Peds-Chapter 13-Interventions
Immediately following administering a medication by enteral tube, the nurse will:
Flush the tube with water. It is important to flush the tube to ensure all of the medication reaches the child's digestive tract and to prevent occlusion of the tube
The pediatric nurse recognizes that what statement is true regarding medications administered via the intravenous route?
Giving medications through the intravenous route is less traumatic than other routes.
The nurse has prepared an IM injection to give a 13-year-old. After some searching, the nurse locates the 13-year-old in the playroom in front of a video game. Which action is the best one for the nurse to take?
Inform the child that it is time for an injection. Explain why the injection is needed and have him move to the procedure room.
A 4-year-old child is admitted to the hospital for surgery. Before you administer medicine, the best way to identify the child would be to:
Read the child's armband. Children may answer to the wrong name to please an adult. For this reason, checking the armband is the best method to identify a child
The nurse is preparing to give a diphtheria, pertussis, and tetanus (DPT) immunization to a child in an acute care setting before discharge. The label on the DPT bottle indicates the immunization expired yesterday. What is the correct nursing action to take?
Return the bottle to the pharmacy and request a replacement.
An infant is to have a scalp-vein intravenous infusion begun. What is an advantage of this insertion site?
The scalp veins are easily visualized. The scalp veins are easily visualized, being covered only by a thin layer of subcutaneous tissue. These veins do not have valves, so the device may be inserted in either direction, although the preference would be in the direction of blood flow.
The student nurse is preparing to care for a recently placed gastrostomy tube. Which action would prompt further instruction from the overseeing nurse?
The student obtains an antimicrobial soap to clean the area surrounding the tube. The skin around a gastrostomy tube requires cleaning at least once a day. Routine site care includes gentle cleansing with sterile water or saline for newly placed tubes, or for established tubes, soap and water followed by rinsing or cleaning with water alone
A nurse is educating the parents how to administer daily oral medication to their 5-year-old boy. Which response indicates a need for further teaching?
"He needs to take his medicine or he will lose a privilege."
8 rights of medication administration
1. Right medication 2. Right patient 3. Right time 4. Right route 5. Right dose 6. Right documentation 7. Right to be educated 8. Right to refuse
A child who is receiving TPN has developed the need to have insulin injections. The child's mother questions thia and states that her child does not have diabetes. What is the appropriate response by the nurse?
"The feedings are high in sugar and insulin is needed to manage this.
The nurse is caring for a 12-year-old post-appendectomy client who weighs 86 pounds. The child has a temperature of 38.5 ºC (101.3 ºF). The nurse prepares to give the client a dose of oral Tylenol. The order reads "Tylenol 15mg/kg/dose every 4 to 6 hours PO PRN for fever or pain." How many milligrams of Tylenol should the nurse give the client?
587 milligrams The child's weight must first be converted to kilograms by dividing 86 by 2.2. The result is 39.1 kilograms. Next, the 39.1 kilograms must be multiplied by 15 milligrams. This answer is 587 milligrams.
The nurse is preparing to administer medication to a 10-year-old who weighs 70 lb (32 kg). The prescribed single dose is 3 to 4 mg/kg per day. Which dose range is appropriate for this child?
96 to 128 mg
An infant is to receive a hepatitis B vaccine within a few hours after birth. What is the best approach for the nurse to take when giving this medication?
Administer the medication in the infant's vastus lateralis with a 25-gauge needle. The vastus lateralis site is a safe choice for IM injections in an infant. A 25-gauge needle is recommended for infants. The dorsogluteal site should not be used until the child has been walking for one year. The deltoid muscle is not a recommended IM site for infants
To gain a preschooler's cooperation to swallow an oral medication, your best approach would be to:
Ask if he would like to take his medicine in a cup or through an oral syringe.
A child needs a peripheral IV start as well as a venous blood sample for a laboratory test. The nurse will take what action?
Coordinate placing the peripheral IV and the lab blood draw. Coordinate the IV placement and lab blood draw to minimize the number of venipunctures for the child. Gaining venous access for each purpose separately does not do this and is not necessary.
A nurse is preparing a dose of insulin to give her client. Which action should the nurse take when giving this medication?
Double-check the dose with another RN before giving.
A 3-year-old boy has been admitted for a tonsillectomy. He is fussy and crying and appears nervous about the procedure. The boy's father is in the room with the child, and the father also appears anxious. Which action by the nurse would be most helpful in alleviating both the child's and the father's anxiety?
Explain the procedure and answer the father's questions completely; stay with the child and father until the father relaxes
The nurse is preparing to give a 4-month-old an oral medication. Which technique demonstrates the nurse's accurate knowledge of the infant's developmental level?
Position the infant upright, offer the infant a bottle of formula, remove the bottle and squirt the medication on the side of the tongue towards the cheek, then offer the infant the bottle again.
The nurse is preparing to administer a medication via a syringe pump as ordered for a 2-month-old girl. Which is the priority nursing action?
Verify the medication order
The nurse is assessing the aspirate of a gavage feeding tube to confirm placement. Which assessment finding indicates intestinal placement?
Yellow aspirate Yellow or bile-stained aspirate indicates intestinal placement. Clean, tan, or green aspirate indicates gastric placement.
Which assessment is the most important for determining an accurate dose of a pediatric medication?
Body surface area Body surface area (BSA) is the most accurate measure for dosing medications for children. In pediatrics, there are no standard amounts of a drug given per age; rather, dosage is based on weight using an established amount of the drug per body weight.
The nurse is caring for a child with an ileostomy. What nursing intervention will be included in this child's plan of care?
Check for leakage around the stoma. An ileostomy is made by bringing a part of the small intestine through the abdominal wall to create an outlet for fecal material. The drainage from the ileostomy contains digestive enzymes, so the stoma must be fitted with a collection device to prevent skin irritation and breakdown. A colostomy is a similar opening in the colon that allows fecal material to be eliminated. A new colostomy may be left open to the air; alternatively a bag, pouch, or other appliance may be used to collect the stool. A urostomy may be created to help in the elimination of urine. Ostomy bags should be checked for leakage, emptied frequently, and changed when needed.
A nurse is administering intravenous medication to a 13-year-old boy. Which potential complication should the nurse be especially concerned about in this situation?
Infiltration into surrounding tissues Despite its common use, IV therapy with children is not without problems. Because children move about a great deal and tend to remove bandages, all IV access sites must be assessed at least hourly for signs of infiltration.
A nurse is administering ear drops to a 7-year-old girl. What should the nurse do?
Pull the pinna of the ear up and back to straighten the external ear canal. Remind the child ear drops can feel odd, as if someone were tickling the ear. Ear drops must always be used at room temperature or warmed slightly as cold fluid, such as medication taken from a refrigerator, does cause pain and may also cause severe vertigo as it touches the tympanic membrane. If the child is older than 2 years, pull the pinna of the ear up and back. Instill the specified number of drops into the ear canal. Hold the child's head in the sideways position while you count to 60 to ensure the medication fills the entire ear cana
The nurse is administering a tube feeding to a child. The nurse aspirates the stomach contents as part of the process for checking placement of the tube. Which action is correct for the nurse to do with the aspirated stomach contents?
The nurse should measure and replace the residual stomach contents. Aspirate, measure, and replace the residual stomach contents at the beginning of the procedure.
The nurse is preparing to administer a vaccine to a 6-month-old child. The medication is to be given intramuscularly. The nurse is correct in choosing which administration site?
Vastus lateralis site The preferred injection site for infants less than 7 months old is the vastus lateralis muscle. In infants and children greater than 7 months old the ventrogluteal site should be considered. The dorsogluteal site, often used in adults, is not recommended in children younger than 5 years of age. The deltoid muscle may be used in a child older than 3 years of age.
The nurse is calculating the urinary output for the infant. The infant's diaper weighed 40 grams prior to placing the diaper on the infant. After removal of the wet diaper, the diaper weighed 75 grams. How many milliliters of urine can the nurse document as urinary output? Record your answer using a whole number.
35 The diaper must be weighed before being placed on the infant and after removal to determine urinary output. For each 1 gram of increased weight, this is the equivalent of 1 milliliter of fluid. 75 grams - 40 grams = 35 grams = 35 mL
A child is being discharged from the hospital and the nurse has completed discharge teaching regarding prescribed liquid medications. Which comments by the parent demonstrates understanding of discharge instructions for safe medication administration?
• "I shouldn't use a liquid dropper from my kitchen because it may be a different measurement than one from the pharmacy." • "I will be sure to not give too much of the liquid medication at one time." • "I need to make sure to use the medicine dropper the pharmacy gives me instead of the syringe I use for my B12 injections."
A preschooler who is receiving gastrostomy feedings occasionally vomits following a feeding. When the parent describes the feeding process, what does the nurse note as the likely cause of the vomiting?
The mother does not check gastric residual prior to feedings. Because gastric residual (amount left in the stomach from prior feeding) is not checked before feeding, there may be times the child's stomach is overfilled when the current nutritional material is added. Aspirating to measure residual would confirm this as well as provide data about how fast the child's stomach is emptying. The feeding plan may need to be modified.
