Chapter 35: Key Pediatric Nursing Interventions
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? "I should never refer to the medicine as candy." "He needs to take his medicine or he will lose a privilege." "We checked that the medicine can be mixed with yogurt or applesauce." "We should never bribe our child to take the medicine."
"He needs to take his medicine or he will lose a privilege." The nurse should emphasize that the parents should never threaten the child in order to make him take his medication. It is more appropriate to develop a cooperative approach that will elicit the child's cooperation since he needs ongoing, daily medication. The other statements are correct.
The nurse is teaching a parent how to administer otic medications to her 4-year-old child. Which comment from the mother would indicate the need for further teaching? "I will have my child turn the head to one side." "I will pull the pinna down and back." "I will be sure that the drops are warm." "I will place my child on the back."
"I will pull the pinna down and back." If the child is older than 2 years of age, the parent should pull the pinna of the ear up and back. Ear drops must always be used at room temperature or warmed slightly because cold fluid may exacerbate pain and may also cause severe vertigo as it touches the tympanic membrane. The parent should turn the child or ask the child to turn onto his or her back, or use restraint as necessary, and then turn the child's head to one side and administer in the ear as prescribed.
The nurse is preparing to administer regular insulin to a nonverbal pediatric client. Which action will the nurse perform prior to administering the medication? Check the full name and age on the client's wristband with the medication administration record and have the parent verbally confirm. Check the full name and birth date on the client's wristband with the medication administration record. Check the full name and room number on the client's wristband with the medication administration record. Check the birth date and full name on the client's wristband with the medication administration record and have another nurse verify.
Check the full name and birth date on the client's wristband with the medication administration record. When administering medications to a child, the nurse needs to use at minimum two client identifiers that are directly associated with the client and the medication to be given, such as full name, client ID number, and birth date. The nurse will take the medication administration record to the room to perform a "double-identifier" check. A client's identity must be verified with two acceptable identifiers, not just one. There is no need to have another nurse verify or have the parent state the client's information. A room number or a bed number is not an acceptable identifier.
A nurse is preparing a dose of insulin to give the client. Which action takes priority when preparing and administering this medication? Double-check the dose with another RN before giving. Have another RN witness the injection given to the client. Ask the client if he or she has had any adverse reactions to insulin in the past. Double-check the math calculations.
Double-check the dose with another RN before giving. Insulin is a high-alert medication and the dosage must be checked with another RN before administering. All rights of medication administration should be adhered to. Insulin dosages come in units and the prescription is to administer a specific number of units; thus, no calculations of dosages are needed. Insulin injections do not have to be witnessed. Insulin is not known for having adverse reactions, but it is always a good practice to ask the client if he or she has experienced any problems receiving insulin.
The nurse is administering an oral liquid medication to a 5-year-old child. What would be the most appropriate for the nurse to do when administering this medication? Administer the medication using a dropper. Ask the parent to hold the child's arms during administration. Let the child hold the medication cup. Have the child lying down with the head elevated on a pillow.
Let the child hold the medication cup. Droppers and oral syringes can be used to administer medications to infants and young children. Medication cups and spoons can be used to administer liquid medications to the older child. The child can hold the medication cup and drink the liquid medication. Depending upon the age of the child, he or she may still prefer to take liquid medications via the syringe. It makes taking the medication fun when the child can squirt it into the mouth by himself or herself. The child who is lying down when being given medications should have the head of the bed elevated to at least 45 degrees A 5-year-old child does not need to be restrained for medication administration.
While working in the emergency room, the nurse receives 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 action should be the nurse perform first? Insert a nasogastric tube to empty the stomach. Give a tetanus toxoid injection. Ask the child to drink a glass of milk. Obtain a weight.
Obtain a weight. A burn victim will require large amounts of fluid hydration to replace fluid losses. Obtaining a weight provides a base for calculating the fluid that will need to be replaced. Nasogastric tube 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 newly admitted school-age child has a temperature of 102°F (38.9°C) and the mother reports that she gave her acetaminophen just before coming to the hospital 2 hours ago. What nonpharmacologic intervention could the nurse implement to help bring the temperature down? Place several blankets on the child to encourage sweating to break the fever. Give the child a tepid sponge bath. Lower the room temperature to 62°F (16.6°C). Place the child in a gown or lightweight pajamas.
Place the child in a gown or lightweight pajamas. Fever is a common problem for children and nurses need to be aware of nonpharmacologic interventions to reduce the fever when medication is not possible. These interventions include dressing the child in lightweight clothing (or just a diaper for infants). Tepid sponge baths are no longer advised because they do not help lower the temperature and make the child uncomfortable. It is a good idea to keep the room cool but turning the room temperature to 62°F (16.6°C) is too cold. The nurse should never place the child under blankets. That will increase the temperature.
The nurse is administering otic medication to a 22-month-old with a diagnosis of otitis media. Which nursing action ensures that the medication is distributed appropriately? Place in a side-lying position. Place a cotton ball in the outer ear. Pull the pinna down and back. Pull the pinna up and back.
Pull the pinna down and back. By making sure that the ear canal is straight for the medication to progress to the tympanic membrane, the medication is distributed appropriately. It is also appropriate to place the child in a side-lying position. Some nurses place a cotton ball in the ear but that does not impact distribution of the medication. A child over 3 years of age needs the pinna pulled up and back.
To give eardrops to a 4-year-old child, what would be the best technique to use? Press the pinna of the ear forward. Pull the pinna of the ear up and back. Lift the pinna of the ear down and back. Pull the pinna of the ear downward.
Pull the pinna of the ear up and back. Pulling the pinna upward and back straightens the ear canal in the child older than 3 years of age. To administer otic drops to a child younger than 3 years, the pinna would be pulled downward and back. Pressing the pinna of the ear forward or downward would occlude the ear canal.
A child reports pain at the IV insertion site. The nurse suspects infiltration based on which assessment finding? The vein feels hard on palpation. The area is red and hot. The area is cool to the touch. The site has purulent drainage.
The area is cool to the touch. Signs of infiltration are coolness and swelling. If the area is red and hot with hard veins on palpation, this is usually phlebitis. Purulent drainage is usually an infection.
The nurse is administering a gavage feeding through a nasogastric feeding tube. Which nursing intervention is the highest priority? The nurse documents how the child tolerated the feeding. The nurse verifies the position of the feeding tube. The nurse replaces stomach content that has been aspirated. The nurse positions the child in a sitting position.
The nurse verifies the position of the feeding tube. Verifying the position of the tube to ensure that the tube is in the stomach by aspirating stomach contents is the highest priority. This is a top priority because of the danger of aspiration if the tube is not in the stomach but rather in the esophagus or the lung.
The nurse is determining a pediatric dosage of medication using the West nomogram for estimating body surface area (BSA). Which two known factors are on the left and the right scales? Use the milligrams and milliliters of medication. Use the weight and milliliters of medication. Use the height and milligrams of medication. Use the client's height and weight.
Use the client's height and weight. The West nomogram for estimating body surface area uses the dimensions of the client to form a line that passes through a point determined as the body surface area. Following that determination, the particulars of the medication prescribed are used.
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. Gather the necessary equipment and supplies. Wash hands and put on gloves. Gather the medication.
Verify the medication order. The priority nursing action is to verify the medication ordered. The first step in the eight rights of pediatric medication administration is to ensure that the child is receiving the right medication. After verifying the order, the nurse would then gather the medication, the necessary equipment and supplies, wash hands, and put on gloves.
A medical/surgical nurse has been floated to the pediatric unit. Which action by the float nurse would require the pediatric nurse to intervene? scanning the child's barcode on the identification band requesting the pediatric nurse to double-check calculations asking the child his or her name prior to giving medications speaking to both the parents and child about medications
asking the child his or her name prior to giving medications To prevent errors, the nurse should never ask children their names for identification. This action would require the pediatric nurse to intervenes. Instead, nurses must read or scan the bar code on clients' identification arm bands and compare them with the medication sheet or electronic record. It is important to include both the parents and child in teaching about a medication. Calculating pediatric doses is not something medical/surgical nurses do on a regular basis, so it would be appropriate for the float nurse to have a pediatric nurse double-check the calculations.
The site most often used when administering a medication using the intradermal route is the: abdomen. thigh. forearm. deltoid.
forearm. Intradermal injections deposit medications just under the epidermis. They are most often used for tuberculosis screening and allergy testing. The forearm is the site most often used. The anterior thigh, lateral upper arms, and abdomen are the preferred sites for subcutaneous administration. The deltoid, vastus lateralis and the ventrogluteal are the preferred sited for intramuscular injections.
A parent must administer a medication in syrup form to a 2-month-old infant. The nurse suggests: using a measured medicine spoon. placing the syrup in an medicine syringe. mixing the syrup in a small amount of formula. placing the syrup in a small amount of rice cereal.
placing the syrup in an medicine syringe. The young infant should naturally and easily suck the medicine through a medicine syringe. Formula and rice cereal are essential foods for the infant and the desirability of them should not be altered by the taste of the medication. In addition, a 2-month-old infant is not developmentally ready for spoon feeding of rice cereal or medication from a medicine spoon.
The nurse is preparing an injection of ceftriaxone sodium 500 mg IM for a 9-month-old client. When assessing the best site for injection, which landmarks are determined in preparation for injection? posterior superior iliac spine, greater trochanter, and gluteus maximus trochanter and knee joint acromion process and armpit anterior superior iliac spine, iliac crest, and greater trochanter
trochanter and knee joint When locating the trochanter and knee joint as landmarks, the nurse is using the vastus lateralis site—the main injection site for infants. The ventrogluteal site uses the anterior superior iliac spine, iliac crest, and greater trochanter. The deltoid site uses the acromion process and armpit. The dorsogluteal site, which is not recommended for the infant, uses the posterior superior iliac spine, greater trochanter, and gluteus maximus.
A 4-year-old child is admitted to the hospital for surgery. Before the nurse administers medicine, the best way to identify the child would be to: ask the child to state his or her name. tell the child to state his or her nickname. read the child's armband. call the child's name and see if he or she answers.
read the child's armband. A child may answer to the wrong name or deny his or her identity to avoid an unpleasant situation or if scared of the unknown. If the child is avoiding the situation he or she may fail to answer. Using the child's nickname is okay in conversation but it is not a legal identification of the child. To verify the correct identity the nurse should verify the child's armband and the correct name with the child's caregiver. Bar code scanning the child's armband would also be a correct method of identification.
A child needs a peripheral IV start as well as a venous blood sample for a laboratory test. The nurse will take what action? Place the IV and start intravenous fluids promptly; then request the laboratory obtain the blood specimen. Make sure the laboratory specimen is drawn prior to placing the IV access device. Delay both the IV start and blood draw until the child is well hydrated orally. Coordinate placing the peripheral IV and the lab blood draw.
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. Having a well-hydrated child makes venous access easier, but oral hydration will take some time, thus delaying needed treatment.
A child is receiving intravenous fluids for dehydration. The nurse notes coarse breath sounds and increased pulse and blood pressure. What does the nurse do first? Discontinue the IV infusion. Request a chest X-ray for evaluation. Contact the health care provider. Assess intake, output, and weight.
Discontinue the IV infusion. Signs of fluid overload are those of congestive heart failure and include coarse breath sounds, increased pulse rate, and increased blood pressure. These are not symptoms of extravasation because this would be swelling of fluid around the IV site. The nurse would need to stop the IV infusion, then assess weight, intake, and output. The nurse would then contact the health care provider.
The nurse is caring for a child prescribed ophthalmic drops. Place the steps in the order the nurse will complete them when administering the ophthalmic medication to the child. Use each option once.
Place the child in the supine position, slightly hyperextending the neck with the head lower than the body Retract the lower conjunctival sac Place the prescribed number of drops into the lower eyelid Instruct the child to gently close the eyes Wipe any excess medication from the skin After performing the rights of medication administration, the nurse would place the child in the supine position, slightly hyperextending the neck with the head lower than the body. Next, the nurse would retract the lower eyelid and instill the drops. The child would then gently close the eyes and the nurse would remove any excess medication.
The nurse is preparing an intravenous solution of D5 ¼ NS @ 20 ml/hour for a 6-month-old client. Which safety device will be added to protect against fluid overload? a syringe pump a secondary line a volume control device pediatric IV tubing
a volume control device A volume control device (also called buretrol) is designed to deliver only the amount of medication placed in the chamber. The nurse places no more than 2 hours of fluid within the device. Should the pump fail, the client will receive only the fluid amount in the chamber, thus preventing fluid overload.
The nurse is showing the student nurse how to flush a pediatric client's peripherally inserted central catheter (PICC) line. The nurse prepares a 3-ml normal saline flush using a 5-ml syringe. The student asks the nurse why the flush was prepared this way. What is the most accurate response by the nurse? "It is standard policy in our facility to use a 5-ml syringe for all PICC line flushes." "The 5-ml syringe is what we have the most stock of so I just always use it." "Using a larger-volume syringe exerts less pressure on the PICC line." "I like how the 5-ml syringe fits in my hand. I feel like I have a better grip on it than a smaller syringe."
"Using a larger-volume syringe exerts less pressure on the PICC line." Using a larger-volume syringe (i.e., 5 mL or larger) exerts less pressure on the PICC, thereby reducing the risk of rupture.
A child is having difficulty swallowing pills. What is the best action for the nurse to take to help this child swallow medications? Crush all medications and dissolve in water. Hold the medication and notify the health care provider. Place the pills in a bite of ice cream or applesauce. Obtain small round candy to practice swallowing techniques.
Place the pills in a bite of ice cream or applesauce. The most useful technique when children cannot swallow pills is to put them into some ice cream or applesauce. This allows the medication to be administered in the original form. The nurse should not use candy for practice, because this may suggest to the child that medicine is the same as candy. The nurse should never crush medications which are enteric coated or time released. The nurse should always strive to administer a prescribed medication, even if doing so may be difficult.
A child on oxygen reports a "sore nose" and the nurse assesses that the child is experiencing dry nasal passages. What action can the nurse take to help relieve the child's discomfort? Turn the oxygen flow rate down to reduce the amount of air passing through the child's nose. Place lotion on a cotton swab and gently place some inside each nostril to moisturize the nasal passages. Use a water-based gel or spray for lubrication of the dry nasal passages. Apply a petroleum-based lubricant such as Vaseline on and around the nose to ease the discomfort.
Use a water-based gel or spray for lubrication of the dry nasal passages. Any time a client is on oxygen, he or she needs to be instructed to use a non-petroleum or water-based product for dry nasal passages. Petroleum products greatly increase the risk of catching fire since they are so flammable. The nurse cannot reduce the amount of needed oxygen for the client by turning down the flow rate nor should the nurse insert lotion into the nasal passages.
The nurse is preparing a subcutaneous insulin injection for a preschooler. How and where should the nurse administer the insulin? at a 90-degree angle into the vastus lateralis at a 45- to 90-degree degree angle into the rectus femoris at a 45- to 90-degree angle into the elevated tissue of the upper arm at a 45-degree angle into the deltoid of the upper arm
at a 45- to 90-degree angle into the elevated tissue of the upper arm Subcutaneous administration distributes medication into the fatty layers of the body. It is used for insulin administration. Preferred subcutaneous sites include anterior thigh, buttocks, upper arms, and abdomen. The rest of the sites are intramuscular ones and not appropriate for insulin administration.
The nurse is teaching parents of a 12-year-old child how to administer otic medication. Which statement by the parent indicates a need for further education? "I will pull the outer ear down and back before administering the medication." "I will hold the dropper 0.5 in (1.25 cm) above the ear canal and be certain not to touch the ear with the dropper." "After removing the medication from the refrigerator, I need to roll it gently in my palms to warm it." "After administering the drops, I will ask my child to remain side-lying for several minutes."
"I will pull the outer ear down and back before administering the medication." The proper technique to instill ear drops in a child older than 3 years of age involves pulling the pinna up and back. Otic medication should not be administered if it is cold. Cold medication may cause discomfort and produce vomiting or vertigo in the child. If an otic medication must be refrigerated, it should be warmed in the palms of the hands. Proper otic administration technique involves holding the dropper 0.5 in (1.25 cm) above the ear canal and being careful not to touch the dropper to the ear to prevent contamination of the dropper with microorganisms. The child should remain in a side-lying (or supine) position for several minutes after administration.
A child is reporting pain where an IV infiltrated his hand earlier in the shift. The doctor orders warm compresses to the right hand every 4 hours. What precautions would the nurse implement for this client? Have the parents apply the warm compresses if the nurse is tied up elsewhere. Limit treatments to 20 minutes at a time. Heat the moistened towels in the microwave. Use hot water on gauze for the warm compress.
Limit treatments to 20 minutes at a time. Warm compresses are used to increase circulation to an area of the body and to promote pain relief. For a child having warm compresses, the length of each session is a maximum of 20 minutes to prevent skin damage. Towels used in warm compresses are never heated in a microwave because of uneven heating. Parents are not to apply compresses because the nurse needs to assess the skin before and after the treatment. Gauze is not a good material for compresses; it does not hold heat well.
A preschool-age child 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? A feeding pump is used to administer the feedings. Bolus feedings are administered over a period of about 25 minutes. Caretakers omit flushing the tube at the conclusion of bolus feedings. The mother does not check gastric residual prior to feedings.
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. Not flushing the tube would not be related to vomiting. Using 25 minutes to administer a bolus feeding is an appropriate amount of time in most instances. A feeding pump would precisely control feeding rate and should not be the source of vomiting.
The nurse has brought a 3-year-old's oral medications into the room for administration. Upon approaching the child, the nurse said, "I have your medication. Would you rather have me hand it to you or Mommy?" In critiquing the nurse's actions, which is most accurate? The nurse's behavior is correct. The nurse provided the child a choice between two acceptable options with the outcome of taking the medication. The nurse's behavior is incorrect. The nurse should have been firm in expecting the child to take the medication. The nurse's behavior is incorrect. The mother did not prepare the medication and should not have administered the medication. The nurse's behavior is correct. Children are afraid of the nurse.
The nurse's behavior is correct. The nurse provided the child a choice between two acceptable options with the outcome of taking the medication. The nurse is correct to offer a choice to the preschooler and then for the mother to administer the medication, if chosen. This meets the developmental level of autonomy. The nurse prepared the medication and the medication remained with the nurse until handing it to the mother, who handed it to the child. The nurse witnessed the medication administration and documents it. The nurse firmly requires the medication to be taken but found a way for the child to take it that was acceptable to the child and accomplished the goal.
A toddler requires 1.5 ml of an antibiotic given intramuscularly (IM). How will the nurse administer this medication? Reduce the volume of the dose using less diluent than recommended to prepare the antibiotic for IM injection. Divide the dose. Administer 0.75 ml IM in each vastus lateralis. Administer the antibiotic IM in the rectus femoris. Seek an order for an oral form of the antibiotic.
Divide the dose. Administer 0.75 ml IM in each vastus lateralis. The recommended amount of solution a toddler should receive in one IM injection should not exceed 1 ml. Dividing the dose is necessary even though two injections will cause additional stress. These could be given simultaneously by two nurses. Seeking an oral route could be explored, but may not be feasible. The manufacturer's directions regarding the amount of diluent should be followed to ensure safety.
The nurse is giving discharge instructions to a parent of a 3-month-old infant. What is the best information to give the parent concerning oral medication administration? Lay the infant in a crib and, over time, use a syringe to squirt small amounts of medicine beside the tongue. Mix the oral medication in a small amount of formula or breast milk in a bottle. Hold the infant's nose while squirting the medication into the mouth. Give the medication with a syringe and direct the liquid toward the posterior side of the mouth while holding the infant upright.
Give the medication with a syringe and direct the liquid toward the posterior side of the mouth while holding the infant upright. Infants should be given oral medications with a syringe. The liquid should be directed toward the posterior side of the mouth while the parent is holding the infant upright, to prevent aspiration. Medications should be given in small amounts and the infant should be allowed to swallow before administering more. Medications should never be mixed with an infant's formula or breast milk since this is the infant's primary source of nutrition. If the infant does not drink all the formula or milk there is no way to know if the entire dose of medication was ingested. Infants should be positioned upright or with the head of the bed elevated when giving oral medications. Infants are obligatory nose breathers so holding shut the nose is contraindicated.
The nurse has an order to administer a rectal suppository to a 3-month-old child. In addition to lubricating the suppository, which intervention will help assure appropriate administration of the medication? Using the index finger to insert the suppository into the rectum Holding the buttocks tightly together for 1 to 2 minutes after insertion Pre-warming the suppository in the hand for 10 to 20 seconds Placing the child on the abdomen for insertion of the suppository
Holding the buttocks tightly together for 1 to 2 minutes after insertion For the administration of rectal medications, the child is placed in a side-lying position and the nurse must wear gloves or a finger cot. The suppository is lubricated, then inserted into the rectum, followed by a finger, which is inserted up to the first knuckle joint. The little finger should be used for insertion in infants. After the insertion of the suppository, the buttocks must be held tightly together for 1 to 2 minutes until the child's urge to expel the suppository passes. The suppository would begin to soften making it difficult to insert if warmed prior to insertion.
The nurse is caring for a breastfed infant hospitalized for gastroenteritis. Which method can be used to most accurately measure intake? It is impossible to get an accurate intake measurement. Weigh the infant before and after feeding and subtract weight. Estimate based on comparison with bottle-fed infants. Document breastfeeding for elapsed time the baby feeds
Weigh the infant before and after feeding and subtract weight. Intake in breast-fed infants is generally recorded as "breast-fed for X minutes." If it is necessary to estimate the amount more closely than this, an infant can be weighed before and after a feeding. The difference in weight (measured in grams) is calculated to establish the number of milliliters of breast milk ingested (1 g = 1 ml). Weighing the infant before and after feeding is the most accurate method for strict intake. Comparing to a bottle-fed infant is inaccurate and therefore not correct.
The nurse has been caring for a 12-year-old boy during his 5-day hospitalization. The child's IV has infiltrated, and the care provider is getting ready to change the intravenous line site. Which statement made by the nurse would be appropriate in supporting the child? "The client is left-handed and likes to draw; an IV site in his right arm would be best." "Would you like me to stay with you or are you OK alone?" "I will be back after your IV is in place." "The nurses on the unit know the client well, so maybe a nurse could start the IV."
"The client is left-handed and likes to draw; an IV site in his right arm would be best." The staff nurse may serve as the child's advocate when the care provider comes to start an infusion. The staff nurse who has cared for the child has the child's confidence and knows the child's preferences.
A child who is receiving TPN has developed the need to have insulin injections. The child's mother questions this and states that her child does not have diabetes. What is the appropriate response by the nurse? "There is no need to worry. This is temporary." "Illness can sometimes result in the need for insulin." "The feedings are high in sugar and insulin is needed to manage this." "There is a chance these feedings your child is receiving are causing her to have diabetes."
"The feedings are high in sugar and insulin is needed to manage this." Glucose levels may be elevated when TPN is administered. While illness can impact serum glucose levels, this is not an appropriate response. Telling the parent there is no need to worry minimizes concerns and is not a correct response. The child does not have diabetes but warrants insulin coverage.
The nurse is providing discharge education to the parents of a 2-year-old who will be taking amoxicillin orally at home. The nurse would include which statement in the teaching? "Give the medication until your child has no symptoms." "Mixing the medication with milk will help." "Use a dosing cap to measure the dosage." "Crush the pills and mix with applesauce when giving the medication."
"Use a dosing cap to measure the dosage." When talking to parents about giving medicine, stress that if a medicine comes supplied with a dosing cap, it is best to use that to measure the correct dose (Pham et al., 2011). If there is no dosing cap, then an oral medicine syringe or dropper are the next best methods to measure liquid medicine because kitchen teaspoons are rarely exactly 5 ml. Antibiotics need to be taken for the full course, not until symptoms subside. Mixing the medication with a drink or in food makes it difficult to determine how much the child has taken if the child refuses to finish it all. Amoxicillin comes in a liquid form, so crushing the pills is not appropriate.
The nurse enters the room to give a subcutaneous injection of insulin to a 6-year-old child with diabetes. What is the best method of medication administration? Tell the child that the client is to remain very still and not cry. Announce to the child that it is time for insulin and give the injection matter-of-factly. Ask the child if it is okay to give the injection now. Ask the child where the child would like to have the injection.
Ask the child where the child would like to have the injection. Asking the client to choose where to receive the injection gives a degree of control. Announcing that it is time for the medication does not give any sense of control to the child. Asking permission to give a medication to a child is not appropriate—a child should not be given the opportunity to decline a medication. It is not appropriate to tell a child not to cry during a painful procedure. The child should be given permission to yell out or cry if he or she feels the need to.
An 8-month old infant has a colostomy placed following abdominal surgery for removal of a section of bowel. The stoma is 2/3 full, draining liquid stool and the bag appears inflated. What actions would the nurse take in caring for this client? Select all that apply. Remove the stoma bag and discard it every day. Examine the skin around the stoma site for redness or irritation. Empty the bag and record the output. Remove the stoma bag and allow the stoma to remain open to air for 1 to 2 hours. Look at the infant's intake to determine if any foods could be causing gas.
Empty the bag and record the output. Examine the skin around the stoma site for redness or irritation. Look at the infant's intake to determine if any foods could be causing gas. In caring for an infant with a colostomy, the nurse empties the contents of the bag on a regular basis, rinses it out, closes it again, but does not discard it each time it is emptied. The nurse also inspects the skin around the stoma for any redness or skin breakdown. Since the bag was inflated initially, the nurse should review the infant's intake to note if the infant is consuming any gas-causing foods and recommend limiting them. The bag is never left off for any length of time due to the constant stooling pattern of the infant.
The nurse has prepared an IM injection to give a 13-year-old child. After some searching, the nurse locates the child in the playroom in front of a video game. Which action is best for the nurse to take? Inform the child that it is time for an injection. Explain why the injection is needed and have the child move to the treatment room. Ask the child when the game will be over. Ask the child to take a break from the game and come back to the child's room to give the injection. Give the injection in the playroom since the child is distracted with the video game.
Inform the child that it is time for an injection. Explain why the injection is needed and have the child move to the treatment room. Explaining the reason for a medication is appropriate for a 13-year-old child. The medication should not be given in the playroom. The playroom is a safe area for clients. Painful procedures should be done in a treatment room. Asking the child to take a break from the game sounds like the nurse is asking permission to give the medication. A child should not be given the opportunity to refuse a medicine.
Parents asks the nurse why their premature infant is receiving a feeding through the mouth rather than the nose. What is the best explanation by the nurse? Nasogastric tubes decrease the possibility of striking the vagal nerve. It is equally acceptable to use either insertion site. Newborns are obligate nose breathers so nasogastric may obstruct their breathing. Orogastric tube insertion can cause inflammation and obstruction of the nares.
Newborns are obligate nose breathers so nasogastric may obstruct their breathing. Whether enteral catheters should be passed through the nares or the mouth is controversial. Because newborns are obligate nasal breathers, passing a catheter through the nose may obstruct their breathing space, and repeated insertion of a nasogastric tube can cause inflammation and obstruction of the nose; thus most tubes are inserted orally in small infants. Orogastric insertion can also decrease the possibility of striking the vagal nerve in the back of the throat and causing bradycardia, whereas nasogastric tubes increase the possibility of striking the vagal nerve.
Included in the nursing care plan for the child receiving total parenteral nutrition (TPN) will be which intervention? A daily stool softener Flushing the peripheral catheter delivering the TPN solution regularly with saline Keeping the child nothing by mouth (NPO) Regularly monitoring the child's blood glucose
Regularly monitoring the child's blood glucose Monitoring the blood glucose is important with TPN since the glucose content of the solution is high and can cause hyperglycemia. The need for a stool softener would be determined on an individual basis. Children receiving TPN may or may not be taking food and fluids orally. The catheter delivering the TPN solutions will be centrally placed to accommodate the concentrated TPN solution (larger vessel with more rapid blood flow).
Immediately following administering a medication by enteral tube, the nurse will: elevate the head of the bed. flush the tube with water. check for signs of nausea or vomiting. position the child on his left side.
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. Right (not left) side-lying position will aid in stomach emptying, although it was not specified that the enteral tube was located in the stomach. Elevating the head of the bed is done prior to placing material in the gastrointestinal tract. Checking for signs of nausea and vomiting is always important but does not have to be done immediately following enteral tube medication administration.
The nurse is caring for a comatose school-age child receiving gastrostomy tube feedings. The nurse aspirates 15 ml of stomach contents prior to administering a feeding. What is the appropriate action by the nurse? Discard the stomach contents and notify the health care provider of the aspiration amount. Discard the stomach contents and continue with the feedings as prescribed. Replace the stomach contents and hold the feeding. Replace the stomach contents and continue with the feedings as prescribed.
Replace the stomach contents and continue with the feedings as prescribed. The nurse should always aspirate nasogastric or gastrostomy tubes for stomach contents to check for tube placement and assess gastric residual amounts prior to administering feedings. The nurse will return any amount of stomach residue aspirated so the child does not lose large amounts of stomach acid. 15 ml is a very small amount of gastric contents and should not interfere with feedings.
The nurse is caring for a 7-year-old with a low-profile gastrostomy tube placed 6 months ago. Which is the priority intervention to prevent irritation of the skin at the insertion site? cleaning under the external disc or bumper with diluted hydrogen peroxide rotating the gastrostomy tube or button daily cleaning the surrounding skin with soap and water daily plus keeping the area dry cleansing the skin around the site with an alcohol wipe after each feeding
cleaning the surrounding skin with soap and water daily plus keeping the area dry Daily cleansing with soap and water and keeping the area dry are essential. Moisture can create irritation and encourage the growth of organisms in the warm, moist climate created. Alcohol can sting if used on the area; in addition, it can remove protective skin oils and promoting excess drying, which can lead to skin breakdown. Cleaning under the bumper or disc with hydrogen peroxide is not recommended because it is irritating and damaging to skin cells. Rotating the gastrostomy tube or button daily is important to prevent adherence in the tract, but keeping the skin clean and dry is the priority.
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? Select all that apply. "I need to make sure to use the medicine dropper the pharmacy gives me instead of the syringe I use for my B12 injections." "I can probably pinch my child's nose to help in swallowing the medication. I do this when I don't want to taste a liquid medication." "I will be sure to not give too much of the liquid medication at one time." "I will only need one medicine dropper for both of the medications being prescribed." "I shouldn't use a liquid dropper from my kitchen because it may be a different measurement than one from the pharmacy."
"I need to make sure to use the medicine dropper the pharmacy gives me instead of the syringe I use for my B12 injections." "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." Only droppers given by the pharmacy for the specific medication should be used. Different syringes may have different measurements than pediatric oral syringes. Mixing medication syringes is avoided if a dropper is packaged with a certain medication since the drop size may vary from one dropper to another. Giving small amounts of liquid avoids aspiration. Pinching the child's nose increases the risk for aspiration and interferes with the development of a trusting relationship.
The nurse is showing the student nurse how to flush a pediatric client's peripherally inserted central catheter (PICC) line. The nurse prepares a 3-ml normal saline flush using a 5-ml syringe. The student asks the nurse why the flush was prepared this way. What is the most accurate response by the nurse? "It is standard policy in our facility to use a 5-ml syringe for all PICC line flushes." "I like how the 5-ml syringe fits in my hand. I feel like I have a better grip on it than a smaller syringe." "The 5-ml syringe is what we have the most stock of so I just always use it." "Using a larger-volume syringe exerts less pressure on the PICC line."
"Using a larger-volume syringe exerts less pressure on the PICC line." Using a larger-volume syringe (i.e., 5 mL or larger) exerts less pressure on the PICC, thereby reducing the risk of rupture.
A 5-year-old child is to receive long-term IV antibiotics. The mother is concerned about what type of administration method will be used. Which medication administration route may be the most easily accepted? An intraosseous line in the left lower leg A port in the left upper chest A peripherally inserted central catheter (PICC) line in an antecubital space A Hickman catheter in the right upper chest
A peripherally inserted central catheter (PICC) line in an antecubital space If IV antibiotic therapy is going to be needed for an extended period of time, a type of longer-term device needs to be used as opposed to a peripheral IV. A peripheral IV would need to be changed often and the risks of dislodgement or inflammation are much greater. Peripherally inserted central catheters (PICCs) are placed in the upper arm under ultrasound guidance. If maintained properly they can remain for many months. This means no IV sticks for the time the child would need IV therapy. It also leaves the hands free to use. A port must be surgically implanted into the child's chest. It can remain for many months. This would not be warranted for a one-time treatment of antibiotic therapy. A Hickman catheter is inserted via sterile procedure by a surgeon. This catheter is placed near the heart and has an increased risk of infection. An intraosseous line is not a route for long-term administration. It is used for emergent situations.
The mother of a 9-year-old girl calls the physician's office complaining that her daughter continues to vomit soon after being given an oral amoxicillin capsule for her strep throat. The nurse recognizes that the child's vomiting will interfere with which pharmacokinetic process? Absorption Distribution Excretion Metabolism
Absorption Drug absorption (transfer of the drug from its point of entry in the body into the bloodstream) is influenced by the route of administration as well as by the concentration and acidity of the drug. Vomiting and diarrhea, frequent symptoms of childhood illnesses, interfere with absorption because a drug does not remain in the gastrointestinal tract long enough to be absorbed. Distribution refers to the movement of the drug through the bloodstream to a specific site of action. Metabolism involves conversion of the drug into an active form (biotransformation) or an inactive form (inactivation). Excretion is the elimination of raw drug or drug metabolites, a process that largely prevents properly administered drugs from becoming toxic.
The nurse is caring for a 13-year-old client. The nurse prepares and verifies several medications and brings them and the medication administration record to the client's room. The nurse observes that the client is not wearing an identification band. Which action will the nurse take? Ask the client to recall his or her name and date of birth. Locate another RN who can identify the client. Call the admitting department and have another ID band prepared stat, so the medications can be given on time. Notify the prescribing health care provider.
Ask the client to recall his or her name and date of birth. If the client does not have an identification band in place, the nurse must first identify the client before administering any medication. A parent should identify an infant or younger child. The nurse can ask an older child his or her name and date of birth (or some other identifier). There is no need to notify the prescribing health care provider. The nurse should call the admitting department at a later time to obtain a new identification band. Locating another RN to identify the client is not necessary.
The nurse is preparing to administer a PO medication to a 6-year-old in the hospital for an exacerbation of asthma. The nurse notes that the child is due for an oral dose of lansoprazole in 1 hour. What is the most important action for the nurse to take before administering this medication to the client? Prepare to give the medication as ordered in 30 to 90 minutes. Obtain parental permission to administer this medication. Clarify the order, since there is no apparent link between the client's diagnosis and the medication. Ask the mother how she usually gives this medication to the client.
Clarify the order, since there is no apparent link between the client's diagnosis and the medication. There is no clear link between this client's diagnosis and the lansoprazole administration. The nurse should clarify a medication order that does not have a clear link to the client's diagnosis before giving the medication. Asking the mother how she usually gives the medication is a good idea; however, it is not the priority nursing action in this scenario. Parental permission is not required to administer this medication. Consent to treat is signed upon admission to the hospital.
Age affects how the medication is distributed throughout the body. Which factors affect how medication distribution is altered in infants and young children? Select all that apply. Infants and young children have an increased percentage of water in their bodies. The blood-brain barrier in infants and young children does not easily allow permeation by many medications. The livers of infants and young children are immature. Infants and young children have an increased number of plasma proteins available for binding to drugs. Infants and young children have an increased percentage of body fat.
Infants and young children have an increased percentage of water in their bodies. The livers of infants and young children are immature. It is true that infants and young children have an increased percentage of water in their bodies. Infants and young children have immature livers.
The health care provider orders a urinalysis on a 15-month-old toddler. The mother states that the child is not potty-trained. What is the best way for the nurse to collect the specimen? Aspirate urine out of the diaper with a syringe and place it in a specimen cup. Place a urine collection bag on the child after cleaning off the perineum. Observe the child for signs he needs to urinate and quickly pull the diaper down and catch the urine when he voids. Clean off the penis with a commercial cleaning pad and catheterize the client.
Place a urine collection bag on the child after cleaning off the perineum. In clients that are not potty-trained, the best method for collecting a urine specimen is to place a urine collection bag on the child and wait for them to void. The doctor did not order a urine culture, so a catheterized urinalysis is not needed and would be traumatic for the child. Trying to catch urine from a voiding toddler is nearly impossible. Aspirating urine out of the diaper is not the best approach or one that ensures the best results.
A young client has a temperature of 102℉ (38.9℃). In addition to the scheduled antipyretic the child received, the nurse is treating the fever with nonpharmacologic methods by removing the blanket that covers the child. What is the rationale for this action? The blanket adds heat to the child. Removing excess coverings allows for evaporation, which aids in cooling the child. Covering the child with a blanket leads to shivering, which will only generate more heat. The blanket soaks up the sweat, making the child warmer.
Removing excess coverings allows for evaporation, which aids in cooling the child. Removing covering from a child when he or she is febrile aids in additional cooling by allowing evaporative heat loss. The rationale is not that the blanket warms the child further, or that it will soak up sweat. Nor will covering the child lead to shivering. Shivering occurs when the child is chilled by some intervention; shivering serves as a sign that the cooling procedure needs to be stopped.
A parent informs the nurse about having a hard time getting her 6-year-old child to take the liquid medication at home. Which would be the best suggestion for the nurse to offer the parent to help correct this concern? Tell the parent to say calmly, "Can you drink this for me?" Tell the parent to tell the child, "It tastes just like candy!" Tell the parent to ask the child nicely, "Will you drink this for me?" Tell the parent to state firmly, "It's time for you to drink your medicine."
Tell the parent to state firmly, "It's time for you to drink your medicine." The best guideline for the parent to help in getting a child to take the liquid medication is to state firmly, "It's time to take your medication." Asking or pleading with the child does not work. Firmness is required. The child can be, however, allowed to choose what liquid to use to help swallow the medication. This helps with self-esteem and independence. The parent should also be honest about the taste of the medication. Adults also should never refer to medicine as candy. If a child happens to like a particular medicine, he or she may help themselves to it, and consuming too much can be fatal.
The nurse is working to gain a preschooler's cooperation to swallow an oral medication. What would be the nurse's best approach? compare the taste of the medicine to a chocolate bar leave the medicine on the night stand so the child can take it independently ask if the child would like to take the medicine in a cup or through an oral syringe offer to play a game with the child if the child takes the medicine
ask if the child would like to take the medicine in a cup or through an oral syringe The preschool age is when the child develops initiative. This is the sense that the child is helping. Thus, the nurse should allow the child to participate in the medication task. The instructions and choices need to be simple. The nurse can ask if the preschooler would like to take the medicine in a cup or through an oral syringe. Medicine never should be compared to candy or any other foods. Doing so can present a safety problem if the child gets into the medication cabinet at home thinking he or she is getting candy. Children cannot be depended on to take medicine without supervision, so leaving the medication on the night stand would not only be ineffective it would also be dangerous. Bribing is ineffective. A preschooler is not going to do a task he or she does not like and the medication is needed to make the child well. The nurse should be gentle but firm in the administration of the medication.
The nurse is caring for a pediatric client who requires vitamins, minerals, lipids and amino acids through the circulatory system instead of the gastrointestinal tract. Which type of intravenous therapy is anticipated for long-term therapy? intermittent fluids via a syringe pump use of a short line catheter and volume control chamber central venous catheter infusions peripheral venous catheter infusions
central venous catheter infusions Total parenteral nutrition (TPN) is the administration of dextrose, lipids, amino acids, electrolytes, vitamins, minerals and trace elements through the circulatory system. It is anticipated that long-term therapy will be completed via a central venous access device. Peripheral devices and short catheters are for short-term therapy. Syringe pumps are for small amounts of fluid over a period of time. The volume control chamber prevents fluid overload from pump malfunction.
The nurse is preparing to administer medication to a 5-month-old client. The nurse is aware that at least two different client identifiers must be used. Which identifiers could the nurse use? Select all that apply. birthday parent's name hospital ID number room number full name
full name birthday hospital ID number Client identifiers include such things as the client's full names, birth dates, and hospital ID numbers. Client room numbers and parents' names should not be used as identifiers.
The charge nurse is assisting the new graduate nurse in administering eye drops to a child. The charge nurse would stop the new graduate if which action was observed? positions the child supine on the bed holds the eyelids apart for about 30 seconds allows the child to sit up after blinking a few times administers drops into conjunctival sac
holds the eyelids apart for about 30 seconds To prevent the conjunctiva from drying, the nurse should not hold the eyelids apart any longer than necessary. Therefore, the charge nurse would need to stop the new nurse. It is best to use the supine position. Instill the correct number of drops into the conjunctiva of the lower lid. Allow the eyelid to close. Avoid placing the drops directly on the cornea because that can be painful. To prevent the conjunctiva from drying, do not hold the eyelids apart any longer than necessary. After the child has blinked 2 or 3 times, allow the child to sit up.
The nurse is preparing to administer albuterol to a 14-year-old client for the first time. Prior to administration, which adverse reaction is priority for the nurse to educate the client? hypoactivity increased appetite tachycardia bronchial muscle relaxation
tachycardia Adverse reactions of albuterol, a bronchodilator, include tachycardia, nervousness, tremors, hyperactivity, malaise, palpitations, increased appetite, hypokalemia, and muscle cramps. The expected action of albuterol is to relax bronchial, uterine, and vascular smooth muscle by stimulating beta-2 receptors. While tachycardia and increased appetite are both adverse reactions, tachycardia happens abruptly following the first dose and can be alarming for clients. It is a priority for the nurse to provide education on this over a slower, less concerning change.
