vSim - Sabina Vasquez
The nurse is caring for a patient who is showing signs of respiratory distress. List the interventions in the order that they should be performed.
1) Elevate the head of the bed and reposition the client. 2) Encourage the patient to cough to clear the airway. 3) Apply oxygen and titrate flow as needed. 4) Collect sputum to send to the lab for culture. 5) Administer an antipyretic and antibiotics as ordered. The priority is to consider airway, breathing, and circulation. Elevating the head of the bed, assisting the patient into a position of comfort, and encouraging the patient to cough will help to open the airway. Oxygen administration will ease the overall work of breathing. It is important to obtain any cultures prior to administering antibiotics or antipyretics.
The provider has given an order for acetaminophen suspension 240 mg orally every 4 to 6 hours as needed for fever. Which of the following considerations does the nurse need to remember when administering acetaminophen? a) Acetaminophen can affect laboratory test results for white blood cell count, hemoglobin, and hematocrit. b) Food must be given with acetaminophen to reduce gastrointestinal upset. c) Pediatric doses of acetaminophen should not exceed 4,000 mg daily. d) In high doses, acetaminophen has nephrotoxic effects and can cause renal failure.
a) Acetaminophen can affect laboratory results for white blood cell count, hemoglobin, and hematocrit. Acetaminophen can affect laboratory test results, causing decreases in the following: glucose, hemoglobin, hematocrit, and neutrophil levels and white blood cell, red blood cell, and platelet counts. Acetaminophen does not cause gastrointestinal upset and can be given without regard to food. Excessive doses of acetaminophen can have a hepatotoxic, no nephrotoxic, effect and can cause liver, not renal, failure. Adult doses of acetaminophen should not exceed 4,000 mg daily. Maximum dosing of acetaminophen for pediatrics varies by age and weight, but dosing should not exceed five doses in a 24 hour period.
The nurse is planning care for a preschooler hospitalized with pneumonia. Which of the following are appropriate choices to offer when administering oral medications? (Select all that apply.) a) After you take your medicine, would you like a puppy sticker or a heart sticker? b) Which do you want to take first: the pink medicine or the yellow medicine? c) Who do you want to squirt the medicine in your mouth, you or me? d) Would you like to take your medicine now? e) Do you want to drink water or apple juice with your medicine?
a) After you take your medicine, would you like a puppy sticker or a heart sticker? b) Which do you want to take first: the pink medicine or the yellow medicine? c) Who do you want to squirt the medicine in your mouth, you or me? e) Do you want to drink water or apple juice with your medicine? When administering medications to preschoolers, provide simple choices that are possible. Do not offer a choice when one is not available.
A patient arrives at the emergency department in respiratory distress with a history of asthma. Upon assessment, the nurse notes that the patient sits forward with intercostal retractions, has a productive cough, and wheezes upon auscultation. Which of the following interventions is most appropriate for the nurse to implement at this time? a) Elevate the head of the bed and allow the patient to assume a position of comfort b) Apply a pulse oximeter and have the patient lie down to conserve energy c) Obtain a throat culture and administer an expectorant to help clear secretions d) Encourage the patient to drink clear liquid to replace insensible fluid losses
a) Elevate the head of the bed and allow the patient to assume a position of comfort The priority is to consider the ABCs. Elevating the head of the bed and assisting the patient into a position of comfort will help to open the airway and aid in the work of breathing. A throat culture is not needed, as the symptoms indicate a lower airway condition. Expectorants are contraindicated for asthma exacerbations as further airway irritation and bronchoconstriction may occur. Patients in respiratory distress should limit oral intake to reduce the risk of aspiration. Measuring the patient's oxygen saturation and having the patient lie down to conserve energy are not priority interventions at this time for a patient in respiratory distress. Having the patient lie down can cause further respiratory distress.
After giving discharge instructions, which response by Sabina's mother indicates that teaching has been effective? a) Even if she is feeling better, Sabina must finish taking her oral antibiotics as ordered. b) I will need to bring Sabina back to the hospital if her cough doesn't resolve in a few days. c) If Sabina starts to breathe fast, I need to make sure she is drinking enough to stay hydrated. d) It is normal for Sabina to feel tired, so I will make sure she stays in bed to get plenty of rest.
a) Even if she is feeling better, Sabina must finish taking her oral antibiotics as ordered. Completion of the entire course of antibiotics is key to prevent antibiotic resistance and recurrence of infection. Pneumonia is a self-limiting disorder. The patient may tire easily for up to two weeks, but activity should be encouraged as able. Oral hydration is important, but if the patient experiences tachypnea or increased work of breathing, limited fluids should be given by mouth to avoid aspiration.
A nurse is explaining the pathophysiology of asthma and asthma exacerbations to a group of nursing students at a workshop. Which of the following statements would be most accurate for the nurse to make? (Select all that apply.) a) Exposure to bacterial and viral infections increases airway responsiveness and inflammation b) Chronic inflammation contributes to irreversible airway changes and decreased lung function c) Frequent contact with triggers desensitizes the airways and improves overall lung function d) The smooth muscles in the airway increase in responsiveness, causing bronchoconstriction e) Airway mucus secretion is inhibited, decreasing the risk of infection and airway plugging
a) Exposure to bacterial and viral infections increases airway responsiveness and inflammation b) Chronic inflammation contributes to irreversible airway changes and decreased lung function d) The smooth muscles of the airway increase in responsiveness, causing bronchoconstriction The acute inflammatory process in asthma consists of acute bronchoconstriction, airway edema, and increased mucus production. Chronic inflammation results from repeated exposure to triggers, causing hypersensitive airways and permanent remodelling. Both processes result in decreased pulmonary function and decreased ability to compensate when exposed to viral or bacterial respiratory infections.
The nurse is preparing a 5-year-old for a chest x-ray. Which of the following statements would be the nurse's best explanation of this procedure to the patient? a) I am sending you to have a big camera take pictures of your body. b) I am going to put you on a stretcher before you go down to have your chest x-ray. c) It is a special test that doesn't hurt; you won't feel any pain or discomfort. d) You will be in the x-ray department for about an hour; your mom can go with you.
a) I am sending you to have a big camera take pictures of your body. It is important to explain procedures to a child in simple terms that are nonthreatening. The terms stretcher, x-ray, and test may be too technical or confusing, causing the child to misunderstand what is going to occur. When explaining time frames to small children, it is important to use points of reference that are familiar to them (i.e., the length of a cartoon or the time after dinner) as they may not have a firm understanding of the concept of time.
What techniques can the nurse employ when providing care for Sabrina and her family to reduce the overall stress of hospitalization? (Select all that apply.) a) Use a certified medical interpreter to aid in communication. b) Involve the family in daily care and give the patient simple choices when possible. c) Complete all discharge teaching in one session. d) Have family members and visitors help explain medical information. e) Provide copies of written materials in both English and Spanish.
a) Use a certified medical interpreter to aid in communication. b) Involve the family in daily care and give the patient simple choices when possible. e) Provide copies of written materials in both English and Spanish. An interpreter should be used for all medical communication, not family members and visitors. This helps ensure that the patient and family can read and understand all written and translated materials. It is important to provide patients and families with written handouts and visuals in both English and their primary language to help reinforce communication and teaching. Including the patient and family in daily care allows them to have a sense of control during hospitalization and reinforced as necessary to avoid information overload.
Which of the following children should receive the pneumococcal vaccine? (Select all that apply.) a) 3-year-old who is healthy with up-to-date vaccines b) 3-year-old who has not received any immunizations. c) 2-month-old who is at a well-child checkup. d) 4-year-old with congenital heart disease who has received an age-appropriate series. e) 6-month-old who was born at 25 weeks gestation.
b) 3-year-old who has not received any immunizations. c) 2-month-old who is at a well-child checkup. d) 4-year-old with congenital heart disease who has received an age-appropriate series. e) 6-month-old who was born at 25 weeks gestation. The pneumococcal conjugate vaccine (PCV13) should be given to all infants at 2, 4, and 6 months of age, with a booster dose at 12 through 15 months of age. Previously unvaccinated, healthy children 24 months through 4 years of age only need to receive one dose of the vaccine. Additional doses of PCV13 may be recommended, depending on the child's age and health status, such as presence of congenital heart disease. The pneumococcal polysaccharide vaccine is recommended for use in children who are 2 years and older and at high risk for diseases, such as those with immune deficiencies or other chronic conditions like sickle-cell disease.
A nurse must administer maintenance fluid intravenously to a patient weighing 43 lb. What is the daily maintenance fluid requirement for this patient? a) 2,992 mL/day b) 1,960 mL/day c) 1,475 mL/day d) 2,400 mL/day
c) 1,475 mL/day Daily maintenance fluid requirement is calculated using the 100-50-20 formula. Convert pounds to kilograms: 43/2.2 = 19.5 kg. Multiply 100 by the first 10 kg: 100 x 10 = 1,000. Multiply 50 by the second 10 kg: 50 x 9.5 = 475. Add the sum of the calculations together to get the daily fluid maintenance: 1,000 + 475 = 1,475.
During assessment, the pediatric patient reports good control of asthma symptoms with no interferences in daily activities and one incidence of nighttime coughing in the past month. The patient uses a rescue inhaler occasionally during the week of asthma exacerbations. The patient would be classified as having which of the following levels of asthma severity? a) Mild persistent b) Severe persistent c) Mild intermittent d) Moderate persistant
c) Mild intermittent Asthma severity is classified based on the following: type, frequency, and timing of symptoms reported; lung function; interferences with normal ADLs; and frequency of use of short-acting B2 agonists for symptom control. Patients with mild intermittent asthma experience daily symptoms 1 or 2 times a week and nighttime symptoms 1 or 2 times a month. Forced expiratory volume is greater than or equal to 80% of predicted values. The patient experiences no interferences with normal activity and uses short-acting B2 agonists 1 or 2 days a week.
The nurse is preparing Sabrina for her nebulized albuterol treatment. Which of the following demonstrates that the nurse understands developmentally appropriate communication? a) The breathing treatment will take approximately 15 minutes. b) The breathing treatment is noisy and you will see some smoke, but it doesn't hurt. c) Some kids say the breathing treatment makes them feel a little shaky. d) It is time to take your breathing treatment now, OK?
c) Some kids say the breathing treatment makes them feel a little shaky. It is important to explain procedures to a child in simple terms that are nonthreatening but that will identify any sensations they may experience, such as feeling shaky. The use of terms such as OK or asking whether the patient wants to do something offers the illusion of a choice when there is not one available. When explaining time frames to small children, it is important to use points of reference that are familiar to them (i.e., the length of a cartoon or the time after dinner) as they may not have a firm understanding of the concept of time. Avoid terms that are too technical or confusing causing the child to misunderstand what is going to occur. Hearing "smoke" may cause the child to think that something will be burning or on fire.
Sabina was discharged with instructions to complete the course of oral azithromycin started during her hospitalization. The next day, her mother calls asking how to prepare the medication for administration. How would the nurse instruct the mother to prepare 3.8 mL of this medication for administration? a) Fill a medicine cup with the medication, stopping between the 2.5-mL and 5-mL marks. b) Hide the medication in an 8-oz glass of juice so that Sabina won't taste it. c) Use the calibrated syringe provided to draw up the medication and check dose at eye level. d) Use a regular teaspoon to measure out the prescribed amount.
c) Use a calibrated syringe provided to draw up the medication and check dose at eye level. The most accurate way to prepare to ordered amount of medication is to have the parent measure it using a calibrated oral syringe. A medication cup will not be as accurate when preparing the ordered dose. Household cups and measuring spoons are not calibrated and may deliver an incorrect dose. If the medication is mixed into an entire glass of juice and then the patient does not drink the full amount, the parent will be unable to determine how much medication the patient has ingested.
A patient weighing 43 lb has an order for intravenous cefuroxime 475 mg every 8 hours. The safe dose range is 50 to 100 mg/kg/day. Is this order safe? a) No, the safe range is 975 to 1,950 mg/day. b) Yes, the safe range is 2,150 to 4,300 mg/day c) Yes, the safe range is 975 to 1,950 mg/day . d) No, the safe range is 2,150 to 4,300 mg/day.
c) Yes, the safe range is 975 to 1,950 mg/day. Convert pounds to kilograms: 43/2.2 = 19.5 kg. Multiply low end of dosage range by weight: 50 x 19.5 = 975 mg/day. Multiply high end of dosage range by weight: 100 x 19.5 = 1,950 mg/day. Safe dosage range equals 975 to 1,950 mg/day. Divide daily safe dosage range by frequency of administration per day: 975 /3 = 325 mg/dose; 1,950/3 = 650 mg/dose. The ordered dose of cefuroxime 475 mg falls within the range of 325 to 650 mg/dose, so the ordered dose is safe to administer.
A nurse observes that a preschooler who is hospitalized appears stressed. Which of the following is the most likely stressor for this child? a) Disruption in autonomy b) Separation anxiety c) Loss of control d) Fear of mutilation
d) Fear of mutilation While preschoolers may experience other stressors related to hospitalization, the primary stressor is fear of mutilation and invasive procedures as they do not understand the body's integrity. Separation anxiety, loss of control, and disruption in autonomy are more characteristic of toddlers than of preschoolers.
When teaching Sabina's mother how to recognize respiratory distress, what is the best way to determine whether the teaching has been effective? a) Send the mother to watch a video on the signs and symptoms. b) Ask whether the mother has any questions. c) Offer the mother a handout and ask whether she understands the information. d) Have the mother point to areas on the body and describe what she is looking for.
d) Have the mother point to areas on the body and describe what she is looking for. Return demonstration, or re-teaching of knowledge, is the most effective way to ensure that patients and families understand the information provided.
The nurse is caring for a patient hospitalized with an asthma exacerbation secondary to pneumonia. Which of the following is the highest priority nursing diagnosis for this patient? a) Fear related to difficulty breathing and unfamiliar hospital environment. b) Readiness for enhanced family coping related to increased control of asthma with daily therapeutic care. c) Risk for deficient fluid volume related to decreased oral intake. d) Impaired gas exchange related to excess mucous production and carbon dioxide retention.
d) Impaired gas exchange related to excess mucous production and carbon dioxide retention. The highest priority nursing diagnosis for a child with asthma exacerbation and pneumonia is impaired gas exchange. The other nursing diagnoses are appropriate but are not the highest priority.
A nurse is administering medications and fluids intravenously to a pediatric patient. Which of the following must the nurse do to prevent complications? a) Inspect the insertion sire once per day for signs of inflammation or infiltration. b) Rotate the insertion site every 72 hours to reduce the risk of contamination. c) Layer tape over the insertion site and connections to ensure they are secure. d) Use standard precautions when assessing the insertion site and handling tubing per institution protocol.
d) Use standard precautions when assessing the insertion sire and handling tubing per institution protocol. Adherence to standard precautions is crucial to reduce the risk of contamination and associated complications. Transparent dressings and intravenous houses keep the device secure while allowing for easy visualization and assessment. The insertion sire should be inspected every 1 to 2 hours, not once per day, for patency and signs of complications. In pediatrics, the time frame for site rotations is extended to when clinically indicated and may be adjusted to minimize the patient's exposure to repeated trauma of insertion.
