Peds Chapter 31
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) Examine the child for signs of pneumothorax. b) Suction the tube to remove a mucus plug. c) Confirm that the ventilator is working properly. 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 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) Encouraging them to read to their daughter b) Giving them brief explanations of procedures c) Providing honest answers in a reassuring manner d) Describing the treatment plan for their daughter
Providing honest answers in a reassuring manner 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 assessing the neurologic status of an infant. Which of the following would the nurse identify as a nonreassuring finding? a) Vigorous crying b) Making eye contact with the nurse c) Soft flat anterior fontanel d) Lack of interest in surroundings
Lack of interest in surroundings
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) Three b) Two c) Five d) Four
Three
Which medication is used for symptomatic bradycardia unresponsive to ventilation and oxygenation? a) Sodium bicarbonate b) Naloxone c) Atropine d) Calcium carbonate
Atropine 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.
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
A child is learning to ride a bicycle. He should be instructed to use a(an) a) Wrist guard b) Knee pads c) Light d) Helmet
Helmet
A 5-year-old girl is breathing spontaneously but is unable to maintain an airway. Which of the following would be the priority? a) Inserting an oropharyngeal airway b) Placing a towel under her shoulders c) Positioning her using head tilt/chin lift d) Assisting with tracheal tube insertion
Inserting an oropharyngeal airway 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.
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 anterior fontanel b) Palpating the abdomen for soreness c) Observing skin color and perfusion d) Auscultating for bowel sounds
Palpating the anterior fontanel 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.
A 2-year-old boy is in respiratory distress. Which nursing assessment finding would suggest the child aspirated a foreign body? a) Hearing dullness when percussing the lungs b) Noting absent breath sounds in one lung c) Hearing a hyperresonant sound on percussion 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 group of nursing students are reviewing information about tachyarrhythmias in children. The students demonstrate a need for additional review when they identify which of the following as a characteristic of sinus tachycardia in children? a) Heart rate below 180 beats per minute b) Beat-to-beat variability in rhythm c) Presence of P waves d) Narrow QRS complex
Narrow QRS complex Explanation: With sinus tachycardia, the QRS complex is normal. A heart rate below 180 beats per minute is a characteristic of sinus tachycardia. P waves are present with sinus tachycardia. Sinus tachycardia exhibits a beat-to-beat variability in rhythm.
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) Draw blood for type and cross-match. b) Establish a suitable IV site. c) Provide oral analgesics as ordered. d) Begin hyperventilation.
Establish a suitable IV site. 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.
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) Placing the hand under the neck d) Employing the jaw-thrust maneuver
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.
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) Initiate chelation therapy. b) Perform a gastric lavage. c) Administer N-acetylcysteine. 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.
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) Noncompliance b) Risk for Suffocation c) Risk for Falls d) Risk for Imbalanced Body Temperature
Risk for Suffocation 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 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.
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) "He fell out of a shopping cart in the store." c) "Mom turned and he fell from changing table." d) "The gate was open and he fell down three steps."
"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.
The nurse is providing support to the parents of a 10-year-old boy receiving emergency care. The boy is their foster child. Which of the following comments will be most effective? a) "I think you had better stay out here and wait to hear from us." b) "Since you are not his biological parents, you must wait outside." c) "Hold your child's hand while this is going on." d) "Your child is hypovolemic and needs fluid."
"Hold your child's hand while this is going on."
Fill in the blank (with a number) question - Enter the answer in the space provided. Your answer should contain only numbers and, if necesary, a decimal point. 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
25ml/hr 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
Fill in the blank (with a number) question - Enter the answer in the space provided. Your answer should contain only numbers and, if necesary, a decimal point. 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
When assessing a child with a traumatic injury, which of the following would be the priority assessment? a) Breathing effectiveness and breath sounds b) Pulse rate and skin color c) Airway patency and airflow d) Level of consciousness and papillary reaction
Airway patency and airflow 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.
Cardiopulmonary resuscitation (CPR) is in progress on an 8-year-old boy who is in shock. Which is the priority nursing intervention? a) Attaining central venous access via the femoral route b) Using a large bore catheter for peripheral venous access c) Inserting an indwelling urinary catheter to measure urine output d) Drawing a blood sample for arterial blood gas analysis
Attaining central venous access via the femoral route 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 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? a) Instruct the toddler not to go near the pool. b) Teach the child that water is dangerous. c) Avoid unattended baths for the toddler. d) Provide only partial baths to the toddler.
Avoid unattended baths for the toddler. 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 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? a) Atropine b) Naloxone c) Lidocaine d) Ketamine
Naloxone
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) Providing 100% oxygen via face mask b) Administering epinephrine as ordered c) Giving intravenous isotonic fluids d) Using a convective air warming blanket
Using a convective air warming blanket 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.
Fill in the blank (with a number) question - Enter the answer in the space provided. Your answer should contain only numbers and, if necesary, a decimal point. 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 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 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) Performing hands-only CPR b) Assessing for consciousness c) Stimulation of vomiting d) Administration of acetylcysteine
Administration of acetylcysteine 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.
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) Inducing vomiting b) Administration of activated charcoal c) Gastric lavage d) Intravenous rehydration
Administration of activated charcoal 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.
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 was trapped in a closed burning bedroom. c) The child's clothing was burned. d) The fire was caused by burning weeds.
The child was trapped in a closed burning bedroom. 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.
Fill in the blank (with a number) question - Enter the answer in the space provided. Your answer should contain only numbers and, if necesary, a decimal point. 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.
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 is assessing the respiratory status and lungs of a 6-year-old child. Which of the following would the nurse report immediately? a) Minimal air movement through the lungs b) High-pitched breath sounds over the trachea c) Resonance over the lungs on percussion d) Low-pitched bronchial sounds over the periphery
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.
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) Providing blow-by oxygenation b) Beginning hyperventilation of the child c) Intubation and mechanical ventilation d) Administering small doses of morphine
Intubation and mechanical ventilation 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 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) Spleen b) Pancreas c) Liver d) Stomach
Spleen 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.
When assessing a young child who is experiencing decompensated shock, which of the following would the nurse expect to find? a) Normal blood pressure b) Tachypnea c) Tachycardia d) Irritability
Tachypnea Explanation: In decompensated shock, the child displays decreased blood pressure and level of consciousness (stupor or coma), and tachypnea or signs of respiratory failure. In compensated shock, the child becomes tachycardic in an effort to increase cardiac output. The BP remains normal, capillary refill time may be prolonged (more than 2 seconds), and the child may become irritable because of increasing hypoxia.
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) Check mouth for debris. d) Administer 100% oxygen.
Stabilize the cervical spine. 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.
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) Increased metabolic demands b) Possible tissue damage from hypoxia c) Inadequate systemic perfusion d) Risks from reduced core temperature
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).
The nurse has administered IV adenosine as ordered to a child with supraventricular tachycardia. Which action would the nurse do next? a) Set up a continuous infusion for administration of adenosine. b) Give five positive-pressure ventilations. c) Administer a rapid generous saline flush. d) Monitor for ventricular arrhythmias.
Administer a rapid generous saline flush. 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.
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) One pupil dilated and the other normal c) Both pupils are dilated d) One pupil dilated and the other deviated downward
Both pupils are pinpoints 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.
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) Inspection shows a sluggish pupillary reaction. d) The child's eyes remain closed unless she is spoken to.
Inspection shows a sluggish pupillary reaction. 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 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) 30 to 40 joules d) 2 to 4 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.
Administration of which medication reverses histamine release and hypotension that are seen in anaphylaxis? a) Benadryl b) Zantac c) Epinephrine d) Atropine
Epinephrine
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) Administer antacids. c) Establish IV access. d) Call family members.
Establish a patent airway
Fever increases the basal metabolic rate resulting in: a) Bradycardia b) Bradypnea c) Decreased oxygen demand d) Tachypnea
Tachypnea Explanation: Fever increases the basal metabolic rate, resulting in tachycardia, tachypnea, and increased oxygen demand.
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) Applying ice to the child's face c) Oxygenating and ventilating the child d) Initiating cardiac compressions
Applying ice to the child's face 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 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 pulse pressure and increase in temperature and respiratory rate b) Decrease in pulse and respiratory rate and increase in temperature and pulse pressure c) Decrease in temperature and pulse pressure and increase in pulse and respiratory rate d) Decrease in pulse and temperature and increase in respiratory rate 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.
A 10-year-old boy has just arrived by ambulance at the emergency room following a motor vehicle accident, and a nurse is assessing him. Which three body systems should the nurse evaluate fist? a) Respiratory, cardiovascular, and neurologic b) Respiratory, cardiovascular, and skeletal c) Neurologic, cardiovascular, and endocrine d) Cardiovascular, gastrointestinal, and neurologic
Respiratory, cardiovascular, and neurologic Explanation: Unintentional injuries become fatal when lung, heart, or brain function becomes inadequate. These three body systems (respiratory, cardiovascular, and neurologic), therefore, must be evaluated first (Airway, Breathing, Circulation and Disability, or an ABCD evaluation).
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 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 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) Assess the client's blood pressure b) Test the fluid with a glucose reagent strip c) Evaluate the client's level of consciousness d) Perform a skull x-ray
Test the fluid with a glucose reagent strip 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.
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.
A 3-year-old child who is breathing very rapidly and shallowly has an oxygen saturation level of 90%. The child is also very apprehensive. Which of the following would be most appropriate? a) Administer oxygen via a mask made out of a paper cup. b) Offer the child a drink of her favorite fluid. c) Have the parent hold a mask in place to administer a nebulizer treatment. d) Have the child sit up straight in a chair next to her parent.
Administer oxygen via a mask made out of a paper cup. Explanation: For any child showing respiratory distress or desaturation on pulse oximetry, administer oxygen to keep saturation above 95% using a method tolerated by the child; in the instance of a child with extreme apprehension, the nurse can fashion a nonthreatening oxygen mask made with a styrofoam or paper cup and an oxygen cannula. The child should be allowed to assume whatever position provides the most comfort. The child's level of apprehension will probably interfere with using a mask for a nebulizer treatment. The key here is to administer oxygen. The nebulizer treatment may or may not be appropriate. Additionally, the child's apprehension would most likely increase if the mask is used, further worsening her respiratory distress. Children with respiratory distress should not be fed or given fluids.
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) Closely monitor the toddler's activity. b) Keep cleaning solutions locked up. c) Label poisonous solutions. d) Do not leave the toddler alone.
Keep cleaning solutions locked up. 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.
After assessing a child's airway, breathing, and circulation (ABCs), which of the following would the nurse do next? a) Assess level of consciousness. b) Remove the child's clothing. c) Obtain a full set of vital signs. d) Provide pain management.
Assess level of consciousness. 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.
Assessment of a child reveals a tension pneumothorax. The nurse would prepare the child for which of the following? a) Intubation b) Defibrillation c) Suctioning d) Needle thoracotomy
Needle thoracotomy 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.
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) Placing house plants out of reach of children b) Putting child safety locks on kitchen cabinets c) Removal or covering of flaking paint on the walls of the home d) Putting medicine away where children cannot reach it
Removal or covering of flaking paint on the walls of the home 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.
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 dopamine as ordered b) Giving blood if saline provides inadequate response c) Administering intravenous saline as ordered 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 10-year-old boy with congenital heart disease is in shock. Which nursing intervention would be most appropriate for this child? a) Assessing for pulmonary edema from fluid overload b) Assessing for changes in mental status and alertness c) Monitoring urine output with a goal of 1 to 2 mL/kg/hour d) Palpating for pulses and capillary refill
Assessing for pulmonary edema from fluid overload Explanation: Assessing for pulmonary edema from fluid overload is the most appropriate intervention. Pulmonary edema is rare but may occur in children with preexisting cardiac conditions or severe chronic pulmonary disease. Assessing for changes in mental status and alertness, monitoring urine output, and palpating for improved pulses and capillary refill are valid interventions for managing shock of any kind.
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) Checking the CO2 monitor for a yellow display b) Watching for disconnections in the breathing circuit c) Monitoring the pulse oximeter for oxygen saturation 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.
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) Initiate cardiac compressions b) Give three doses of epinephrine c) Administer doses defibrillator shocks in a row d) Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR)
Initiate cardiac compressions 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.
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) Ask the child to drink a glass of milk. b) Give a tetanus toxoid injection. c) Insert an NG tube to empty the stomach. d) Obtain a weight.
Obtain a weight 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.
The nurse is preparing to insert an oropharyngeal airway. Which action would be most appropriate to determine the proper size? a) Measuring distance from end of nose to tragus of ear b) Inspecting the child's fifth digit to estimate the diameter c) Placing the airway next to the cheek with tip pointing down d) Measuring from the tip of the nose to earlobe to middle of xiphoid process
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.