfort 4. An elevation in blood pressure
1. Frequent swallowing
Signs and Symptoms of RSV:
1. Initial: cold like symptoms (Rhinorrhea, coughing, runny nose, sore throat, Low-grade fever, wheezing) Moderate: copious secretions, retractions, high grade fever Severe: Apneic episodes, diminished breath sounds, decreased LOC
How is RSV diagnosed?
1. Nasal Swab (culture) 2. Chest X ray shows lung hyperinflation and patchy areas in the lung
A mother arrives at the hospital emergency department with her child, in whom a diagnosis of epiglottitis is documented. Which prescription, if written by the primary health care provider, would the nurse question? 1. Obtain a throat culture. 2Obtain axillary temperatures. 3Administer humidified oxygen. 4Administer acetaminophen for fever.
1. Obtain a throat culture. A child's throat with suspected epiglottitis would not be examined or cultured because any stimulation with a tongue depressor or culture swab could cause laryngospasm, thus completing airway obstruction.
Suctioning in an infant with RSV:
1. Suction prior to feeding 2. Suction secretions Use Normal Saline
The parent of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. What would the nurse tell the parent about CF? Transmitted as an autosomal dominant trait 2A chronic multisystem disorder affecting the exocrine glands 3A disease that causes the formation of multiple cysts in the lungs 4A disease that causes dilation of the passageways of many organs
2A chronic multisystem disorder affecting the exocrine glands CF is a chronic multisystem disorder that affects the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. It does not cause the formation of multiple cysts in the lungs. Options 1, 3, and 4 are incorrect.
The nurse is caring for a child who aspirated a piece of celery. Which procedure would the nurse anticipate in the care of this child? Pleurodesis 2Colonoscopy 3Bronchoscopy 4Esophagogastroduodenoscopy
3Bronchoscopy
The nurse is reviewing the pathophysiology of aspirated foreign bodies. Which location would the nurse correctly identify as the most common location for an aspirated foreign body? Left mainstem bronchus in the lower lobe 2Left mainstem bronchus in the upper lobe 3Right mainstem bronchus in the lower lobe 4Right mainstem bronchus in the upper lobe
3Right mainstem bronchus in the lower lobe
Which complication would the nurse expect in a child with cystic fibrosis a. increased insulin production b. passage of watery stools c. Prolapse of the rectum d. Frequent episodes of diarrhea
Prolapse of the rectum
A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this medication be administered? a. Before chest physiotherapy (CPT) b. After CPT c. Before receiving 100% oxygen d. After receiving 100% oxygen
ANS: A Bronchodilators should be given before CPT to open bronchi and make expectoration easier. Aerosolized bronchodilator medications are not helpful when used after CPT. Oxygen administration is necessary only in acute episodes with caution because of chronic carbon dioxide retention.
A parent of a 4-year-old child asks the nurse which maneuver would be done in the event that the child begins to choke on a foreign body and is still conscious. Which initial action would the nurse instruct the parents to take in addition to contacting emergency medical services? Abdominal thrusts 2Deliver rescue breaths 3Cardiopulmonary resuscitation (CPR) 4Alternating back blows and chest thrusts
Abdominal thrusts
The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. How would the nurse interpret this finding? Extreme fatigue 2The presence of pain 3An airway obstruction 4The presence of dehydration
An airway of obstruction - 4 Ds of epiglottis Drooling, Dysphagia, Dysphonia, Distress/Dyspnea
Which clinical manifestation in the child would the nurse relate to asthma? SATA a. barrel chest b. sandpaper rash c. elevated shoulders d. edematous tongue e. flattened malar bones
Barrel chest elevated shoulders flattened mala bones
Bronchiolitis Definition Cause
Bronchiolitis - acute lower airway infection that is the most frequent cause of hospitalization in a child less than 1 The most common cause is RSV
Medications for RSV:
Bronchodilators Racemic Epinephrine Acetaminophen for Fever (Motrin is given for children > 6 months) IM dexamethasone Nebulized Pulmicort (steroid)
A school-age child has been admitted with an acute asthma episode. The child is receiving oxygen by nasal prongs at 2 liters. How often should the nurse plan to monitor the child's pulse oximetry status? a. Continuous b. Every 30 minutes c. Every hour d. Every 2 hours
Continuous The child on supplemental oxygen requires intermittent or continuous oxygenation monitoring, depending on severity of respiratory compromise and initial oxygenation status. The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring.
What intervention would the nurse anticipate by the doctor after a patient goes into respiratory distress?
Endotracheal Intubation
Which trigger tends to precipitate or aggravate asthma in children? a. Exercise b. Breast milk c. Tobacco smoke d. Thyroid disease e. A smoke-free home
Exercise Tobacco smoke Thyroid disease
If the respiratory rate in a baby is over 60, what must the nurse never do?
Feed the baby - risk for aspiration Always assess the patient first Inform the doctor the baby is tachypneic, may have to be NPO and give IV fluids
Parent Teaching RSV / Prevention
Frequent Hand washing / good hand hygiene No smoking in the home Reinforce how to use normal saline with suctioning
A pediatric nurse in the ambulatory surgery unit is caring for a child following a tonsillectomy. The child is complaining of a dry throat. Which item would the nurse offer to the child? Ginger ale Green gelatin A glass of milk Cherry Kool-Aid
Green gelatin
The nurse has provided instructions to the parent of a child with cystic fibrosis about appropriate dietary measures. Which statement by the parent indicates an understanding of these dietary measures? Why Supine, side-lying position with the arms elevated Prone with the head of the bed elevated 15 degrees Trendelenburg's, at a 60-degree angle with pelvis higher than head Head and chest at a 30-degree angle with the neck slightly extended.
Head and chest at 30-degree angle with the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm
The Hib vaccine prevents
Hib prevents - epiglottitis and meningitis
The nurse has provided instructions to the parent of a child with cystic fibrosis about appropriate dietary measures. Which statement by the parent indicates an understanding of these dietary measures?
High-calorie, high protein Pancreatic enzymes with every meal Fat-Soluble vitamins - A, D, E, K
Croup (laryngotracheobronchitis)
Infection in the upper airways characterized by a barking cough, inspiratory stridor Cause: parainfluenza virus, adenovirus, RSV Treatment: racemic Epi, cool mist humidifier, cortosteroids, may need to intubate
What is the first intervention after diagnosing a child with pneumonia and RSV
Initiate droplet and contact precautions
A nurse is teaching nursing students about clinical manifestations of cystic fibrosis (CF). Which is/are the earliest recognizable clinical manifestation(s) of CF? Meconium ileus History of poor intestinal absorption Foul-smelling, frothy, greasy stools Recurrent pneumonia and lung infections
Meconium ileus The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of children with CF. Clinical manifestations include abdominal distention, vomiting, failure to pass stools, and rapid development of dehydration. History of malabsorption is a later sign that manifests as failure to thrive. Foul-smelling stools are a later manifestation of CF. Recurrent respiratory tract infections are a later sign of CF.
Which is the asthma severity classification of a 3 year old with asthma whose parents state that the child has symptoms three times a week, once a day, and they give the child a short-acting B agonist for symptom control 1 day a week?
Mild persistent
Racemic Epinephrine Precautions:
Monitor for 2-3 hours after
Which is a clinical manifestation of acute epiglotitis? SATA a. Pain b. Fever c. Drooling d. Tripod positioning
Pain, Fever, Drooling, and Tripod positioning - also frog-like croaking
What is the treatment for streptococcal pharyngitis?
Penicillin (Oral) Penicillin G (IM), or Amoxicillin for 10 days Erythromycin or Azithromycin is given if the child is allergic to penicillin
Pneumonia Cause: Diagnosis Treatment Signs/symptoms Education
Pneumonia: Viral (most common form), Bacterial, Aspiration Diagnosis: Chest X ray, (patchy areas), Auscultation Treatment for Viral: maintain oxygenation and promote comfort Treatment for bacterial: antibiotics Fluids Oxygenation Sit up in a fowlers position to promote diaphragmatic breathing Nebulizer, chest PT, bronchodilators Signs Symtpoms - productive or nonproductive cough - crackles or rhonchi - cyanosis, tachypnea - vomiting, diarrhea, abdominal pain Education: Take the full course of antibiotics for 7-10 days even if symptoms subside * Give. Antipyretics for Fever * Return to the hospital if symptoms worsen * Encourage Oral Intake *** Monitor I and O
RSV prevention:
RSV prevention - Synergis (Palivizumab) - man-made antibody given to infants who are premature or 6 months of age or younger at the beginning of RSV season.
Which condition is prevented when by treating acute streptococcal pharyngitis with antibiotics?
Streptococcal pharyngitis is treated with antibiotics to prevent: - rheumatic fever - scarlet fever - acute glomerulonephritis
What is the most common bacteria causing Bacterial pneumonia?
Streptococcus Pneumoniae
The nurse is reviewing the primary health care provider's prescriptions for a child following a tonsillectomy. Which prescription would the nurse question? Suction the child frequently if coughing. 2Discharge to home when alert and tolerating fluids. 3Provide clear, cool liquids to the child when awake. 4Instruct the parent not to give the child milk products.
Suction the child frequently if coughing. Suction equipment should be kept on hand and is only used if the child has an obstruction.
Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this diagnosis? a. Bronchoscopy b. Serum calcium c. Urine creatinine d. Sweat chloride test
Sweat chloride test
A child is being admitted to the hospital to be tested for cystic fibrosis (CF). Which tests should the nurse expect? Sweat chloride test, stool for fat, chest radiograph films Stool test for fat, gastric contents for hydrochloride, chest radiograph films Sweat chloride test, bronchoscopy, duodenal fluid analysis Sweat chloride test, stool for trypsin, biopsy of intestinal mucosa
Sweat chloride test, stool for fat, chest radiograph films
A child is diagnosed with influenza. Management includes which recommendation? Clear liquid diet for hydration Aspirin to control fever Oseltamivie (Tamiflu) Antibiotics to prevent bacterial infection
Tamiflu may help reduce the symptoms of influenza if administered within 48 hours of onset.
Tepid Water Baths -
Tepid Water Baths - may induce shivering, and increase the temperature so they are avoided in children with a fever.
Which position(s) would a patient be placed in after a tonsillectomy?
The child would be placed in a prone or side-lying position to facilitate drainage after a tonsillectomy.
Why is it important to monitor electrolyte levels in a patient with RSV?
The patient is at risk for dehydration
During a clinical conference, a nursing student is discussing care for a child with a diagnosis of cystic fibrosis (CF). Which comment by a student indicates the need for further review of information about CF? CF causes mucus that is formed to be abnormally thick. 2It is a condition transmitted as an autosomal recessive trait. 3This disease causes dilation of the passageways of many organs. 4It is a chronic multisystem disorder affecting the exocrine glands.
This disease causes dilation of the passageways of many organs. CF is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction (not dilation) of the small passageways of these organs. It is transmitted as an autosomal recessive trait.
What are the warning signs of RSV
Trouble breathing Tachyonea Cyanosis Coughing Apneic episodes
The mother of a 20 month old tells the nurse that the child has a barking cough at night. The child's temperature is 98.6. The mother states that the child is not having difficulty breathing. The nurse suspecting croup, would recommend what? a. Trying a cool mist vaporizer at night and watching for signs of difficulty breathing b. Bringing the child to the hospital to be admitted and to be observed for impending epiglotitis
Trying a cool mist vaporizer at night and watching for signs of difficulty breathing
Precautions for RSV:
contact and droplet precautions Patient needs their own bp cuff, pulse ox, stethoscope
How are antibiotics given to a patient with a tonsillectomy?
rectally or Intravenously
A peak expiratory flow rate < 60% indicates
severe persistent asthma
What must you do before feedings in a patient with RSV?
suctioning
A child with cystic fibrosis (CF) is receiving recombinant human deoxyribonuclease (DNase). Which is an adverse effect of this medication? a. Mucus thickens b. Voice alters c. Tachycardia d. Jitteriness
b. Voice alters
Which condition is prevented when by treating acute streptococcal pharyngitis with antibiotics? a. Otitis media b. Diabetes insipidus c. Nephrotic syndrome d. Acute rheumatic fever
d. Acute rheumatic fever
An ambulatory care nurse is preparing a list of instructions for the parents of a child who is being discharged after a tonsillectomy. The nurse would place which instructions on the list? Select all that apply. 1. Avoid hot fluids. 2. Avoid raw vegetables. 3. Consume pudding products. 4. Rest in bed or on a couch for 24 hours. 5. Drink cold milkshakes to soothe the throat.
Avoid hot fluids Avoid raw vegetables Rest in bed or on a couch for 24 hours ------------ All milk and milk products should be avoided after a tonsillectomy
What is the most appropriate way to administer penicillin G or penicillin G benzathine suspension?
Intramuscularly
How are fluids given to a child with RSV?
Intravenously
What are the treatments for RSV?
Maintaining an airway by suctioning Supplemental oxygen (nasal cannula); humidified Fluids (IV if the child cannot eat or drink PO) Small frequent feedings if they can eat and drink May need an NG tube if they are intubated Antibiotics if RSV has progressed to Pneumonia. RSV is usually supportive ** I'm severe cases: CPAP, BiPAP, Intubation
Which syndrome would a 3-year-old child who has rapidly progressing dysphagia and stridor, a high fever, and a rapid pulse and respirations most likely have?
Progressive dysphagia, stridor, high fever, rapid pulse and rapid respirations in a 3 year old child are highly suggestive of acute epiglottitis
2. The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which intervention should be included in the child's care? (Select all that apply.) a. Place in a mist tent. b. Administer antibiotics. c. Administer cough syrup. d. Encourage the child to drink 8 ounces of formula every 4 hours. e. Cluster care to encourage adequate rest. f. Place on noninvasive oxygen monitoring.
d. Encourage the child to drink 8 ounces of formula every 4 hours. e. Cluster care to encourage adequate rest. f. Place on noninvasive oxygen monitoring.
Which is the first line of treatment for the child with epiglottitis and severe respiratory distress? a. Antibiotics b. Corticosteroids c. Humidified oxygen via mask d. Nasotracheal intubation or tracheostomy
d. Nasotracheal intubation or tracheostomy
A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child would monitor for which sign, knowing that it indicates a worsening of the condition? Warm, dry skin 2Decreased wheezing 3Pulse rate of 90 beats per minute 4Respirations of 18 breaths per minute
2Decreased wheezing Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dry skin indicates an improvement in the child's condition, because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute. The normal respiratory rate in a 10-year-old is 16 to 20 breaths per minute.
A parent arrives at the clinic with a 3-year-old child. The parent tells the nurse that the child has had a fever and a cough for the past 2 days and that this morning the child began to wheeze. Viral pneumonia is diagnosed. Based on the diagnosis, the nurse anticipates that which will be a component of the treatment plan? Oral antibiotics 2Supportive treatment 3Hospitalization and IV antibiotics4Intravenous (IV) fluid administration
2Supportive treatment With viral pneumonia, treatment is supportive. Children who are more severely ill may be hospitalized and given oxygen, chest physiotherapy, and IV fluids. Antibiotics are not given. Bacterial pneumonia, however, is treated with antibiotic therapy.
Breathing exercises and postural drainage are prescribed for a hospitalized child with cystic fibrosis. What instruction would the nurse include in the client's teaching plan? Schedule the procedures so that they are 4 hours apart. 2Perform the breathing exercises and then the postural drainage. 3Perform the postural drainage first and then the breathing exercises. 4Perform postural drainage in the morning and breathing exercises in the evening.
3Perform the postural drainage first and then the breathing exercises. postural drainage will help mobilize secretions first then breathing exercises follow to expectorate secretions
The nurse in the ambulatory care unit is caring for a child after a tonsillectomy. The child's parent tells the nurse that the child is complaining of a dry throat and would like something to relieve the dryness. Which item would the nurse provide for the parent to give to the child? Iced tea 2A glass of milk 3Cool cherry Kool-Aid 4Yellow noncitrus Jell-O
Yellow, noncitrus Jell-O is acceptable since it is a clear liquid. Cold, hot, or citrus beverages are avoided since they may irritate the throat. Milk is avoided since it can induce coughing.
1. An infant has developed staphylococcal pneumonia. Nursing care of the child with pneumonia includes which interventions? (Select all that apply.) a. Cluster care to conserve energy b. Round-the-clock administration of antitussive agents c. Strict intake and output to avoid congestive heart failure d. Administration of antibiotics
a. Cluster care to conserve energy d. Administration of antibiotics Antibiotics are indicated for a bacterial pneumonia. Often the child will have decreased pulmonary reserve, and the clustering of care is essential. Antitussive agents are used sparingly. It is desirable for the child to cough up some of the secretions. Fluids are essential to kept secretions as liquefied as possible.
36. In providing nourishment for a child with cystic fibrosis (CF), which factor should the nurse keep in mind? a. Diet should be high in carbohydrates and protein b. Diet should be high in easily digested carbohydrates and fats c. Most fruits and vegetables are not well tolerated. d. Fats and proteins must be greatly curtailed.
a. Diet should be high in carbohydrates and protein Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption. Enzyme supplementation helps digest foods; other modifications are not necessary. A well-balanced diet containing fruits and vegetables is important. Fats and proteins are a necessary part of a well-balanced diet.
Which would the nurse attribute as a sign of acute epiglottitis? a. drooling b. low grade fever c. Brassy cough d. Stridor when supine e. Toxic appearance
a. Drooling b. Stridor when supine - tongue sticks out and they need to lean forward e. toxic appearance
Which would the nurse teach the parents of a child with cystic fibrosis about the rise of pancreatic enzymes? a. Extra enzymes must be taken with high-fat foods b. Enteric-coated beads may be chewed or crushed c. Mix the powder form exyme with
a. Extra enzymes must be taken with high-fat foods
Which would the nurse teach the family about reducing the risk for otitis media in the child younger than 2 years old? a. Maintain routine childhood immunizations b. Wash the child's hair with bathtub water c. Put the child to bed with a feeding bottle d. Breastfeed the child until 6 months of age e. Eliminate tobacco smoke and allergens
a. Maintain routine childhood immunizations d. Breastfeed the child until 6 months of age e. Eliminate tobacco smoke and allergens
The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy in 2 hours. Which action should the nurse include in the child's postoperative care plan? (Select all that apply.) a. Notify the surgeon if the child swallows frequently. b. Apply a heat collar to the child for pain relief. c. Place the child on the abdomen until fully wake. d. Allow the child to have diluted juice after the procedure. e. Encourage the child to cough frequently.
a. Notify the surgeon if the child swallows frequently c. Place the child on the abdomen until fully wake. d. Allow the child to have diluted juice after the procedure.
4. A nurse is caring for a school-age child with left unilateral pneumonia and pleural effusion. A chest tube has been inserted to promote continuous closed chest drainage. Which interventions should the nurse implement when caring for this child? (Select all that apply.) a. Positioning child on the right side b. Assessing the chest tube and drainage device for correct settings c. Administering prescribed doses of analgesia d. Clamping the chest tube when child ambulates e. Monitoring for need of supplemental oxygen
b. Assessing the chest tube and drainage device for correct settings c. Administering prescribed doses of analgesia e. Monitoring for need of supplemental oxygen
You have a 7-year-old female admitted with CF. Mom asks what she should feed her on a hot, sunny day. a. Popsicle stick b. Broth c. Ice cream
b. Broth - Patients with CF are losing a lot of Na+ and Cl- via sweat and saliva. Broth contains sodium which will help the child retain water.
Which oral rehydration measure must the nurse teach the parents of an infant with a respiratory tract infection? a. Provide water at regular intervals b. Continue to breastfeed the infant c. Provide sips of low-carb drink d. Awaken the infant to take fluids
b. Continue to breastfeed the infant Infants would continue to breastfeed because human milk provides some degree of protection from infection
Which intervention would the nurse perform when caring for an infant with RSV? a. offer formula if infant stops breastfeeding b. Teach parents to instill normal saline drops in the nares c. Teach parents to suction the mucus with a bulb syringe d. Offer small amounts of fluids at frequent intervals e. Administer intramuscular injections of palivizumab
b. Teach parents to instill normal saline drops in the nares c. Teach parents to suction the mucus with a bulb syringe d. Offer small amounts of fluids at frequent intervals
Which complication would the nurse expect in a child with cystic fibrosis? a, increased insulin production b. passage of watery stools c. Prolapse of the rectum d. Frequent episodes of diarrhea
c. Prolapse of the rectum related to large, bulky stools
Which would the nurse teach the parents of a child with streptococcal pharyngitis? a. The child is not considered infectious until antibiotic therapy is started. b. The child can return to daycare after antibiotic therapy is started c. A new toothbrush must be used as soon as antibiotic therapy is started d. Orthodontic appliances used by the child must be washed thoroughly
d. Orthodontic appliances used by the child with strep throat must be washed thoroughly because they may harbor organisms - The child is not considered infectious until 24 hours after antibiotic therapy is started
Pancreatic enzymes are administered to the child with cystic fibrosis (CF). What nursing considerations should be included? a. Do not administer pancreatic enzymes if the child is receiving antibiotics. b. Decrease dose of pancreatic enzymes if the child is having frequent, bulky stools. c. Administer pancreatic enzymes between meals if at all possible. d. Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.
d. Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.
