411 Pediatric Emergency
A young patient in the intensive care unit is in a coma after a severe head injury. The primary nurse is teaching a nursing student how to assess the patient's level of consciousness by using a coma scale. This scale is referred to as which of the following? a) Apgar scale b) Visual analogue scale c) Glasgow scale d) Wong-Baker FACES scale
Glasgow scale Correct Explanation: The Glasgow Coma Scale is used to grade coma according to level of consciousness. The Apgar score is assigned immediately after delivery to determine how the infant tolerated the birth. Wong-Baker FACES and the visual analogue scales are used to rate pain.
A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 BPM. Choose the priority intervention: a) Administer doses defibrillator shocks in a row b) Initiate cardiac compressions c) Give three doses of epinephrine d) Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR)
Initiate cardiac compressions Correct Explanation: The American Heart Association (AHA) emphasizes the importance of cardiac compressions in pulseless clients with arrhythmias, making this the priority intervention in this situation. Current AHA recommendations are for defibrillation to be administered once followed by five cycles of CPR. The AHA now recommends against using multiple doses of epinephrine because they have not been shown to be helpful and may actually cause harm to the child.
A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 BPM. Choose the priority intervention: a) Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR) b) Initiate cardiac compressions c) Administer doses defibrillator shocks in a row d) Give three doses of epinephrine
Initiate cardiac compressions Explanation: The American Heart Association (AHA) emphasizes the importance of cardiac compressions in pulseless clients with arrhythmias, making this the priority intervention in this situation. Current AHA recommendations are for defibrillation to be administered once followed by five cycles of CPR. The AHA now recommends against using multiple doses of epinephrine because they have not been shown to be helpful and may actually cause harm to the child.
Cardiopulmonary resuscitation (CPR) is in progress on an 8-year-old boy who is in shock. Which is the priority nursing intervention? a) Using a large bore catheter for peripheral venous access b) Inserting an indwelling urinary catheter to measure urine output c) Attaining central venous access via the femoral route d) Drawing a blood sample for arterial blood gas analysis
Attaining central venous access via the femoral route Correct Explanation: Attaining central venous access is the priority intervention for a child in shock who is receiving respiratory support. Gaining access via the femoral route will not interfere with CPR efforts. Peripheral venous access may be unattainable in children who have significant vascular compromise. Blood samples and urinary catheter placement can wait until fluid is administered.
A 3-year-old boy has been brought to the doctor's office with symptoms of anorexia and abdominal pain. A blood test reveals a lead level of 20 μg/100 mL. The child is prescribed an oral chelating agent. On discharge, the nurse should counsel the parents regarding which of the following? a) Putting child safety locks on kitchen cabinets b) Placing house plants out of reach of children c) Putting medicine away where children cannot reach it d) Removal or covering of flaking paint on the walls of the home
Removal or covering of flaking paint on the walls of the home Correct Explanation: The usual sources of ingested lead are paint chips or paint dust, home-glazed pottery, or fumes from burning or swallowed batteries. A child with a blood lead level over 5 μg/dL needs to be rescreened to confirm the level and then active interventions begun to prevent further lead exposure such as removal of the child from the environment containing the lead source or removal of the source of lead from the child's environment. Removal of the lead source is not an easy task in homes because simple repainting or wallpapering does not necessarily remove the source of peeling paint adequately. After some months, the new paint will begin to peel because of the defective paint underneath. The walls must therefore be covered by paneling or dry wall or other solid protective material. The other answers refer to safety measures to prevent other types of poisoning, such as from household cleaners, medicine, and plants.
The nurse is ventilating a 9-year-old girl with a bag valve mask. Which action would most likely reduce the effectiveness of ventilation? a) Referring to Broselow tape for bag size b) Setting the oxygen flow rate at 15 L/minute c) Pressing down on the mask below the mouth d) Checking the tail for free fl ow of oxygen
Setting the oxygen flow rate at 15 L/minute Correct Explanation: An adolescent, not a 9-year-old, would most likely require an oxygen flow rate of 15 L/minute for effective ventilation. A flow rate of 10 L/minute is appropriate for infants and children. All other options are valid for preparing to ventilate with a bag valve mask.
A 10-year-old boy who was in a car wreck has been brought to the emergency room for evaluation. He appears to have suffered abdominal trauma do to his seat belt. He has tenderness in the left upper quadrant of the abdomen, especially on deep inspiration. Given these circumstances, the nurse should suspect injury to which of the following organs? a) Pancreas b) Spleen c) Liver d) Stomach
Spleen Correct Explanation: In children, the spleen is the most frequently injured organ when there is abdominal trauma, because it is usually palpable under the lower left rib. Frequent causes of injury are inappropriately applied seat belts in automobiles, handlebar injuries in bicycle accidents, or skateboard or snowboard accidents. The child will have tenderness in the left upper quadrant, of the abdomen, especially on deep inspiration, when the diaphragm moves down and touches the spleen.
The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern? a) Palpation of the head reveals a closed posterior fontanel. b) The child is crying and looking around fearfully. c) The child's eyes remain closed unless she is spoken to. d) Inspection shows a sluggish pupillary reaction.
Inspection shows a sluggish pupillary reaction. Correct Explanation: A sluggish pupillary reaction may occur with increased intracranial pressure, which would be cause for concern. A closed posterior fontanel in an 11-month-old would be a normal finding. Crying and looking around are encouraging signs indicating improved neurologic status. Opening the eyes when being spoken to is an encouraging sign.
A 14-month-old trauma victim has arrived in the emergency department. Which of the following challenges will the nurse need to address first? a) Risks from reduced core temperature b) Inadequate systemic perfusion c) Increased metabolic demands d) Possible tissue damage from hypoxia
Possible tissue damage from hypoxia Explanation: Oxygen should be administered by a non-rebreather mask until oxygenation and perfusion status is completely assessed. This will stabilize the effects of hypoxia. Reduced core temperature and resultant metabolic demands, as well as the need for epinephrine, are secondary to the ABCs (airway, breathing, and circulation).
A 7-year-old girl is in the intensive care unit following a bicycle accident. Which of the following would be most helpful in providing support to the girl's parents? a) Giving them brief explanations of procedures b) Encouraging them to read to their daughter c) Describing the treatment plan for their daughter d) Providing honest answers in a reassuring manner
Providing honest answers in a reassuring manner Correct Explanation: Providing honest answers to the parents' questions and concerns in a reassuring manner will provide the most support. Procedures and treatment plans should be explained in terms they can understand and repeated patiently, if need be. Encouraging the parents to read to their daughter will involve them in their child's care and help normalize the situation for the child.
The nurse is caring for a 4-year-old boy who is receiving mechanical ventilation. Which is the priority intervention when moving this child? a) Monitoring the pulse oximeter for oxygen saturation b) Checking the CO2 monitor for a yellow display c) Watching for disconnections in the breathing circuit d) Auscultating the lungs for equal air entry
Checking the CO2 monitor for a yellow display Explanation: Exhaled CO2 monitoring is recommended when a child has been intubated. It provides quick, visual assurance that the tracheal tube remains in place and that the child is being adequately ventilated. When moving the child, maintaining tube placement would be crucial. The other interventions would also be appropriate but not as essential as monitoring the child's exhaled CO2 level. Unlike the other interventions, exhaled CO2 monitoring can provide an early sign of a problem.
The child's ability to perfuse well 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 pounds. Calculate the amount of normal saline the nurse should administer as a bolus. Round to the nearest whole number. _____ mL
709 Explanation: 78 pounds x 1 kg/2.2 pounds = 35.455 kg x 20 mL/kg = 709.1 mL. When rounded to the nearest whole number = 709 mL
The nurse has been monitoring the child's vital signs. The child is 7 years old. Calculate the child's minimum acceptable systolic blood pressure. ____
84 Use the following formula (according to Pediatric Advance d Life Support (PALS): 70 + (2 times the age in years) Hence, the minimal systolic BP of a 7-year-old is 70 = (2 x 7) = 84.
The nurse is preparing to insert an oropharyngeal airway. Which action would be most appropriate to determine the proper size? a) Measuring from the tip of the nose to earlobe to middle of xiphoid process b) Measuring distance from end of nose to tragus of ear c) Placing the airway next to the cheek with tip pointing down d) Inspecting the child's fifth digit to estimate the diameter
Placing the airway next to the cheek with tip pointing down Explanation: The nurse determines the correct size by placing it next to the child's cheek with the tip pointing down. An airway that is too large will extend past the angle of the child's mandible and can obstruct the glottic opening when inserted. Measuring the distance from the end of the nose to the tragus of the ear is appropriate for a nasopharyngeal airway. Looking at the child's fifth digit reflects the approximate diameter of the nasopharyngeal airway. Measuring from the tip of the nose to the earlobe to the middle area between the xiphoid process and umbilicus is used to determine the length of a nasogastric tube.
The nurse is examining a 10-year-old boy with tachypnea and increased work of breathing. Which finding is a late sign that the child is in shock? a) Significantly decreased skin elasticity b) Delayed capillary refill with cool extremities c) Blood pressure slightly less than normal d) Equally strong central and distal pulses
Significantly decreased skin elasticity Explanation: Decrease skin turgor is a late sign of shock. Blood pressure is not a reliable method of evaluating for shock in children because they tend to maintain normal or slightly below normal blood pressure in compensated shock. Equal central and distal pulses are not a sign of shock. Delayed capillary refill with cool extremities are signs of shock that occur earlier than changes in skin turgor.
After assessing a child's airway, breathing, and circulation (ABCs), which of the following would the nurse do next? a) Remove the child's clothing. b) Obtain a full set of vital signs. c) Assess level of consciousness. d) Provide pain management.
Assess level of consciousness. Correct Explanation: Once the ABCs are completed, the nurse's next step is to assess the child's level of consciousness or disability. This would be followed by removing the child's clothing and diaper (exposure) to assess for underlying signs of illness or injury. Next, full vital signs are taken while facilitating the family presence, followed by giving comfort by managing pain and providing emotional support. The acronym ABCDEFG is a useful reminder of the order of assessment: airway, breathing, circulation, disability, exposure, full vital signs and facilitating family, and giving comfort.
A 16-year-old boy is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to which of the following? a) Play-related injuries b) Falls from beds c) Automobile accidents d) Falls from staircases
Automobile accidents Correct Explanation: Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-aged children, and falling from staircases is a common injury among toddlers.
A home care nurse provides health education to parents regarding the care of their toddler. Which of the following precautions should the nurse suggest the parents take to protect the toddler from drowning? 1) Teach the toddler water is bad 2) Tell the toddler to stay away from the pool 3) Avoid unattended baths for the toddler.
Avoid unattended baths for the toddler. Correct Explanation: The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool or teaching them that water is dangerous is insufficient to ensure safety.
A 14-year-old girl arrives at the hospital in a comatose state. Her father, who found her comatose in her room, tells you that she has an opiate addiction. Which of the following would confirm that the coma was caused by opiate intoxication? a) Both pupils are pinpoints b) Both pupils are dilated c) One pupil dilated and the other normal d) One pupil dilated and the other deviated downward
Both pupils are pinpoints Correct Explanation: Observe the child's eyes for signs of dilated pupils from increased ICP. If both pupils are dilated, irreversible brainstem damage is suggested, although such a finding may also be present with poisoning with an atropine-like drug. Pinpoint pupils suggest barbiturate or opiate intoxication. One pupil dilated or the eye deviated downward or laterally more than the other suggests third cranial nerve compression or a tentorial tear (laceration of the membrane between the cerebellum and cerebrum) with herniation of the temporal lobe into the torn membrane.
When a poison has been ingested by a child, the parents should be instructed to do which of the following first? a) Induce vomiting. b) Call the local poison control center. c) Administer an emetic. d) Get to an emergency facility.
Call the local poison control center. Correct Explanation: Not all poisons should be vomited. Strong acids, for example, could cause as much destruction of tissue being vomited as being swallowed. The poison control center will provide the most accurate information on the next steps for the patient.
The condition of an 11-year-old boy who is on mechanical ventilation begins to deteriorate. Which of the following would the nurse do next? a) Confirm that the ventilator is working properly. b) Examine the child for signs of pneumothorax. c) Suction the tube to remove a mucus plug. d) Check to see if the tracheal tube is displaced.
Check to see if the tracheal tube is displaced. Explanation: Use the mnemonic DOPE for troubleshooting when the status of a child who is intubated deteriorates. This means checking for displacement and disconnections first. Checking the ventilator, suctioning for obstruction, and examining for signs of pneumothorax would come later.
A 7-year-old boy is brought to the emergency room by his parents following an accident in which he was struck in the back of the head with a baseball bat. The nurse is assessing him. Which of the following would indicate increased intracranial pressure in this child? a) Decrease in pulse and temperature and increase in respiratory rate and pulse pressure b) Decrease in temperature and pulse pressure and increase in pulse and respiratory rate c) Decrease in pulse and pulse pressure and increase in temperature and respiratory rate d) Decrease in pulse and respiratory rate and increase in temperature and pulse pressure
Decrease in pulse and respiratory rate and increase in temperature and pulse pressure Explanation: All children with head trauma require a neurologic assessment as soon as they are seen and again at frequent intervals to detect signs and symptoms of increased intracranial pressure (ICP) as increasing pressure puts stress on the respiratory, cardiac, and temperature centers, causing dysfunction in these areas. The mark of increased pressure is a decrease in pulse and respiratory rate and an increase in temperature and pulse pressure (the distance between the diastolic and systolic pressure). The child's pupils also become slow or unable to react immediately. Level of consciousness and motor ability both also decrease.
Administration of which medication reverses histamine release and hypotension that are seen in anaphylaxis? a) Atropine b) Epinephrine c) Benadryl d) Zantac
Epinephrine Correct Explanation: Epinephrine reverses histamine release and hypotension due to anaphylaxis.
An unconscious client is brought to the emergency department after ingesting too much prescribed medication. Which of the following is the highest priority nursing intervention? a) Establish a patent airway. b) Establish IV access. c) Call family members. d) Administer antacids.
Establish a patent airway. Correct Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function. This is a priority over communication with the family, establishing IV access or administering other medications.
A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which of the following actions should the nurse take first? a) Provide oral analgesics as ordered. b) Draw blood for type and cross-match. c) Begin hyperventilation. d) Establish a suitable IV site.
Establish a suitable IV site. Correct Explanation: The goal of treating shock is to restore circulating blood volume. This requires that vascular access be obtained to administer fluids and vasoactive drugs. Hyperventilation is reserved for temporary treatment of severe intracranial pressure. Analgesics should not be administered prior to neurologic and cardiovascular examination being performed. Chelation therapy is a treatment for metallic poisoning.
A child is learning to ride a bicycle. He should be instructed to use a(an) a) Helmet b) Knee pads c) Light d) Wrist guard
Helmet Correct Explanation: Children should wear properly fitted helmets when cycling, riding, or playing contact sports
The nurse is caring for a 10-month-old infant with signs of respiratory distress. Which is the best way to maintain this child's airway? a) Inserting a small towel under shoulders b) Using the head tilt chin lift technique c) Employing the jaw-thrust maneuver d) Placing the hand under the neck
Inserting a small towel under shoulders Explanation: Inserting a small, folded towel under shoulders best positions the infant's airway in the "sniff" position as is recommended by the American Heart Association (AHA) Basic Cardiac Life Support (BCLS) guidelines. The hand should never be placed under the neck to open the airway. The head tilt chin lift technique and the jaw-thrust maneuver are used with children over the age of 1 year.
A 5-year-old girl is breathing spontaneously but is unable to maintain an airway. Which of the following would be the priority? a) Placing a towel under her shoulders b) Inserting an oropharyngeal airway c) Assisting with tracheal tube insertion d) Positioning her using head tilt/chin lift
Inserting an oropharyngeal airway Correct Explanation: Inserting an oropharyngeal airway will help ensure that the child maintains a patent airway. Placing a towel under the shoulders would be helpful for opening the airway if this child were an infant. A tracheal tube would not be appropriate since the child is breathing spontaneously and able to maintain her ventilatory effort. Repositioning her using the head tilt/chin lift won't help if she can't maintain an airway independently.
A 14-year-old child is brought to the emergency department. His parents state that they think he took "too many of his pain pills." The child had been prescribed oxycodone every 4 hours for pain secondary to a bone infection. Which agent would the nurse expect to be administered to counteract the analgesics? 1) Atropine 2) Naloxone 3) Lidocaine 4) Ketamine
Naloxone Correct Explanation: Oxycodone is an opioid analgesic whose effects can be reversed by the administration of naloxone. Atropine decreases secretions and reduces the vagal effects of intubation. It also is used for sinus bradycardia, asystole, and pulseless electrical activity. Lidocaine is used to correct ventricular arrhythmias. Ketamine may be used for rapid-sequence intubation.
A 2-year-old boy is in respiratory distress. Which nursing assessment finding would suggest the child aspirated a foreign body? a) Noting absent breath sounds in one lung b) Hearing a hyperresonant sound on percussion c) Hearing dullness when percussing the lungs d) Auscultating a low-pitched, grating breath sound
Noting absent breath sounds in one lung Explanation: Unilateral absent breath sounds are associated with foreign body aspiration. Dullness on percussion over the lung is indicative of fluid consolidation in the lung as with pneumonia. Auscultating a low-pitched, grating breath sound suggests inflammation of the pleura. Hearing a hyperresonant sound on percussion may indicate pneumothorax or asthma.
A 3-year-old child has sustained injuries from a fall. Once the airway is secured, which of the following interventions would be next? a) Stabilize the cervical spine. b) Set up antecubital IV access. c) Administer 100% oxygen. d) Check mouth for debris.
Stabilize the cervical spine. Correct Explanation: If head or spine injuries are suspected, then after the airway is opened, the cervical spine must be stabilized to prevent damage. Checking the mouth for debris is part of securing an airway. Administering oxygen and IV access occur after the C-spine is stabilized.
The nurse is examining a 10-month-old girl who has fallen from the back porch. Which assessment will directly follow evaluation of the "ABCs?" a) Palpating the abdomen for soreness b) Palpating the anterior fontanel c) Auscultating for bowel sounds d) Observing skin color and perfusion
Palpating the anterior fontanel Correct Explanation: Once the ABCs have been evaluated, the nurse will move on to "D" and assess for disability by palpating the anterior fontanel for signs of increased intracranial pressure. Observing skin color and perfusion is part of evaluating circulation. Palpating the abdomen for soreness and auscultating for bowel sounds would be part of the full-body examination that follows assessing for disability.
The nurse is caring for a 2-year-old who has been rushed to the clinic immediately after swallowing an unknown number of acetaminophen tablets. Which of the following is the priority intervention? a) Perform a gastric lavage. b) Administer N-acetylcysteine. c) Initiate chelation therapy. d) Start IV fluid replacement.
Perform a gastric lavage. Explanation: If the child ingested the pills within the last 60 minutes, a gastric lavage and administration of activated charcoal would be the preferred treatment. If the acetaminophen is in the bloodstream, N-acetylcysteine may be administered. Chelation therapy is meant for metal poisoning. IV fluid replacement is used to treat hypovolemic shock.
Fever increases the basal metabolic rate resulting in: a) Bradypnea b) Bradycardia c) Tachypnea d) Decreased oxygen demand
Tachypnea Correct Explanation: Fever increases the basal metabolic rate, resulting in tachycardia, tachypnea, and increased oxygen demand.
A 13-year-old girl suffered a serious fall while hiking with friends and injured her head. She is now being evaluated by a nurse in the emergency room. The nurse notices clear fluid flowing from the girl's nose. The girl's friend said that she had been suffering from pollen allergy recently. Which of the following interventions should the nurse implement to determine whether the fluid is cerebrospinal fluid (CSF) or rhinitis from an allergy? a) Evaluate the client's level of consciousness b) Assess the client's blood pressure c) Perform a skull x-ray d) Test the fluid with a glucose reagent strip
Test the fluid with a glucose reagent strip Correct Explanation: Rhinorrhea or otorrhea (clear fluid draining from the nose or ear, respectively) may be noticeable. The fluid is cerebrospinal fluid (CSF) and is a serious finding because it means that the child's central nervous system is open to infection. If it's not clear if the fluid is CSF or rhinitis from an allergy, test the fluid with a glucose reagent strip. CSF will test positive for glucose, whereas the clear, watery drainage from an upper respiratory tract infection or allergy will not. The other interventions would not help determine whether the fluid was CSF or rhinitis.
Which finding from the history of a child with extensive burns would make you most alert to assess for respiratory complications? a) Firemen found the child sobbing silently. b) The child's clothing was burned. c) The child was trapped in a closed burning bedroom. d) The fire was caused by burning weeds.
The child was trapped in a closed burning bedroom. Correct Explanation: When a child is confined in a closed space during a fire, he or she can inhale a great deal of smoke, causing respiratory tract burns or irritation.
The nurse has performed an across-the-room assessment of an 8-year-old child and has classified her as emergent. Which of the following signs and symptoms has the nurse seen? a) The child is guarding one hand. b) The child is asleep on the mother's lap. c) The child is scratching a rash. d) There is a blue color to the lips.
There is a blue color to the lips. Correct Explanation: Blue lips is a sign of cyanosis. The child is in respiratory distress and should be cared for on an emergency basis. An injured hand and a rash are not emergencies. The sleeping child could have a fever that may be the result of an underlying pathology; however, this cannot be determined from across the room.
The nurse is attempting to establish peripheral vascular access in child requiring pediatric advanced life support. The decision to use the intraosseous route would be made if the nurse were unsuccessful after how many attempts within 90 seconds? a) Two b) Four c) Three d) Five
Three Explanation: No more than three attempts should be made within 90 seconds to obtain peripheral vascular access.
The effect of the bite of a rattlesnake, copperhead, or cottonmouth moccasin (all pit vipers) is the almost immediate failure of the blood coagulation system. a) False b) True
True
Which medication is used for symptomatic bradycardia unresponsive to ventilation and oxygenation? a) Atropine b) Naloxone c) Sodium bicarbonate d) Calcium carbonate
Atropine Correct Explanation: Atropine is used for symptomatic bradycardia unresponsive to ventilation and oxygenation. Sodium bicarbonate is used for metabolic acidosis. Naloxone reverses the effect of opioids. Calcium carbonate is used for documented or suspected hypocalcemia, hyperkalemia, hypermagnesemia, and calcium channel blocker overdose.
The nurse is caring for a 7-year-old child with suspected basilar head trauma. Which of the following interventions is most likely to be required? a) Beginning hyperventilation of the child b) Intubation and mechanical ventilation c) Administering small doses of morphine d) Providing blow-by oxygenation
Intubation and mechanical ventilation Correct Explanation: A child with a basilar skull fracture may require intubation and mechanical ventilation to maintain a normal PaCO2. Morphine and other pain medications should be administered after completing primary and secondary assessments. Prophylactic hyperventilation is not indicated because it could cause vasoconstriction of cerebral arteries and ischemia. Blow-by oxygen is used when there is a history of chronic pulmonary disease.
A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in teaching parents about how to protect a toddler from accidental poisoning? a) Label poisonous solutions. b) Do not leave the toddler alone. c) Closely monitor the toddler's activity. d) Keep cleaning solutions locked up.
Keep cleaning solutions locked up. Correct Explanation: The parents should keep cleaning solutions locked up to protect the toddler from accidental poisoning. Accidental poisonings usually occur among toddlers and commonly involve substances located in bathrooms or kitchens. Labeling poisonous substances may not help as toddlers are unable to read. Not leaving the child alone and closely monitoring the child are important, but not feasible all the time.
The nurse is assessing the neurologic status of an infant. Which of the following would the nurse identify as a nonreassuring finding? a) Vigorous crying b) Soft flat anterior fontanel c) Lack of interest in surroundings d) Making eye contact with the nurse
Lack of interest in surroundings Correct Explanation: An infant who is not interested in the environment is a cause for concern. Vigorous crying is a reassuring sign. Making eye contact with the nurse is a reassuring finding. A normal anterior fontanel is soft and flat and would be considered a reassuring finding.
The parents of a 7-month-old boy with a broken arm agree on how the accident happened. Which account would lead the nurse to suspect child abuse? a) "He was climbing out of his crib and fell." b) "The gate was open and he fell down three steps." c) "Mom turned and he fell from changing table." d) "He fell out of a shopping cart in the store."
"He was climbing out of his crib and fell." Explanation: The nurse would be suspicious of a 7-month-old climbing out of his crib, since it is not consistent with his developmental stage. Other areas of concern are if the parents have different accounts of the accident and if the injury is not consistent with the type of accident.
A child is to undergo synchronized cardioversion. The child weighs 44 lbs. The nurse would expect how many joules to be delivered? a) 10 to 20 joules b) 5 to 10 joules c) 2 to 4 joules d) 30 to 40 joules
10 to 20 joules Explanation: Energy for cardioversion is delivered at 0.5 to 1 joule/kg. The child weighs 44 lbs or 20 kg. Therefore, the child would receive 10 to 20 joules.
The child's physician requests that the nurse should notify her if the child's urine output is less than 1 mL/kg of body weight each hour. The child weighs 56 pounds. Calculate the minimum amount of urine output the child should produce each hour. Round to the nearest whole number. _____ mL/hour
25 Correct Explanation: 56 pounds x 1 kg/2.2 pounds = 25.455 kg of body weight. 25.455 kg x 1 mL/kg = 25.455 mL/hour The child must produce 25 mL/hour
The nurse must calculate the adolescent's cardiac output. The child's heart rate is 76 beats per minute and the stroke volume is 75 mL. Calculate the child's cardiac output.
5700 Explanation: Cardiac output (CO) is equal to heart rate (HR) times ventricular stroke volume (SV). That is, CO = HR x SV 76 beats per minute x 75 mL = 5,700
The child needs a tracheal tube placed. The child is 8 years old. Calculate the size of the tracheal tube that should be used for this child. _____ mm
6 Correct Explanation: The following formula should be used to calculate the correct tracheal tube size for a child: Divide the child's age by 4 and add 4 = size in millimeters (8 years old/4) + 4 = 6 mm
A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. Which of the following is the priority intervention? a) Provide sedation as ordered. b) Check his capillary refill time. c) Administer 100% oxygen by mask. d) Have the child sit up straight in a chair.
Administer 100% oxygen by mask. Explanation: Management of the near-drowning victim focuses on assessing his airway, breathing, and circulation (ABCs) and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the child assume the most comfortable position for him. Checking capillary refill time helps determine ineffective tissue perfusion. Providing sedation is an intervention for pain that will be assessed after effective breathing is established.
The nurse has administered IV adenosine as ordered to a child with supraventricular tachycardia. Which action would the nurse do next? a) Monitor for ventricular arrhythmias. b) Set up a continuous infusion for administration of adenosine. c) Administer a rapid generous saline flush. d) Give five positive-pressure ventilations.
Administer a rapid generous saline flush. Correct Explanation: Administration of IV adenosine should be followed immediately by a rapid generous saline flush. Adenosine is given rapidly over 1 to 2 seconds and repeated every 1 to 2 minutes to a maximum dose of 0.3 mg/kg. Five positive-pressure ventilations are given after atropine, which is diluted with 3 to 5 mL of normal saline, is given via the tracheal route. After giving adenosine, the nurse would monitor for shortness of breath, dyspnea, and a worsening of asthma. Monitoring for ventricular arrhythmias is necessary when giving dobutamine, dopamine, and epinephrine.
An 8-year-old girl with tachycardia is alert, breathing comfortably, and exhibiting signs of adequate tissue perfusion. Which nursing intervention would be most appropriate for this child? a) Administering epinephrine as ordered b) Oxygenating and ventilating the child c) Applying ice to the child's face d) Initiating cardiac compressions
Applying ice to the child's face Explanation: The child is exhibiting compensated supraventricular tachycardia (SVT). Vagal maneuvers such as ice to the face or blowing through a straw that is obstructed are priority interventions for compensated SVT. Oxygenating and ventilating the child as ordered are interventions for bradycardia. Epinephrine is given for bradycardia. Initiating cardiac compressions is the priority intervention for collapsed (pulseless) rhythms.
A nurse is preparing discharge teaching for a client being discharged with her newborn baby. What is the highest priority item that must be included in the teaching plan? a) Keep all pots and pans in lower cabinets. b) Give warm bottles of formula to the baby. c) Lock all cabinets that contain cleaning supplies. d) Restrain the baby in a car seat.
Restrain the baby in a car seat. Correct Explanation: The client should restrain the baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets and giving warm bottles of formula to the baby are secondary teachings.
The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of which of the following? a) Underlying heart disease b) Respiratory failure c) Neurologic trauma d) Lethal arrhythmia
Respiratory failure Correct Explanation: Cardiopulmonary arrest in infants and children typically results from disorders that lead to respiratory failure and shock. In adults, the most common causes of cardiopulmonary arrest are lethal arrhythmias secondary to heart disease. Although neurologic trauma can lead to respiratory failure, it alone is not the most likely factor.
Which of the following nursing diagnoses would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub? a) Risk for Falls b) Risk for Imbalanced Body Temperature c) Noncompliance d) Risk for Suffocation
Risk for Suffocation Correct Explanation: Death from drowning occurs from suffocation. Nearly half of all drowning victims are children under the age of 5. Most drowning deaths in young children occur because of inadequate supervision of a bathtub or pool.
The nurse is assessing the respiratory status and lungs of a 6-year-old child. Which of the following would the nurse report immediately? a) High-pitched breath sounds over the trachea b) Minimal air movement through the lungs c) Low-pitched bronchial sounds over the periphery d) Resonance over the lungs on percussion
Minimal air movement through the lungs Explanation: Minimal or no air movement requires immediate intervention because this child's status is severely compromised. Breath sounds over the trachea typically are high pitched. Breath sounds over the peripheral lung fields are lower pitched. Normally percussion over air-filled lungs reveals resonant sounds.
When developing the plan of care for a 10-month-old infant in septic shock, which of the following would the nurse most likely include? a) Administering intravenous saline as ordered b) Administering intravenous dopamine as ordered c) Giving blood if saline provides inadequate response d) Inserting a urinary catheter for monitoring urinary output
Administering intravenous dopamine as ordered Explanation: Although isotonic intravenous solutions such as saline, blood transfusion, and urinary catheter insertion are important for any child with shock, children experiencing septic shock often require larger volumes of fluid as a result of the increased capillary permeability. Thus, fluid alone may not improve the status of a child with septic shock, necessitating the use of vasoactive medications such as dopamine. Saline is the first choice for restoring fluid volume, but this child will most likely need vasoactive medications. Children in shock from trauma may require blood transfusions to restore volume. Once fluids are given, a urinary catheter will be placed to monitor urine output.
A 4-year-old girl is brought to the emergency room following ingestion of large amounts of acetaminophen (Tylenol). Which of the following interventions does the nurse expect? a) Stimulation of vomiting b) Assessing for consciousness c) Performing hands-only CPR d) Administration of acetylcysteine
Administration of acetylcysteine Correct Explanation: In the emergency department, activated charcoal or acetylcysteine, a mucolytic agent and also the specific antidote for acetaminophen poisoning, will be administered. Acetylcysteine prevents hepatotoxicity by binding with the breakdown product of acetaminophen so that it will not bind to liver cells. Unfortunately, acetylcysteine has an offensive odor and taste. Administering it in a small amount of a carbonated beverage can help the child to swallow it.
When assessing a child with a traumatic injury, which of the following would be the priority assessment? a) Airway patency and airflow b) Breathing effectiveness and breath sounds c) Level of consciousness and papillary reaction d) Pulse rate and skin color
Airway patency and airflow Correct Explanation: When assessing the child with a traumatic injury, the ABCs are assessed first: assess the patency of the airway and establish the effectiveness of breathing, examining the child's respiratory effort, breath sounds, and color; evaluate the circulation, noting pulse rate and quality and observing the color, skin temperature, and perfusion. Once this is accomplished, the nurse assesses for disability (D), rapidly assessing critical neurologic function including level of consciousness, pupillary reaction, and verbal and motor responses to auditory and painful stimuli.
A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which of the following treatments is most likely appropriate in the immediate treatment of the girl's poisoning? a) Intravenous rehydration b) Administration of activated charcoal c) Gastric lavage d) Inducing vomiting
Administration of activated charcoal Correct Explanation: Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl's poisoning.
Assessment of a child reveals a tension pneumothorax. The nurse would prepare the child for which of the following? a) Needle thoracotomy b) Suctioning c) Intubation d) Defibrillation
Needle thoracotomy Correct Explanation: A needle thoracotomy is indicated for tension pneumothorax to relieve the air collected in the space. Intubation is indicated for apnea and in situations in which the airway cannot be maintained. Suctioning would be indicated for excessive airway secretions that influence airway patency. Defibrillation is used to stimulate or alter the heart's electrical rhythm.
While working in the emergency room, you receive a call that a 3-year-old child sustained extensive burns in a house fire. Assuming all of the following actions are included in the standing burn-care protocol, which would be your first nursing action? a) Insert an NG tube to empty the stomach. b) Ask the child to drink a glass of milk. c) Give a tetanus toxoid injection. d) Obtain a weight.
Obtain a weight. Correct Explanation: Obtaining a weight provides a base for calculating the fluid that will need to be replaced. NG placement and/or drinking milk are not actions to take at this point. Tetanus can be given later and is not critical to active management.
A 3-year-old girl had a near-drowning incident when she fell into a wading pool. Which intervention would be of the highest priority? a) Inserting a nasogastric tube to decompress stomach b) Assuring the child stays still during an X-ray c) Suctioning the upper airway to ensure airway patency d) Covering the child with warming blankets
Suctioning the upper airway to ensure airway patency Correct Explanation: Due to the potentially devastating effects of drowning-related hypoxia on a child's brain, airway interventions must be initiated immediately. The child's airway should be suctioned to ensure patency. Other interventions such as covering the child with blankets, inserting a nasogastric tube, and assuring that the child remains still during X-ray are interventions that are appropriate once airway patency is achieved and maintained.
A 9-year-old boy nearly drowned when he fell through the ice while skating on a pond. The child is exhibiting bradycardia. Which of the following would the nurse expect to implement to resolve the child's bradycardia? a) Administering epinephrine as ordered b) Using a convective air warming blanket c) Providing 100% oxygen via face mask d) Giving intravenous isotonic fluids
Using a convective air warming blanket Explanation: Bradycardia may be resolved by addressing the underlying condition—in this case by relieving hypothermia with a convective air warming blanket. Providing 100% oxygen and then administering epinephrine are primary and secondary treatments for arrhythmias. Giving fluids is an intervention for collapsed rhythms and hypovolemic shock.
