Ricci Chapter 51 PrepU (Shock Only)
A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which action should the nurse take first? - Begin hyperventilation. - Establish a suitable IV site. - Provide oral analgesics as ordered. - Draw blood for type and cross-match.
Establish a suitable IV site.
The child's ability to perfuse is poor due to inadequate circulation. The physician writes an order for the child to receive 20 ml of normal saline for each kilogram of body weight. The child will receive the normal saline as a bolus through a central intravenous line. The child weighs 78 lb (35.46 kg). Calculate the amount of normal saline the nurse should administer as a bolus. Record your answer using a whole number.
709 Explanation: Dose should be calculated using weight in kilograms. 35.456 kg x 20 ml/kg = 709.1 ml. When rounded to the nearest whole number = 709 ml.
Administration of which medication reverses the histamine release and hypotension that are seen in anaphylaxis? - diphenhydramine - atropine - epinephrine - cimetidine
epinephrine
A child is hospitalized with suspected sepsis. The health care provider has prescribed an intravenous fluid bolus of lactated Ringer's solution 15 ml/kg to infuse over 20 minutes. The child weighs 52 lb (23.6 kg). How much fluid should the nurse administer? Record your answer using a whole number.
354 Explanation: The nurse will multiply the client's weight in kilograms by the prescribed amount of fluid. 23.6 kg × 15 ml/kg = 354 ml
The nurse is assessing a 10-year-old child with tachypnea and increased work of breathing. Which finding demonstrates the child is in the late stages of shock? - stable blood pressure and cool extremities - increased heart rate with weak distal pulses - hypotension and capillary refill time greater than 5 seconds - cool and clammy extremities
hypotension and capillary refill time greater than 5 seconds
Which medication would not be administered through a tracheal tube? - lidocaine - sodium bicarbonate - epinephrine - naloxone
sodium bicarbonate
A nurse witnesses a child get hit by a car while riding a bike. The child is lying motionless in the street. What action should the nurse take next? - Assess the level of consciousness. - Check the vital signs. - Ensure a safe environment. - Check for visible injuries.
Ensure a safe environment.
A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 bpm. Which intervention is priority? - Give three doses of epinephrine. - Administer two consecutive defibrillator shocks. - Initiate cardiac compressions. - Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR).
Initiate cardiac compressions.
The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern? - Inspection shows a sluggish pupillary reaction. - Palpation of the head reveals a closed posterior fontanel (fontanelle). - The child is crying and looking around fearfully. - The child's eyes remain closed unless she is spoken to.
Inspection shows a sluggish pupillary reaction.
The nurse is assessing the respiratory status and lungs of a 6-year-old child. What finding would the nurse report immediately? - Minimal air movement through the lungs - High-pitched breath sounds over the trachea - Low-pitched bronchial sounds over the periphery - Resonance over the lungs on percussion
Minimal air movement through the lungs
A child is exhibiting symptomatic bradycardia that has been unresponsive to ventilation and oxygenation. Which of the following would the nurse expect to be administered? - atropine - sodium bicarbonate - naloxone - calcium carbonate
atropine
Which assessment finding would indicate to the health care team that a child would need to be reintubated due to improper placement of the endotracheal tube? - Symmetrical chest rise is observed. - There's water vapor on the inside of the tube. - Breath sounds are heard over the abdominal area. - Oxygen saturation rises from 78% to 93% after intubation.
Breath sounds are heard over the abdominal area.
A 9-year-old has suffered a severe anaphylactic reaction and dies. The nurse is providing support for the grieving parents. Which comment would best help them cope? - "You would be more comfortable here in the lounge." - "Would you like to see the chaplain?" - "How can I help you get through this?" - "Can I get you something to eat?"
"How can I help you get through this?"
The nurse plans to educate the parents of a child experiencing septic shock about the purpose of administering dobutamine intravenously to their child. What would the nurse include in this educational plan? - Dobutamine is used to improve cardiac contractility. - Dobutamine will work to eliminate the bacteria causing the infection. - Dobutamine is used to provide vasodilation, thus increasing blood pressure. - Dobutamine will work to dry secretions and inhibit serotonin and histamine.
Dobutamine is used to improve cardiac contractility.
The nurse is conducting an educational class regarding the use of the intraosseous site for administration of fluid to the pediatric client experiencing an emergency, such as shock. What would the nurse include in this educational presentation? - The intraosseous site is preferred if peripheral access cannot be attained rapidly. - The child must be in a left-side lying position with the spine flexed to access properly. - The nurse will utilize a small gauge catheter for children, such as a 25 gauge. - The intraosseous site is used only for crystalloid fluids such as normal saline.
The intraosseous site is preferred if peripheral access cannot be attained rapidly.
A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which of the following would the nurse do first? - Begin hyperventilation. - Establish a suitable IV site. - Provide oral analgesics as ordered. - Draw blood for type and crossmatch.
Establish a suitable IV site.