Charlie Snow VSIM Post

A 6-year-old patient with anaphylaxis is receiving oxygen via nasal cannula at 2 L/min with an order to titrate oxygen to maintain oxygen saturation of greater than 94%. Fifteen minutes later, the nurse notes that the patient is sleepy, breathing with mouth open at a rate of 32 breaths/min, and has oxygen saturations of 89%. Which of the following would be the best method of oxygen delivery for the patient at this time? A) bag valve mask with manual ventilation B) Nonrebreather mask at 12 L/min C) Nasal cannula at 4 L/min D) Oxygen hood at 15 L/min

B

A nurse is preparing a 6-year-old patient to have a peripheral IV line inserted. Which of the following demonstrates that the nurse understands developmentally appropriate communication? (Select all that apply.) A) If you hold really still, it will only take one stick to insert the catheter B) Some kids say it hurts a little bit when inserted but then the pain goes away C) Are you ready to have your IV started? Pick which arm you want me to put it in D) I am going to insert a tiny tube into your arm to help give your body a drink

B D

The nurse is caring for a patient with anaphylaxis who is exhibiting signs of distributive shock. Which of the following should be included in the plan of care for this patient? (Select all that apply) A) Replace fluid losses B) Support the BP C) Treat underlying infection D) Maintain an adequate airway E) Decrease Cardiac workload

B D

The nurse is caring for a 21 kg patient with anaphylaxis and poor perfusion. Which of the following orders for IV fluids would the nurse expect to implement? A) Dextrose 5%/0.45% sodium chloride IV at 63 mL/h B) Dextrose 5% 210 mL IV now over 30 minutes C) NS 420 mL IV now over 30 min D) LR IV at 21 mL/h

C

The nurse is educating Charlie about avoidance of peanut allergens and management of allergic reactions. Which response by Charlie indicates the need for further teaching? A) My aunt can help read labels to make sure foods don't have nuts in them B) It is OK to eat peanut butter cookies if I take a dose of diphenhydramine first C) I will make sure that I keep my epinephrine auto-injector with me at all times D) I can make snack mix at home using popcorn, marshmallows, and raisins

C

Charlie demonstrates knowledge of appropriate food choices for avoidance of peanut-containing foods when he chooses which of the following meals? A) Baked chicken strips and broccoli B) Enchiladas and refried beans C) Pork eggrolls and steamed brown rice D) Barbecue beef sandwich and chips

A

The nurse is preparing a teaching session for Charlie's aunt regarding the use of an epinephrine auto-injector (EpiPen) for the treatment of an anaphylactic reaction. Which of the following best indicates that teaching has been effective? A) I need to give Charlie the auto-injector immediately if he has a reaction with trouble breathing and then call 911 or take him to the doctor B) If Charlie has an allergic reaction, I need to call the doctor's office to see if it is OK to give the auto-injector C) After giving the injection, I will have Charlie lie down at home and rest so that the medicine has time to work D) It is important to keep the auto-injector and a written copy of the emergency plan in a bag at home in case Charlie has an allergic reaction

A

The nurse is reviewing medication orders for a patient admitted with anaphylaxis. Which of the following IV medications is the priority for the nurse to administer at this time? A) Epinephrine 0.3 mg (1:10,000) B) Diphenhydramine 25 mg C) Ranitidine 20 mg D) Methylprednisolone 10.5 mg

A

The nurse is reassessing a patient following rapid administration of a NS bolus. Which of the following would indicate that the treatment has been effective? (Select all that apply.) A) Decreased HR B) Decreased BP C) Increased oxygen saturation D) Decreased capillary refill time E) Increased strength of peripheral pulses

A C D E

What would be the highest priority and most appropriate nursing diagnosis for a patient exhibiting signs of anaphylaxis? A) ineffective breathing pattern r/t inflammatory process B) Fear r/t difficulty breathing C) Ineffective tissue perfusion r/t systemic vasodilation D) Ineffective airway clearance r/t inflammation

D