Cue Cards on Pediatrics & Management of Care

The nurse admits a client with a c-spine injury to the neuro intensive care unit (ICU). The admission assessment is completed. What is the nurse's priority intervention when they report the following? Client reports blurred vision and a headache rated 9/10. BP 200/110, pulse 55. 1. Monitor BP every 15 minutes 2. Loosen tight clothing 3. Elevate the head of the bed to high-Fowler's 4. Administer hydralazine

3. Correct: This client is experiencing autonomic dysreflexia! This is a priority question, so what would I do first. Elevate the HOB to decrease the BP. 1. Incorrect: This is a correct answer, but not the priority response. If I don't elevate the bed or sit them up, they could have a hypertensive stroke! 2. Incorrect: This is a correct answer, but not the priority response. If I don't elevate the bed or sit them up, they could have a hypertensive stroke! 4. Incorrect: This is a correct answer, but not the priority response. If I don't elevate the bed or sit them up, they could have a hypertensive stroke!

A nurse educator is teaching first responders about disaster management, and provided the following scenario: A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. First responders arrive on the scene. The nurse educator recognizes education has been successful when the first responders identify which action as priority? 1. Triage victims and tag according to injury. 2. Assess the immediate area for electrical wires on the ground and in vicinity of victims. 3. Activate the community emergency response team. 4. Begin attending to injuries as they are encountered.

3. Correct: With mass casualties, community response teams are needed. 1. Incorrect: This would be the third step. 2. Incorrect: This would be the second step so that further injuries are not encountered. 4. Incorrect: Triage must occur before treatment of anyone so that an accurate assessment of level of injuries can be made. With mass casualties, a color tag system is usually implemented.

The nurse is caring for a client with a history of Gastroesopeageal Reflux (GERD). Based on the assessment, what is the priority intervention? Lung sounds diminished on the left side posteriorly with crackles noted bilaterally. Frequent, moist cough. Temp of 103º F (39.45ºC) 1. Administer ibuprofen 2. Establish IV access 3. Obtain oxygen saturation 4. Chest x-ray

3. Correct: Y'all, what do you think is wrong with this client? Did you say.............................Pneumonia? Yes, these are classic things we see with Pneumonia, so you better be checking oxygenation. Is a client with GERD at risk for pneumonia? Yes, because the acid that is refluxing can be aspirated into the lungs. 1. Incorrect: Oxygenation takes priority here. 2. Incorrect: The nurse needs to check oxygenation first. 4. Incorrect: Oxygenation takes priority.

A client is admitted with a diagnosis of exacerbation of left-sided heart failure. Which interventions are appropriate for the nurse to initiate? Select all that apply 1. Administer two puffs from albuterol inhaler. 2. Start IV of normal saline (NS) at 75 mL/hr. 3. Obtain ABGs. 4. Initiate oxygen at 2 L/nasal cannula. 5. Elevate head of bed 65-70 degrees. 6. Give furosemide 40 mg IVP.

3., 4., 5., & 6. Correct: Priority nursing interventions for a client with an acute exacerbation of left-sided heart failure include monitoring ABGs, oxygen administration, high-fowler's position and diuretic therapy. 1. Incorrect: Albuterol is used for asthma clients. 2. Incorrect: IV of NS would make the problem worse. NS is isotonic and increase the vascular space even more.

The nurse is to administer a fluid bolus to a 25 pound (11.36 kg) child. The primary healthcare provider prescribes a bolus of 20 mL/kg. 1. 500 mL isotonic solution 2. 500 mL hypotonic solution 3. 227 mL isotonic solution 4. 227 mL hypotonic solution

3.Correct: 11.34 x 20 = 226.8 mL Ok I know I'm going to be giving 227mL. WHY is the answer isotonic???- Think back to your fluid and electrolyte lecture: I want the fluid to go into the vascular space and stay there so I want an isotonic solution like NS 1. Incorrect: 11.34 x 20 = 226.8 mL Ok I know I'm going to be giving 227mL. WHY is the answer isotonic???- Think back to your fluid and electrolyte lecture: I want the fluid to go into the vascular space and stay there so I want an isotonic solution like NS 2. Incorrect: 11.34 x 20 = 226.8 mL Ok I know I'm going to be giving 227mL. WHY is the answer isotonic???- Think back to your fluid and electrolyte lecture: I want the fluid to go into the vascular space and stay there so I want an isotonic solution like NS 4. Incorrect: 11.34 x 20 = 226.8 mL Ok I know I'm going to be giving 227mL. WHY is the answer isotonic???- Think back to your fluid and electrolyte lecture: I want the fluid to go into the vascular space and stay there so I want an isotonic solution like NS

The nurse is caring for a client that is 3 days post tonsillectomy and reports a 2 pound (0.91 kg) weight loss, lethargy, and frequent swallowing. What is the nurse's priority assessment? 1. Urinary Output 2. Daily weight 3. Heart rate 4. Breath sounds

3.Correct: This client is in a FVD. The weight has dropped. Fluid is moving out of the vascular space and the client is getting worse so what could happen to my heart rate... drop! And then I am not going to perfuse adequately and I could kill my brain, kidneys..............all my vital organs. Right? My body will be able to compensate for awhile, but when my HR starts to drop I know my client is getting worse. 1. Incorrect: SURE, you are going to watch the urinary output and the daily weight. Breath sounds are very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I better take the heart rate because that is the one that says SHOCK 2. Incorrect: SURE, you are going to watch the urinary output and the daily weight. Breath sounds are very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I better take the heart rate because that is the one that says SHOCK 4. Incorrect: SURE, you are going to watch the urinary output and the daily weight. Breath sounds are very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I better take the heart rate because that is the one that says SHOCK

Which client would be appropriate for the charge nurse to assign to a room with a client who has undergone debulking of a tumor? 1. Client who is one day post laminectomy. 2. Client scheduled for a bone marrow transplant. 3. Client admitted with neutropenia. 4. Client being treated with intracavity radiation therapy.

1. Correct. These clients can be in the same room as neither has an infection or is immunocompromised. 2. Incorrect. The client scheduled for a bone marrow transplant is immunocompromised and should not be placed in the room with another client. 3. Incorrect. This client is at risk for infection and should be in a private room. 4. Incorrect. This client will be emitting radiation to the external environment and should be in a private room.

Which discharge referral would be a priority for the nurse to make in order to promote continuity of care for a client following a colectomy and colostomy formation due to colon cancer? 1. Home health 2. Meals on Wheels 3. Hospice care 4. Registered dietitian

1. Correct: Clients often go home quickly and do not completely understand discharge instructions. The first priority would be for colostomy care, which can be provided by home health. 2. Incorrect: Meals on Wheels will be important later during rehabilitation but is not the priority. 3. Incorrect: Hospice care is premature. The question does not reveal if surgery was successful or not to remove the colon cancer. 4. Incorrect: A dietary consult may be necessary later, but is not the priority at present.

Which client should the RN assess first? 1. Client experiencing unstable angina. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client five days post right-sided cerebral vascular accident. 4. Client diagnosed with Bell's palsy scheduled to be discharged.

1. Correct: This client is experiencing unstable angina, so is the most critical of the clients assigned to this RN. This client should be seen first. 2. Incorrect: The client with chronic emphysema is expected to have mild shortness of breath. This client is not the most critical client and would not be assessed first. 3. Incorrect: There is nothing in this option to indicate the nurse should assess this client first. The client experiencing unstable angina takes priority. 4. Incorrect: There is nothing in this option to indicate the nurse should assess this client first. The client experiencing unstable angina takes priority.

A pediatric nurse plans care for a child diagnosed with acute post-streptococcal glomerulonephritis. Which assessment findings should the nurse anticipate? Select all that apply 1. Edema 2. Proteinuria 3. Hematuria 4. Anasarca 5. Decreased urine specific gravity

1., 2. & 3. Correct: The nurse should anticipate that the child may be edematous and exhibit signs of proteinuria and hematuria. Glomerulonephritis results in a decrease in kidney filtration of the blood, which leads to fluid retention (edema), leakage of protein from the blood into the urine (proteinuria), and leakage of a large number of red blood cells into the urine. 4. Incorrect: Anasarca is total body edema. It is much greater than edema of the extremities. The entire body is edematous.This would be seen with nephrotic syndrome. 5. Incorrect: Urine specific gravity (density as compared to water) increases because of the inability of the kidney to filter out particulates.

Which tasks can the RN safely delegate to an LPN/LVN when caring for a client scheduled for an adrenalectomy? Select all that apply 1. Check fingerstick glucose level. 2. Administer regular insulin SQ based on sliding scale prescription. 3. Assess client's cardiac rhythm. 4. Reinforce teaching regarding postoperative care. 5. Review client's pre-surgical laboratory values.

1., 2., & 4. Correct: The LPN/LVN can perform these tasks and can reinforce teaching. 3. Incorrect: The RN must assess, evaluate, and teach. The LPN/LVN can collect data to assist the RN, but the RN must validate that the data is correct. 5. Incorrect: The RN must assess, evaluate, and teach. The LPN/LVN can collect data to assist the RN, but the RN must validate that the data is correct.

A mother brings her 6 week old infant to the ED and reports that the baby isn't gaining weight, and has not wet a diaper in 12 hours. The baby vomits after every feeding. Which nursing interventions would help this infant? Select all that apply 1. Upright position with feedings and at night 2. Small frequent feedings that are thickened 3. Supine position for sleeping 4. Administration of H2 blockers 5. Give Pedialyte only until vomiting stops

1., 2., & 4. Correct: These interventions will promote stomach emptying and prevent gastric reflux. 3. Incorrect: First, did you recognize that this infant has Gastric Reflux? And the ideal position for sleeping with Gastric reflux is HOB elevated 30 degrees and the prone position. Y'all elevated and prone will help to improve stomach emptying, not supine. 5. Incorrect: We definitely don't want to give this baby thin liquids, they need thickened feedings. This is really important to decrease chance of aspiration.

What should be the priority nursing actions when caring for a child following a tonsillectomy and adenoidectomy? Select all that apply 1. Encourage oral intake of fluids. 2. Suction the mouth and throat as needed. 3. Administer pain medication around the clock. 4. Apply ice collar to the front of the neck as needed. 5. Encourage coughing and deep breathing every two hours.

1., 3. & 4. Correct: Following tonsillectomy and adenoidectomy, the nurse should encourage the oral intake of fluids, administer pain medication around the clock, and apply an ice collar to the front of the neck if needed. Oral fluid intake prevents dehydration, weight loss, and local infection. Pain medication, such as acetaminophen with or without codeine, administered at regular intervals controls pain more effectively than PRN administration. An ice collar that is applied to the front of the neck decreases pain as well as the risk for hemorrhage. 2. Incorrect: Oral suctioning puts stress on the tonsillectomy site and causes bleeding. 5. Incorrect: Coughing should be discouraged as this puts stress on the tonsillectomy site and causes bleeding.

Which interventions would the nurse initiate in a 1 year old with Sickle Cell Crisis? Select all that apply 1. IV hydration 2. PCA pump for pain relief 3. Exercise 4. Analgesics 5. Antibiotics 6. Strict neutropenic precautions

1., 4., & 5. Correct: The client with Sickle Cell Crisis is dehydrated. Increasing hydration will improve ability of RBCs flow through the vascular system. Analgesics are needed for pain control. Antibiotics are needed to fight infection. 2. Incorrect: False, the client is not old enough to manage a PCA pump 3. Incorrect: False, during a crisis we want to promote rest to limit oxygen needs 6. Incorrect: False, sickle cell clients aren't neutropenic from sickle cell, and in order to pick an answer like this for a sickle cell client, the nurse would need to know what the client ANC (absolute neutrophil count) is. Y'all what are neutrophils? They are part of the WBC count, so if a client is on neutropenic precautions their neutrophil count is low and we are worried about them getting an infection. The client in this scenario has sickle cell, so the problem is the RBCs, we would be looking for anemia, not neutropenia.

Which client would be appropriate for the charge nurse to assign to the LPN/VN? Select all that apply 1. The client with a leg cast who needs neurovascular checks. 2. The client diagnosed with arthritis who needs pain medication and heat application. 3. The client reporting abdominal pain and rebound tenderness after a bicycle accident. 4. The client diagnosed with anorexia nervosa who is experiencing muscle weakness and decreased urinary output. 5. The client experiencing nausea and vomiting after receiving chemotherapy.

2. & 5. Correct: These are uncomplicated, stable clients. The LPN/VN can provide pain medication and heat application to the arthritis client and can care for a client experiencing nausea and vomiting after chemotherapy. 1. Incorrect: The LPN/VN can not do a neurovascular assessment independent of the RN. 3. Incorrect: This is a complicated client who has abdominal pain and rebound tenderness. This client is at risk for bleeding, and peritonitis. 4. Incorrect: This client has muscle weakness which is a symptom of hypokalemia. Also a decreased urinary output which could be due to FVD which could lead to shock.

Which infant in the newborn nursery requires an immediate intervention by the nurse? 1. Four hours old, who has passed a small meconium stool. 2. Three hours old, who is having tremors. 3. Two hours old, who has several episodes of apnea lasting 10 seconds. 4. One hour old, who has acrocyanosis.

2. Correct. Tremors and jitteriness indicate hypoxia which requires immediate intervention by the nurse. 1. Incorrect. Meconium is usually passed within 24 hours. This does not require intervention by the nurse. 3. Incorrect. Apnea of 5-15 seconds is not unusual and decreases with time. This does not require intervention by the nurse. 4. Incorrect. Acrocyanosis in the newborn is due to premature peripheral circulation that will improve. This does not require intervention by the nurse.

A nurse is caring for a 5 year-old child who has a spinal cord injury at the sixth thoracic vertebrae. Vital signs are heart rate - 56 beats per minute and a blood pressure of 154/86 mm Hg. Which action should the nurse take first? 1. Complete a neurological assessment 2. Assess patency of the urinary catheter 3. Place the client in Sims position 4. Notify the primary healthcare provider immediately

2. Correct: The child is experiencing symptoms of autonomic dysreflexia, an excessive stimulation of the sympathetic nervous system that is a potential complication of spinal cord injury. Since bladder distention can lead to this problem, the nurse should first assess the urinary catheter for obstruction or malfunction. 1. Incorrect: Although a neurological assessment is an important priority of care, the nurse should first investigate the potential cause of the problem. 3. Incorrect: Head of bed elevation is essential in autonomic dysreflexia to decrease blood pressure. 4. Incorrect: The nurse should first assess the likely causes of problem before notifying the primary healthcare provider.

When providing care to a client diagnosed with pheochromocytoma, which actions could the nurse safely delegate to the unlicensed nursing personnel (UAP)? Select all that apply 1. Explain the purpose of the vanillylmandelic acid test. 2. Remove caffeinated beverages from the client's meal tray. 3. Remind client not to smoke. 4. Tell the client to limit activity. 5. Monitor hydration status.

2., & 3. Correct: The UAP can follow directions about removing items from a client's meal tray. The UAP can provide simple instruction reminders after the nurse has provided teaching. 1. Incorrect: The UAP cannot teach. 4. Incorrect: This is teaching and cannot be done by the UAP. Further explanation by the nurse would need to be included as well. 5. Incorrect: The UAP cannot evaluate, which would include monitoring hydration status. The UAP could collect data but cannot monitor or evaluate.

The nurse is providing discharge teaching for a family of a 2 year old going home on digoxin. Which teaching should the nurse include? Select all that apply 1. Use a 5 mL syringe to draw up the medication so the numbers can be seen easily 2. Give 1 hour before or 2 hours after feedings 3. Add the medication to the bottle so it is easier to administer 4. Check the apical pulse before giving medication 5. Store the medication in the refrigerator

2., & 4. Correct: Digoxin should be given on an empty stomach for better absorption. The apical pulse should be checked prior to administering digoxin. 1. Incorrect: Remember rarely do we give more than 1mL to an infant, it should be drawn up in the smallest available syringe (1mL syringe), you are increasing the chance of a medication error using the larger syringe. 3. Incorrect: NEVER add medication to a bottle, if the infant doesn't eat the entire bottle you have no idea how much medication was actually administered. 5. Incorrect: Digoxin is stored at room temperature.

As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement? Select all that apply 1. Developing a response plan for each potential disaster. 2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. 5. Every hospital should prepare for all the same emergencies.

2., 3. & 4. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. The basic principle of emergency preparedness are the same for all types of disasters. Only the response interventions vary to address the specific needs of the situation. 1. Incorrect: One good response plan should be developed rather than multiple plans. This will ensure adequate understanding of the plan and decrease confusion of roles that could occur with multiple plans. 5. Incorrect: Consideration must be given to the proximity of chemical plants, nuclear facilities, schools and areas where large groups gather.

The RN is reviewing client assignments with the LPN/VN working on a medical floor. Which clinical assignments would be appropriate for the LPN/VN? Select all that apply 1. The client with nausea, vomiting, and mild metabolic alkalosis 2. The client with chronic back pain admitted for pain management 3. The client on-call to OR for a scheduled total knee replacement 4. The client with a stage 3 decubitus ulcer requiring a dressing change 5. The client newly diagnosed with Addison's disease

2., 3., & 4. Correct: The LPN/VN can manage pain and can prep someone for the OR. The LPN/VN can also do wound care on a decubitus ulcer. Remember, look at the client where they are here and now. 1. Incorrect: The LPN/VN cannot take care of an unstable client and that includes anyone with an acid base imbalance. 5. Incorrect: The LPN/VN cannot take care of a complicated client. The client newly diagnosed with Addison's disease has adrenal insufficiency. That means the client does not have enough aldosterone, so cannot hold on to sodium and water. This puts the client into a fluid volume deficit which could lead to shock. This is an unstable client.

The nurse admits a child with a history of cystic fibrosis (CF) with vomiting for 3 days, headache, and unusual behavior. What does the nurse anticipate the lab values will show? 1. Hypernatremia 2. Hypercalcemia 3. Hypocalcemia 4. Hyponatremia

4. Correct: CF kids are always losing sodium! That's why mom will often say they taste "salty" when she kisses them and why the sweat chloride test is diagnostic. They are looking for sodium chloride when they do the test. So when they are sick their risk for becoming hyponatremic goes up even more because they are stressed. And we know the brain doesn't like for our Na to be messed up. Did you pick out these Key words: Vomiting x3 days, headache, and unusual behavior. 1. Incorrect: CF kids are always losing sodium! Also, when you vomit, you lose all electrolytes. 2. Incorrect: CF kids are always losing sodium! Calcium is not the problem here. 3. Incorrect: CF kids are always losing sodium! Calcium is not the problem here.

A client who comes to the emergency department (ED) reporting chest pain does not have the ability to pay for care. Which action should the nurse implement first? 1. Transfer the client by ambulance to a charity hospital. 2. Request the client sign a contract agreeing to pay the hospital bill. 3. Notify a family member to provide a deposit for care. 4. Connect client to a heart monitor.

4. Correct: Federal law requires that ED clients be assessed and treated without regard to payment. 1. Incorrect: The nurse must assess the client. A client cannot be transferred until after stabilization and acceptance from the receiving hospital. 2. Incorrect: Federal law requires that ED clients be assessed and treated without regard to payment. The hospital will attempt to recover costs after the client treatment. 3. Incorrect: Federal law requires that ED clients be assessed and treated without regard to payment. The hospital will attempt to recover costs after the client treatment.

A nurse is caring for four pediatric clients. In what order should the nurse attend these clients? Prioritize the clients by placing them in order from first to last. 1. 12 month old child who is due for an inhalation treatment of ribavirin 2. 4 year old child with intravenous heparin infusing at a maintenance rate 3. 10 year old child who has been prescribed intravenous cefoxitin 4. 7 year old child needing a consultation with a certified diabetic educator

First, see the 4 year old child with an IV heparin infusion. Heparin is a high alert drug that increases the child's risk for bleeding. Ribavarin in an antiviral medication used for severe lower respiratory tract infections. It is not a bronchodilator or respiratory inhaler for opening the airway. The 12 month old child who is due for a breathing treatment should be assessed second and given the treatment. The treatment does need to be given on time to prevent respiratory problems due to the illness. The third client to see is the 10 year old child who has been prescribed an intravenous antibiotic. This client is not a high priority, however, the medication will need to be given on time. The 7 year old who needs insulin teaching should be assessed fourth or last because the nurse will want to allow time for teaching and return demonstration.

A nurse utilizes the Braden Scale to assess and document the pressure sore risk of a client diagnosed with Guillain-Barré syndrome. 0900 The client has very limited sensory perception and is occasionally moist. The client is wheelchair bound and has very limited mobility. The client is receiving adequate caloric intake by tube feeding and is moved easily by the nursing staff without any evidence of friction or sheering. Based on this documentation, what score should the nurse assign to this client?

The correct answer is 15, placing this client at mild risk. Sensory perception very limited = 2 Moisture occasionally moist = 3 Chair fast = 2 Mobility very limited = 2 Adequate nutrition = 3 No friction/shear = 3 Total = 15 Braden Scale Assessment Score: Very High Risk: Total Score of 9 or less High Risk: Total Score of 10-12 Moderate Risk: Total Score of 13-14 Mild Risk: Total Score of 15-18 No Risk: Total Score of 19-23