NURS 355 Chapter 24

What is the required number of milliliters of fluid needed per day for a 14-kg child?

1200 For the first 10 kg of body weight, a child requires 100 ml/kg. For each additional kilogram of body weight, an extra 50 ml is needed. 10 kg × 100 ml/kg/day = 1000 ml 4 kg × 50 ml/kg/day = 200 ml 1000 ml + 200 ml = 1200 ml/day Eight hundred to 1000 ml is too little; 1400 ml is too much.

What amount of fluid loss occurs with moderate dehydration?

50 to 90 ml/kg Moderate dehydration is defined as a fluid loss of between 50 and 90 ml/kg. Mild dehydration is defined as a fluid loss of less than 50 ml/kg. Weight loss up to 5% is considered mild dehydration. Weight loss over 15% is severe dehydration.

What is a systemic response to severe burns in a child?

Abrupt drop in cardiac output The initial physiologic response to a burn injury is a dramatic change in circulation. A precipitous drop in cardiac output precedes any change in circulating blood or plasma volumes. A circulating myocardial depressant factor associated with severe burn injury is thought to be the cause. Metabolic acidosis usually occurs secondary to the disruption of the body's buffering action resulting from fluid shifting to extravascular space. There is a greatly accelerated metabolic rate in burn patients, supported by protein and lipid breakdown. With the loss of circulating volume, there is decreased renal blood flow and depressed glomerular filtration.

A child is admitted with extensive burns. The nurse notes burns on the child's lips and singed nasal hairs. The nurse should suspect what condition in the child?

An inhalation injury Evidence of an inhalation injury includes burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestations may be delayed for up to 24 hours. Chemical burns, electrical burns, and burns associated with hot-water scalds would not produce singed nasal hair.

What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?

Anaphylactic shock Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission after a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure.

The nurse is caring for a child with hypercalcemia. The nurse evaluates the child for which signs and symptoms of hypercalcemia? (Select all that apply.)

Anorexia Constipation Muscle hypotonicity Signs and symptoms of hypercalcemia are anorexia, constipation, and muscle hypotonicity. Tetany and laryngospasm are signs of hypocalcemia.

What substance is released from the posterior pituitary gland and promotes water retention in the renal system?

Antidiuretic hormone (ADH) ADH is released in response to increased osmolality and decreased volume of intravascular fluid; it promotes water retention in the renal system by increasing the permeability of renal tubules to water. Renin release is stimulated by diminished blood flow to the kidneys. Aldosterone is secreted by the adrenal cortex. It enhances sodium reabsorption in renal tubules, promoting osmotic reabsorption of water. Renin reacts with a plasma globulin to generate angiotensin, which is a powerful vasoconstrictor. Angiotensin also stimulates the release of aldosterone.

What is the most frequent cause of hypovolemic shock in children?

Blood loss Blood loss is the most frequent cause of hypovolemic shock in children. Sepsis causes septic shock, which is overwhelming sepsis and circulating bacterial toxins. Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Heart failure contributes to hypervolemia, not hypovolemia.

When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action?

Check the insertion site frequently for signs of infiltration The nursing responsibility for IV therapy is to calculate the amount to be infused in a given length of time; set the infusion rate; and monitor the apparatus frequently, at least every 1 to 2 hours, to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop. Insertion sites do not need to be changed every 24 hours unless a problem is found with the site. This exposes the child to significant trauma. A minidropper (60 drops/ml) is the recommended IV tubing in pediatric patients. Intravenous sites should be protected. This may require soft restraints on the child.

What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?

Confusion and somnolence Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.

A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solutions (ORS). The child's mother calls the clinic nurse because he is also occasionally vomiting. The nurse should recommend which intervention?

Continue to give ORS frequently in small amounts. Children who are vomiting should be given ORS at frequent intervals and in small amounts. Intravenous fluids are not indicated for mild dehydration. Carbonated beverages are high in carbohydrates and are not recommended for the treatment of diarrhea and vomiting. The child is not kept NPO because this would cause additional fluid losses.

Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. What is the purpose of hydrotherapy?

Debride the wounds Soaking in a tub or showering once or twice a day acts to loosen and remove sloughing tissue, exudate, and topical medications. The hydrotherapy cleanses the wound and the entire body and helps maintain range of motion. Appropriate pain medications are necessary. Dressing changes are extremely painful. The total bacterial count of the skin is reduced by the hydrotherapy, but this is not the primary goal. There may be an increase in peripheral blood flow, but the primary purpose is for wound débridement.

What laboratory finding should the nurse expect in a child with an excess of water?

Decreased hematocrit The excess water in the circulatory system results in hemodilution. The laboratory results show a falsely decreased hematocrit. Laboratory analysis of blood that is hemodiluted reveals decreased serum osmolality and blood urea nitrogen. The urine specific gravity is variable relative to the child's ability to correct the fluid imbalance.

What sign is one of the first to indicate overwhelming sepsis in a child with burn injuries?

Disorientation Disorientation in the burn patient is one of the first signs of overwhelming sepsis and may indicate inadequate hydration. Seizures, bradycardia, and decreased blood pressure are not initial manifestations of overwhelming sepsis.

The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?

Dry mucous membranes and generally ill appearance A good predictor of a fluid deficit of at least 5% is any two four factors: capillary refill of more than 2 seconds, absent tears, dry mucous membranes, and ill general appearance. Weight loss is associated with fluid deficit, but the degree needs to be quantified. Heart rate is usually elevated. Skin elasticity is decreased, not increased. The anterior fontanel is depressed.

Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms?

Dry, sticky mucous membranes Dry, sticky mucous membranes are associated with hypernatremia. Hyperreflexia is associated with hyperkalemia. Abdominal cramps, weakness, dizziness, nausea, and apprehension are associated hyponatremia. Cardiac dysrhythmias are associated with hypokalemia.

What type of diarrhea is associated with an inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents?

Dysenteric Dysenteric diarrhea is associated with an inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents such as Campylobacter, Salmonella, or Shigella organisms. Edema, mucosal bleeding, and leukocyte infiltration occur. Osmotic diarrhea occurs when the intestine cannot absorb nutrients or electrolytes. It is commonly seen in malabsorption syndromes such as lactose intolerance. Secretory diarrhea is usually a result of bacterial enterotoxins that stimulate fluid and electrolyte secretion from the mucosal crypt cells, the principal secretory cells of the small intestine. Cytotoxic diarrhea is characterized by the viral destruction of the villi of the small intestine. This results in a smaller intestinal surface area, with a decreased capacity for fluid and electrolyte absorption.

A school-age child with diarrhea has been rehydrated. The nurse is discussing the child's diet with the family. What food or beverage should be tolerated best?

Easily digested foods Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a regular diet has no adverse effects and actually lessens the severity and duration of the illness. Clear fluids (e.g., fruit juices and gelatin) and carbonated drinks have high carbohydrate content and few electrolytes. Caffeinated beverages should be avoided because caffeine is a mild diuretic. In some children, lactose intolerance will develop with diarrhea, and cow's milk should be avoided in the recovery stage.

The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?

End the infusion and notify the practitioner A vesicant causes cellular damage when even minute amounts escape into the tissue. The intravenous infusion is immediately stopped, the extremity is elevated, the practitioner is notified, and the treatment protocol is initiated. The applying of heat or ice depends on the fluid that has extravasated. The catheter is left in place until it is no longer needed.

Nurses should be alert for increased fluid requirements in which circumstance?

Fever Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. The mechanically ventilated child has decreased fluid requirements. Congestive heart failure is a case of fluid overload in children. Increased intracranial pressure does not lead to increased fluid requirements in children.

The nurse is teaching the family of a child with a long-term central venous access device about signs and symptoms of bacteremia. What finding indicates the presence of bacteremia?

Fever and general malaise Fever, chills, general malaise, and an ill appearance can be signs of bacteremia and require immediate intervention. Hypotension would be indicative of sepsis and possible impending cardiovascular collapse. Pain, redness, and swelling at the entry site indicate local infection.

Physiologically, the child compensates for fluid volume losses by which mechanism?

Fluid shift from interstitial space to intravascular space Compensatory mechanisms attempt to maintain fluid volume. Initially, interstitial fluid moves into the intravascular compartment to maintain blood volume. Aldosterone is released to promote sodium retention and conserve water in the kidneys. Hemoconcentration results from the fluid volume loss. With less circulating volume, tachycardia results. Vasoconstriction of peripheral arterioles occurs to help maintain blood pressure.

The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins?

Gently tap over the site Gently tapping the site can sometimes cause the veins to be more visible. This is done before the skin is prepared. Warm compresses (not cold) may be useful. The extremity is held in a dependent position. A tourniquet may be helpful, but if too tight, it could cause the vein to burst when punctured. Five minutes is too long.

What organism is a parasite that causes acute diarrhea?

Giardia lamblia G. lamblia is a parasite that represents 10% of nondysenteric illness in the United States. Shigella, Salmonella, and E. coli are bacterial pathogens.

Isografts

Histocompatible tissue obtained from genetically identical individuals

A toddler sustains a minor burn on the hand from hot coffee. What is the first action in treating this burn?

Hold the hand under cool running water In minor burns, the best method to stop the burning process is to hold the burned area under cool running water. Ointments are not applied to a new burn; the ointment will contribute to the burning. Ice is not recommended. Gauze dressings do not stop the burning process.

Prevention of burn injury is important anticipatory guidance. In the infant and toddler period, which mode is the most common cause of burn?

Hot liquids in the kitchen Infants and toddlers are most commonly injured by hot liquids in the kitchen and bathroom. This often occurs as a result of inadequate supervision of this curious and energetic age group. Matches and lighters are seen as toys by young children and should be kept out of reach. Older toddlers and preschool children are at risk of chewing on electrical cords and placing objects in outlets. Microwave-heated fluids and foods can become superheated, resulting in oral burns.

The nurse is caring for a child with hypokalemia. The nurse evaluates the child for which signs and symptoms of hypokalemia? (Select all that apply.)

Hypotension Muscle weakness Cardiac arrhythmias Signs and symptoms of hypokalemia are hypotension, muscle weakness, and cardiac arrhythmias. Twitching and hyperreflexia are signs of hyperkalemia.

What type of dehydration occurs when the electrolyte deficit exceeds the water deficit?

Hypotonic dehydration Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion. Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Hyperosmotic dehydration is another term for hypertonic dehydration.

What factor predisposes an infant to fluid imbalances?

Immature kidney functioning The infant's kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration.

What explains physiologically the edema formation that occurs with burns?

Increased capillary permeability With a major burn, capillary permeability increases, allowing plasma proteins, fluids, and electrolytes to be lost into the interstitial space, causing edema. Maximum edema in a small wound occurs about 8 to 12 hours after injury. In larger injuries, the maximum edema may not occur until 18 to 24 hours later. Vasodilation occurs, causing an increase in hydrostatic pressure.

After the acute stage and during the healing process, what is the primary complication from burn injury?

Infection During the healing phase, local infection or sepsis is the primary complication. Respiratory problems, primarily airway compromise, and shock are the primary complications during the acute stage of burn injury. Renal shutdown is not a complication of the burn injury but may be a result of the profound shock.

What is an effective strategy to reduce the stress of burn dressing procedures?

Involve the child and give choices as feasible Children who have an understanding of the procedure and some perceived control demonstrate less maladaptive behavior. They respond well to participating in decisions and should be given as many choices as possible. Analgesia and sedation can and should be used. The dressing change procedure is very painful and stressful. Misinformation should not be given to the child. Encouraging the child to master stress with controlled passivity is not a positive coping strategy.

The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?

Irritability and seizures Irritability, somnolence, headache, vomiting, diarrhea, and generalized seizures are manifestations of water intoxication. Urinary output is increased as the child attempts to maintain fluid balance. Weight gain is usually associated with water intoxication. Muscle weakness and cardiac dysrhythmias are not associated with water intoxication.

What is a strategy used to minimize scarring with burn injury in a child?

Limitation of period without pressure to areas of scarring Uniform pressure to the scar decreases the blood supply and forces the collagen into a more normal alignment. When pressure is removed, blood supply to the scar is immediately increased; therefore, periods without pressure should be brief to avoid nourishment of the hypertrophic tissue. Moisturizing agents are used with massage to help stretch tissue and prevent contractures. Compression garments, not loose-fitting garments, are indicated. Range of motion exercises are done to minimize contractures.

What condition is often associated with severe diarrhea?

Metabolic acidosis Metabolic acidosis results from the increased absorption of short-chain fatty acids produced in the colon. There is an increase in lactic acid from tissue hypoxia secondary to hypovolemia. Bicarbonate is lost through the stool. Ketosis results from fat metabolism when glycogen stores are depleted. Metabolic alkalosis and respiratory alkalosis do not occur from severe diarrhea.

What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany?

Metabolic and respiratory alkalosis The major symptoms and signs of alkalosis include nervous system stimulation and excitement, including overexcitability, nervousness, tingling sensations, and tetany that may progress to seizures. Acidosis (both metabolic and respiratory) has clinical signs of depression of the central nervous system, such as lethargy, diminished mental capacity, delirium, stupor, and coma. Respiratory alkalosis has the same symptoms and signs as metabolic alkalosis.

The nurse is caring for an 18-month-old child with rotavirus. What clinical manifestations should the nurse expect to observe?

Mild fever and vomiting followed by onset of watery stools Rotavirus is one of the most common pathogens that cause gastroenteritis in children younger than the age of 2 years. Clinical manifestations include mild to moderate fever and vomiting followed by the onset of watery stools. The fever and vomiting usually abate in 1 or 2 days, but the diarrhea persists for 5 to 7 days. Severe abdominal cramping and bloody diarrhea are seen with Escherichia coli infection; colicky abdominal pain and vomiting are seen with salmonella infection; and high fever, diarrhea, and lethargy are seen with infection by Salmonella typhi.

What is the purpose of a high-protein diet for a child with major burns?

Minimize protein breakdown Initially after major burns, there is a hypometabolic phase, which lasts for 2 or 3 days. A hypermetabolic phase follows, characterized by increased body temperature, oxygen and glucose consumption, carbon dioxide production, glycogenolysis, proteolysis, and lipolysis. This response continues for up to 9 months. A diet high in protein and calories is necessary. Healing, not growth, is the primary consideration. Many children have poor appetites, and supplementation is necessary. Hypoglycemia, not hyperglycemia, can occur from the stress of burn injury because the liver glycogen stores are rapidly depleted.

The nurse is caring for a child with hypernatremia. The nurse evaluates the child for which signs and symptoms of hypernatremia? (Select all that apply.)

Nausea Oliguria Dry, sticky mucous Signs and symptoms of hypernatremia are nausea; oliguria; and dry, sticky mucos. Apathy and lethargy are signs of hyponatremia.

What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)?

Neuromuscular irritability Neuromuscular irritability is a clinical manifestation of hypocalcemia. Nausea and vomiting occur with hypercalcemia and hypernatremia. Weakness, fatigue, and muscle hypotonicity are clinical manifestations of hypercalcemia.

What is the nursing action related to the applying of biologic or synthetic skin coverings for a child with partial-thickness burns of both legs?

Observe wounds for signs of infection When applied early to a superficial partial-thickness injury, biologic dressings stimulate epithelial growth and faster wound healing. If the dressing covers areas of heavy microbial contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such infection may convert the wound to a full-thickness injury. Infection is the primary concern when biologic dressings are used.

In what condition should the nurse be alert for altered fluid requirements in children? (Select all that apply.)

Oliguric renal failure Increased intracranial pressure Mechanical ventilation The nurse should recognize that conditions such as oliguric renal failure, increased intracranial pressure, and mechanical ventilation can cause an increase or a decrease in fluid requirements. Conditions such as hypotension, tetralogy of Fallot, and diabetes mellitus (type 1) do not cause an alteration in fluid requirements.

Fentanyl and midazolam (Versed) are given before débridement of a child's burn wounds. What is the purpose of using these medications?

Provide pain relief Partial-thickness burns require débridement of devitalized tissue to promote healing. The procedure is painful and requires analgesia and sedation before the procedure. Fentanyl and midazolam provide excellent intravenous sedation and analgesia to control procedural pain in children with burns.

The nurse suspects shock in a child 1 day after surgery. What should be the initial nursing action?

Provide supplemental oxygen The initial nursing action for a patient in shock is to establish ventilatory support. Oxygen is provided, and the nurse carefully observes for signs of respiratory failure, which indicates a need for intubation. Cardiac monitoring would be indicated to assess the child's status further, but ventilatory support comes first. Oxygen saturation monitoring should be begun. Arterial blood gases would be indicated if alternative methods of monitoring oxygen therapy were not available. The Trendelenburg position is not indicated and is detrimental to the child. The head-down position increases intracranial pressure and decreases diaphragmatic excursion and lung volume.

A 7-year-old child with acute diarrhea has been rehydrated with oral rehydration solution (ORS). The nurse should recommend that the child's diet be advanced to what kind of diet?

Regular diet It is appropriate to advance to a regular diet after ORS has been used to rehydrate the child. Clear liquids are not appropriate for hydration or afterward. A high carbohydrate diet may contribute to loose stools because of the low electrolyte content and high osmolality. The BRAT diet has little nutritional value and is high in carbohydrates.

What flush solution is recommended for intravenous catheters larger than 24 gauge?

Saline The recommended solution for flushing venous access devices is saline. The turbulent flow flush with saline is effective for catheters larger than 24 gauge. The use of heparin does not increase the longevity of the venous access device. In 24-gauge catheters, heparin may offer an advantage. Alteplase is used for treating catheter-related occlusions in children. The heparin and saline combination does not offer any advantage over saline or heparin individually.

What is the most immediate threat to life in children with thermal injuries?

Shock The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis is the primary complication.

Allografts

Skin that is obtained from genetically different members of the same species who are free of disease

Xenografts

Skin that is obtained from members of a different species, primarily pigskin

What clinical manifestations should be observed in a 2-year-old child with hypotonic dehydration? (Select all that apply.)

Slightly moist mucous membranes Absent tears Very rapid pulse Clinical manifestations of hypotonic dehydration include slightly moist mucous membranes, absent tears, and a very rapid pulse. A thick, doughy feel to the skin and hyperirritability are signs of hypertonic dehydration.

Ongoing fluid losses can overwhelm the child's ability to compensate, resulting in shock. What early clinical sign precedes shock?

Tachycardia Shock is preceded by tachycardia and signs of poor tissue perfusion and decreased pulse oximetry values. Respirations are increased as the child attempts to compensate. As a result of the poor peripheral circulation, the child has skin that is cool and mottled with decreased capillary refilling after blanching. In children, lowered blood pressure is a late sign and may accompany the onset of cardiovascular collapse.

The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)

Tachypnea Oliguria Confusion Pale extremities As shock progresses, perfusion in the microcirculation becomes marginal despite compensatory adjustments, and the signs are more obvious. Signs include tachypnea, oliguria, confusion, and pale extremities, as well as decreased skin turgor and poor capillary filling. Hypotension and a thready pulse are clinical manifestations of irreversible shock.

Several types of long-term central venous access devices are used. What is a benefit of using an implanted port (e.g., Port-a-Cath)?

The patient does not need to limit regular physical activity, including swimming. No limitations on physical activity are needed. The child is able to participate in all regular physical activities, including bathing, showering, and swimming. The skin over the device is pierced with a Huber needle to access. Long-term central venous access devices are difficult to use for self-administration. The port is placed under the skin. If the child manipulates the device and plays with the actual port, the catheter can be dislodged.

Autografts

Tissue obtained from undamaged areas of the patient's own body

What finding is the most reliable guide to the adequacy of fluid replacement for a small child with burns?

Urinary output of 1 to 2 ml/kg of body weight/hr Replacement fluid therapy is delivered to provide a urinary output of 30 ml/hr in older children or 1 to 2 ml/kg of body weight/hr for children weighing less than 30 kg (66 lb). Thirst is the result of a complex set of interactions and is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling hematocrit would be indicative of hemodilution. This may reflect fluid shifts and may not accurately represent fluid replacement therapy. Increased seepage from a burn wound would be indicative of increased output, not adequate hydration.

What consideration is important for the nurse when changing dressings and applying topical medication to a child's abdomen and leg burns?

Wash hands and forearms before and after dressing change Frequent hand and forearm washing is the single most important element of the infection-control program. Topical medications should be applied with a tongue blade or gloved hand. Dressings that have adhered to the wound can be removed with tepid water or normal saline. Dressings are applied with sufficient tension to remain in place but not so tightly as to impair circulation or limit motion.

An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation?

Water depletion These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or overhydration. Sodium or potassium excess would not cause these symptoms.

What is an approximate method of estimating output for a child who is not toilet trained?

Weigh diapers after each void Weighing diapers will provide an estimate of urinary output. Each 1 g of weight is equivalent to 1 ml of urine. Having parents estimate output would be inaccurate. It is difficult to estimate how much fluid is in a diaper. The urine collection device would irritate the child's skin. It would be difficult for a toddler who is not toilet trained to sit on a potty chair 30 minutes after eating.

The nurse is teaching a group of female adolescents about toxic shock syndrome and the use of tampons. What statement by a participant indicates a need for additional teaching?

"I can use a superabsorbent tampon for more than 6 hours." Teaching female adolescents about the association between toxic shock syndrome and the use of tampons is important. The teaching should include not using superabsorbent tampons; not leaving the tampon in for longer than 4 to 6 hours; alternating the use of tampons with sanitary napkins; washing hands before inserting a tampon to decrease the chance of introducing pathogens; and informing a health care provider if a sudden high fever, vomiting, muscle pain, dizziness, or a rash that looks like a sunburn appears.

The nurse is teaching a parent of a 10-year-old child who will be discharged with a venous access device (VAD). What statement by the parent indicates a correct understanding of the teaching?

"I should apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed." The parents of a child with a VAD should be taught to apply pressure to the entry site to the vein, not the exit site, if the VAD is accidentally removed. The child should not participate in contact sports, even with a protective vest, to prevent the VAD from becoming dislodged. General malaise is a sign of an infection, not an expected finding after insertion of the VAD. The child can shower or take a bath after insertion of the VAD; the child does not need a sponge bath for any length of time.