Ricci CH 51

The nurse is providing care to a 4-year-old boy with a broken arm and an infected laceration from a fall. The nurse notes a significant elevation in the child's heart rate. Which intervention would be least appropriate? A) Administering antipyretics as ordered for fever B) Using a defibrillator to reduce the heart rate C) Administering analgesics to reduce pain D) Allowing the parents to comfort the child

B) Using a defibrillator to reduce the heart rate

A nurse manager is debriefing a group of coworkers who had just finished caring for a child who suffered a cardiac arrest. One of the coworkers states, "Why did they let the family stay while we were working on the child?" What is the best response by the nurse? a. "It's up to the family on if they want to stay or not." b. "Allowing the family to stay during the resuscitation may assist the family in coping." c. "I'm not sure why they were there. It's normally against our policy." d. "If the family members are health care workers, they typically let them stay."

b. "Allowing the family to stay during the resuscitation may assist the family in coping." Explanation: Studies have shown that family presence during resuscitation may assist with family coping. It is up to the family if they want to stay but this is not the best response. It does not matter if the family members are health care workers or not.

Administration of which medication reverses the histamine release and hypotension that are seen in anaphylaxis? a. diphenhydramine b. atropine c. epinephrine d. cimetidine

c. epinephrine Explanation: Epinephrine reverses histamine release and hypotension due to anaphylaxis. It increases the heart rate and systemic vascular resistance. Diphenhydramine and cimetidine are histamine blockers. They are used for milder forms of allergic reactions. Atropine is an anticholinergic. It causes tachycardia, inhibits secretions, and relaxes smooth muscle.

Which intervention would be most helpful in preventing barotrauma when ventilating a 3-year-old girl with a bag-valve-mask? A) Choosing the correct size bag and face mask B) Setting the flow rate at exactly 10 L/minute C) Maintaining the airway in the open position D) Delivering one breath every 3 to 5 seconds

D) Delivering one breath every 3 to 5 seconds

The nurse is preparing the plan of care for a child experiencing respiratory distress. Which of the following would be the priority? A) Providing supplemental oxygen B) Monitoring for changes in status C) Assisting ventilation D) Maintaining a patent airway

D) Maintaining a patent airway

Which of the following would be most appropriate to use to help maintain a patent airway in an infant experiencing a respiratory emergency? A) Neck hyperextension B) Head tilt-chin lift technique C) Jaw-thrust maneuver D) Small towel under shoulders

D) Small towel under shoulders

A 13-year-old adolescent has had a near-drowning experience. The nurse notices the client has labored breathing and a cough. What is the priority intervention? a. Administer 100% oxygen by mask. b. Have the client sit up straight in a chair. c. Check the client's capillary refill time. d. Perform postural drainage every hour.

a. Administer 100% oxygen by mask. Explanation: Management of the near-drowning victim focuses on assessing the client's airway, breathing, and circulation (ABCs) and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the adolescent assume the most comfortable position for him or her. Checking capillary refill time helps determine ineffective tissue perfusion, but it does not provide an intervention for the labored breathing. Postural drainage techniques to remove water from the lungs are of no proven value in a near-drowning experience.

The nurse is called into a toddler's room. The toddler's parent says "My toddler is having trouble breathing." What should the nurse do first? a. Assess patency of the airway. b. Place on 100% oxygen. c. Notify the health care provider. d. Apply a pulse oximeter to monitor oxygen levels.

a. Assess patency of the airway. Explanation: The first step in airway evaluation and management is assessing the patency of the toddler's airway. Depending on the assessment findings, the nurse may place oxygen and a pulse oximeter on the toddler. Notification of the health care provider needs to occur, but the nurse must assess the toddler first.

The nurse is conducting an educational class regarding the use of the intraosseous site for administration of fluid to the pediatric client experiencing an emergency, such as shock. What would the nurse include in this educational presentation? a. The intraosseous site is preferred if peripheral access cannot be attained rapidly. b. The child must be in a left-side lying position with the spine flexed to access properly. c. The nurse will utilize a small gauge catheter for children, such as a 25 gauge. d. The intraosseous site is used only for crystalloid fluids such as normal saline.

d. The intraosseous site is used only for crystalloid fluids such as normal saline. Explanation: The intraosseous site is preferred if peripheral access cannot be obtained in 90 seconds. The child would be positioned so the nurse can readily access the bone rather than in a position with the spine flexed. The access site is not related to the spine. The intraosseous needles are generally 15 to 18 gauge. Any fluids or medications that can be infused via a peripheral site can be given via an intraosseous site.

The child presents to the emergency department via ambulance in uncompensated SVT at a rate of 262 beats per minute. The nurse receives an order to administer adenosine IV. In addition to adenosine, what would the nurse bring to the bedside in preparation to administer the adenosine? a. a blood pressure cuff in the appropriate size b. a consent form for the child or parent to sign c. an emesis basin for the child to use if vomiting d. a generous saline flush to follow the IV medication

d. a generous saline flush to follow the IV medication Explanation: Adenosine IV is given rapidly (over 1 or 2 seconds) and is followed by a generous saline flush followed by a rapid (to ensure the medication has entered the vessel). The nurse would assess the child's blood pressure but not specifically in relation to the administration of adenosine. The parents would not sign a consent form for this medication. Vomiting is not a side effect of adenosine.

The nurse is examining a 10-month-old infant who has fallen from the back porch. Which nursing action has priority? a. palpating the anterior fontanel (fontanelle) b. assessing skin color and perfusion c. assessing neurological status d. maintaining an adequate airway

d. maintaining an adequate airway Explanation: The highest priority nursing action in the management of an infant with an injury is to establish and maintain an adequate airway. Observing skin color and perfusion is part of evaluating circulation. Once the ABCs have been evaluated, the nurse will move on to "D" and assess for disability by palpating the anterior fontanel (fontanelle) for signs of increased intracranial pressure and assessing neurological status.

The nurse is assessing an 8-year-old child in the emergency department. Which assessment finding would be a priority and alert the nurse to intervene immediately? a. a pleural fiction rub b. expiratory wheezing c. systolic blood pressure of 86 d. minimal air movement in the lung fields

d. minimal air movement in the lung fields Explanation: The nurse must immediately intervene when there is minimal air movement in the lung fields. The child is severely compromised at this time. The assessment findings of a pleural friction rub and an expiratory wheeze would require further assessment but are not as high of priority as minimal air movement. The systolic blood pressure of 86 is a normal finding for an 8-year-old child (70 + twice the age in years would be 70 + 16).

The nurse receives shift report from the previous shift on several pediatric clients. For which child would the nurse further assess the electrolyte levels immediately following report? a. the 18-month-old experiencing unrelenting pain from a fractured femur b. the 5-year-old post-op day #3 following repair of a traumatic injury to her spleen c. the 10-year-old preparing for discharge following a near-drowning 4 days ago d. the 15-year-old who had a resolved episode of ventricular tachycardia the previous shift

d. the 15-year-old who had a resolved episode of ventricular tachycardia the previous shift Explanation: Abnormalities of potassium and hypokalemia have been associated with the development of ventricular tachycardia in children. The other clients' electrolyte levels would require monitoring but there would be no expected deviation.

The nurse is caring for a child who has recently been intubated. The nurse notes that the tracheal tube has an end-tidal CO2 monitoring device that is purple in color. What is the first intervention by the nurse? a. Auscultate the chest to determine breath sounds. b. Observe for cyanosis. c. Notify the physician. d. Prepare the client for a stat chest x-ray.

a. Auscultate the chest to determine breath sounds. Explanation: Colors on the end-tidal CO2 device correspond with tracheal tube placement. Purple indicated little or no CO2 detected. Colorimetric end-tidal CO2 devices may at times fail to detect the presence of exhaled carbon dioxide, so the nurse should assess the client to determine if the endotracheal tube is still in place. The first step in determining tube placement is to auscultate the chest to determine the presence of bilateral breath sounds. Observing for cyanosis does not help to determine ET tube placement. Notifying the physician and preparing the client for a chest x-ray will need to be completed, but they are not the first steps to be taken.

The nurse plans to educate the parents of a child experiencing septic shock about the purpose of administering dobutamine intravenously to their child. What would the nurse include in this educational plan? a. Dobutamine is used to improve cardiac contractility. b. Dobutamine will work to eliminate the bacteria causing the infection. c. Dobutamine is used to provide vasodilation, thus increasing blood pressure. d. Dobutamine will work to dry secretions and inhibit serotonin and histamine.

a. Dobutamine is used to improve cardiac contractility. Explanation: Dobutamine improves the contractility of the heart muscle during shock. The medication is not an antibiotic. Vasodilation would result in lower blood pressure. Atropine (anticholinergic) increases cardiac output, dries secretions, and inhibits serotonin and histamine.

The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern? a. Inspection shows a sluggish pupillary reaction. b. Palpation of the head reveals a closed posterior fontanel (fontanelle). c. The child is crying and looking around fearfully. d. The child's eyes remain closed unless she is spoken to.

a. 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 (fontanelle) 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.

The nurse is assessing the neurologic status of an infant. What would the nurse identify as an abnormal finding? a. Lack of interest in surroundings b. Vigorous crying c. Making eye contact with the nurse d. Soft, flat anterior fontanel (fontanelle)

a. Lack of interest in surroundings Explanation: An infant who is not interested in the environment is a cause for concern. Vigorous crying is a reassuring sign. Making eye contact with the nurse is a reassuring finding. A normal anterior fontanel (fontanelle) is soft and flat and would be considered a reassuring finding.

The nurse is assessing the respiratory status and lungs of a 6-year-old child. What finding would the nurse report immediately? a. Minimal air movement through the lungs b. High-pitched breath sounds over the trachea c. Low-pitched bronchial sounds over the periphery d. Resonance over the lungs on percussion

a. 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.

A 6-year-old girl in shock is receiving dobutamine. What would the nurse most likely do? a. Monitor for ventricular arrhythmias. b. Assess for shortness of breath and dyspnea. c. Monitor for hypotension or seizures. d. Give adequate fluids prior to administration.

a. Monitor for ventricular arrhythmias. Explanation: Once dobutamine has been administered, the nurse should monitor for the development of ventricular arrhythmias. Monitoring for shortness of breath, dyspnea, or worsening of asthma would be appropriate when administering adenosine. Administering lidocaine requires monitoring for hypotension and seizures. Administering fluids is the priority intervention for any child in shock.

When the nurse is caring for a child presenting with a traumatic injury, which action is priority? a. Perform a primary assessment b. Notify the primary health care provider c. Ensure the code cart is available d. Apply an oxygen saturation monitor

a. Perform a primary assessment Explanation: The nurse would perform a primary assessment. When assessing a child with a traumatic injury, airway (A), breathing (B), and circulation (C) 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 would notify the health care provider and apply monitors as needed. The nurse should ensure a code cart is available before the start of the shift.

When creating a care plan for a child with a head injury, the nurse uses the nursing diagnosis of Risk for excess fluid volume related to administration of hypertonic solution. Which is an appropriated outcome evaluation for this diagnosis? a. The child's lungs remain clear to auscultation. b. The child's urine specific gravity is between 1.030 and 1.033. c. The child shows no evidence of any altered thought process. d. The child's parents state an understanding of treatment of increased intracranial pressure.

a. The child's lungs remain clear to auscultation. Explanation: Appropriate outcomes for the diagnosis of Risk for excess fluid volume related to administration of hypertonic solution include lungs are clear to auscultation, respiratory rate, heart rate, and blood pressure remain normal for age of child, and urine specific gravity of 1.003 to 1.030, not 1.030 to 1.033. Although the child's parents should understand the child's treatment, this is not an appropriate outcome for this nursing diagnosis.

A child is exhibiting symptomatic bradycardia that has been unresponsive to ventilation and oxygenation. Which of the following would the nurse expect to be administered? a. atropine b. sodium bicarbonate c. naloxone d. calcium carbonate

a. 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 group of nursing students are reviewing information about tachyarrhythmias in children. The students demonstrate a need for additional review when they identify this as a characteristic of sinus tachycardia in children: a. narrow QRS complex b. heart rate below 180 beats per minute c. presence of P waves d. beat-to-beat variability in rhythm

a. 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 nurse is assessing a child brought to the emergency department. The child has a fever of 102.4°F. (39.1°C). The nurse continues the assessment, integrating knowledge that which of the following reflects the effect of fever on the basal metabolic rate? a. tachypnea b. bradypnea c. bradycardia d. decreased oxygen demand

a. tachypnea Explanation: Fever increases the basal metabolic rate, resulting in tachycardia, tachypnea, and increased oxygen demand.

A 5-year-old girl is cyanotic, dusky, and anxious when she arrives in the emergency department. Which of the following would be most appropriate? A) Ventilating the child with a bag-valve-mask B) Estimating the child's weight using a Broselow tape C) Providing therapy using automated external defibrillation D) Using rescue breathing and chest compressions

A) Ventilating the child with a bag-valve-mask

The nurse is caring for a child brought to the emergency room by the babysitter. The babysitter reports the child was playing and acting "fine" but started to be "sick and get worse" all of a sudden after lunch. The babysitter denies any obvious reason or situation leading to the child's decline. What would the nurse further assess for? a. near drowning b. ingestion of a toxin c. cardiac arrhythmia d. traumatic injury

b. ingestion of a toxin Explanation: When an otherwise healthy child suddenly deteriorates without a known cause, the nurse should suspect a toxic ingestion. A near drowning, cardiac arrhythmia, or traumatic injury would manifest with specific assessment findings.

A nurse is preparing discharge instructions for a child treated for ingestion of an unknown amount of ibuprofen. The child was treated with an activated charcoal gastric lavage. Which piece of information should the nurse include to provide anticipatory guidance to the parent? a. Blood tests will be needed to check liver function. b. The child will continue taking the chelating agent. c. The mouth sores will heal over several weeks. d. Stools will be black in color for the next few days.

d. Stools will be black in color for the next few days. Explanation: Activated charcoal is a gritty black substance that binds with the ingested substance in the bowel and is excreted in the stools. It is important to give parents this information so they do not mistake the color for tarry stools, which indicate blood. The child would return for liver function tests if acetaminophen had been ingested. A chelating agent is treatment for lead poisoning and is not associated with ibuprofen ingestion or treatment with activated charcoal. Mouth sores are not associated with ibuprofen ingestion or activated charcoal. However, they are associated with the ingestion of corrosive agents such as batteries and some household cleaners.

A group of students are working on a presentation for a local health fair about safety for children. When developing this presentation, the students would address which of the following as the most common cause of pediatric injury? A) Sports B) Firearm use C) Falls D) Automobile accidents

C) Falls

As part of their orientation to their pediatric clinical rotation, an instructor is teaching a group of students how to perform cardiopulmonary resuscitation (CPR) on a child. Two students return demonstrate the skill using an infant manikin. Which of the following indicates the proper technique? A) Compressing 30 times for every 2 breaths B) Placing the heel of the hand on the midsternum C) Giving 2 breaths followed by 15 compressions D) Using two hands to perform chest compressions

C) Giving 2 breaths followed by 15 compressions

After teaching a group of nursing students about shock in children, the instructor determines that the teaching was successful when the students identify which type of shock as most common? A) Septic B) Cardiogenic C) Hypovolemic D) Distributive

C) Hypovolemic

When caring for an 8-year-old boy injured in an automobile accident, the nurse demonstrates understanding of the principles of Pediatric Advanced Life Support (PALS) by which action? A) Assisting ventilation with a bag-valve-mask (BVM) device B) Treating ventricular fibrillation using a defibrillator C) Managing compensated shock to prevent decompensated shock D) Treating supraventricular tachycardia using cardioversion

C) Managing compensated shock to prevent decompensated shock

A 1-month-old infant admitted to the emergency department in respiratory distress exhibits a regular pattern of breathing followed by brief periods of apnea, then tachypnea for a short time, eventually returning to a normal respiratory rate. The nurse documents this finding as which of the following? A) Hypoventilation B) Hyperventilation C) Periodic breathing D) Stridor

C) Periodic breathing

A nurse determines that a child is exhibiting compensated supraventricular tachycardia (SVT). Which of the following would be attempted first? A) Adenosine B) Synchronized cardioversion C) Vagal maneuvers D) Amiodarone

C) Vagal maneuvers

The nurse is providing care to a child who is intubated and the child's condition is deteriorating. Which of the following would the nurse do first? A) Check if the tracheal tube is obstructed B) Assess for displacement of the tracheal tube C) Look for signs of a possible pneumothorax D) Check the equipment for malfunction

B) Assess for displacement of the tracheal tube

A group of students are reviewing information about respiratory arrest in children. The students demonstrate understanding of this information when they identify which of the following as a common cause involving the upper airway? Select all answers that apply. A) Croup B) Asthma C) Pertussis D) Epiglottitis E) Pneumothorax

A) Croup D) Epiglottitis

A child is undergoing rapid sequence intubation and is receiving atropine. The nurse understands that this agent is used to accomplish which of the following? A) Lessen the vagal effects of intubation B) Reduce intracranial pressure C) Induce amnesia D) Provide short-term paralysis

A) Lessen the vagal effects of intubation

Which of the following would the nurse do first for a 5-year-old girl with profound bradycardia? A) Provide oxygen at 100% B) Administer epinephrine as ordered C) Use warming blankets D) Perform gastric lavage

A) Provide oxygen at 100%

The nurse is providing care to a child experiencing shock. Which of the following intravenous solutions would the nurse expect to administer? A) Ringer lactate B) Dextrose 5% and water C) Dextrose 5% and normal saline D) Dextrose 10% and water

A) Ringer lactate

The nurse is caring for a 7-year-old boy experiencing respiratory distress who is scheduled to have a chest radiograph. Which of the following would be most important for the nurse to include in the child's plan of care? A) Administering a sedative to help calm the child B) Assisting the child to lie still during the chest radiograph C) Accompanying the child to continue observation D) Informing the child that he might hear a loud banging noise

B) Assisting the child to lie still during the chest radiograph

Which of the following would lead the nurse to suspect that a 5-year-old child is experiencing supraventricular tachycardia? A) Heart rate 160 beats per minute B) Flattened P waves C) Normal QRS complex D) History of fever

B) Flattened P waves

A 9-year-old girl who has fallen from a second-story window is brought to the emergency department. Which assessment would be a priority? A) Evaluating pupils for equality and reactivity B) Monitoring oxygen saturation levels C) Asking the child if she knows where she is D) Using the appropriate pain assessment scale

B) Monitoring oxygen saturation levels

The nurse is collecting a brief health history from the parents of a 3-year-old child brought to the emergency department experiencing a cardiac emergency. What questions are appropriate for inclusion? Select all that apply. a. "Has your child had any recent illnesses?" b. "How many children live in the home?" c. "What foods or drugs is your child allergic to?" d. "Tell me about any coughing or wheezing you may have noticed when your child has been playing lately." e. "What activities does your child like to do?"

a. "Has your child had any recent illnesses?" c. "What foods or drugs is your child allergic to?" d. "Tell me about any coughing or wheezing you may have noticed when your child has been playing lately." Explanation: When a child is being treated for a cardiac emergency a brief health history is needed. This history must highlight possible problems and causes of the illness being experienced. Questions about recent illnesses can show possible links to the cardiac emergency. Information about drug and food allergies is needed as this child will likely need to receive medications and knowing potential allergies is of importance. Wheezing and coughing may signal cardiac or respiratory concerns and should be investigated. The number of children in the home and activities the child enjoys are of interest but are not of emergent value.

A 5-year-old child fell on the playground and briefly lost consciousness. Magnetic resonance imaging (MRI) of the head was normal, and the child is now alert and awake with stable vital signs. The nurse provides discharge teaching for this family. Which statement by the caregiver indicates a need for additional teaching by the nurse? a. "We will wake the child up every hour to assess overnight." b. "We will ask the child to name a familiar object when assessing." c. "We can phone the nurse information line if we have questions or concerns." d. "We will assess every 1 to 2 hours when awake for 24 hours."

a. "We will wake the child up every hour to assess overnight." Explanation: After a concussion head injury, the child should be assessed every 1 to 2 hours while awake and once during the night, for the first 24 hours. This can be done by asking the child to name a familiar object or to provide their name or location to assess orientation or confusion. The child should not be awakened frequently overnight as this can lead to increased confusion and poor sleep. The caregivers should also have a phone number to contact the medical care providers if any concerns arise, such as increased confusion, disorientation, or other unusual symptoms.

The nurse is educating a student nurse about the importance of avoiding overventilation using too much tidal volume when ventilating a pediatric client with a bag-valve mask (BVM). What complications would the nurse include in the teaching plan for this concern? Select all that apply. a. A child with a head injury may suffer from decreased cerebral flow. b. The child's cardiac output may be reduced due to increased intrathoracic pressure. c. A poor seal may lead to an air leak, thus reducing oxygen delivery to the child. d. The rescuer should ventilate until the child's chest rises above the level of the rescuer's hand. e. The BVM is not optimal when compared to mouth-to-mouth ventilation as BVM delivers less concentration of oxygen.

a. A child with a head injury may suffer from decreased cerebral flow. b. The child's cardiac output may be reduced due to increased intrathoracic pressure. c. A poor seal may lead to an air leak, thus reducing oxygen delivery to the child. Explanation: Using a BVM too vigorously in ventilating a pediatric client will cause too a ventilation volume that is too high, leading to decreased cerebral blood flow and increased intrathoracic pressure (thus reducing cardiac output), and may cause reduced oxygen to be delivered to the child if the rescuer does not maintain a tight seal. It is correct to ventilate until the child's chest rises (and no more); the nurse would teach that mouth-to-mouth ventilation delivers less oxygen to the child (as it is the expiratory breath of the rescuer) than a BVM.

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 would be the priority? a. Administer 100% oxygen by mask. b. Have the child sit up straight in a chair. c. Check his capillary refill time. d. Provide sedation as ordered.

a. Administer 100% oxygen by mask. Explanation: Management of the near-drowning victim focuses on assessing the ABCs and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the child assume his own most comfortable position. Checking capillary refill time helps determine ineffective tissue perfusion. Providing sedation is an intervention for pain that will be assessed after effective breathing is established.

The nurse is providing support to the parents of a 10-year-old boy receiving emergency care. The boy is their foster child. Which comment will be most effective? a. "Your child is hypovolemic and needs fluid." b. "Hold your child's hand while this is going on." c. "I think you had better stay out here and wait to hear from us." d. "Since you are not his biological parents, you must wait outside."

b. "Hold your child's hand while this is going on." Explanation: The atmosphere during an emergency can be chaotic and overstimulating. Keep the parents or other family with the child whenever possible. Involve the parents in the child's care; tell the parents in concrete terms what they can do to support the child (e.g., hold the child's hand and talk quietly to him or her). Attempt to talk quietly and soothingly and provide comfort measures. Involving parents in the care helps them to cope. Tell them in concrete terms what they can do to help. Talking about hypovolemia may be too technical. When in doubt, simplify. Many professional organizations, such as the Emergency Nurses Association and the American Heart Association, support giving parents the option to be present during resuscitation efforts. Any caregiver with a parental role should remain with the child when possible.

A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which action should the nurse take first? a. Begin hyperventilation. b. Establish a suitable IV site. c. Provide oral analgesics as ordered. d. Draw blood for type and cross-match.

b. 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.

A nurse is providing discharge teaching to the parent of a child hospitalized after experiencing respiratory arrest. The parent expresses concerns about the child's well-being. Which action(s) is appropriate for the nurse take? Select all that apply. a. Reassure the parent that the child's infection has been cured. b. Reinforce when the health care provider should be called. c. Encourage the parent to discuss specific concerns about the child. d. Tell the parent that the child's provider will address any concerns during the follow-up visit. e. Review signs and symptoms of respiratory distress with the parent.

b. Reinforce when the health care provider should be called. c. Encourage the parent to discuss specific concerns about the child. e. Review signs and symptoms of respiratory distress with the parent. Explanation: The most appropriate actions would be for the nurse to reinforce signs and symptoms of respiratory distress, and when the health care provider or 911 should be called. The nurse should also encourage the parent to share specific concerns about the child and address them at that moment instead of delaying until the follow-up visit. Providing reassurance that the respiratory infection has been cured does not address the parent's expressed concerns.

The nurse provides frequent and ongoing assessments for the child who is intubated and on mechanical ventilation. What assessment findings would be concerning for the nurse? Select all that apply. a. The chest rises with each breath of the ventilator. b. The child's pulse oximeter ranges from 85% to 90%. c. The child's heart rhythm is sinus tachycardia. d. The breath sounds are greater on the right side. e. The child's nail beds are pink with capillary refill.

b. The child's pulse oximeter ranges from 85% to 90%. d. The breath sounds are greater on the right side. Explanation: The assessment of breath sounds unilaterally would indicate the need to further asses the child for displacement of the tracheal tube. In addition, the oxygen saturation level should be 95% or higher. The other findings are normal/expected.

When attempting to locate the pulse of child found in a state of collapse, how much time should be taken? a. 5 to 10 seconds b. no more than 10 seconds c. 15 to 30 seconds d. no more than 30 seconds

b. no more than 10 seconds Explanation: When assessing for the pulse rate for a child found in a state of collapse, no more than 10 seconds should be taken.

The nurse is assessing a 6-week-old infant in the home setting. The nurse notes the infant has a regular breathing pattern with brief periods of apnea followed by a respiratory rate of 40. What would the nurse further assess in the infant? a. birth weight and Apgar scores b. skin color and heart rate c. anterior lung fields d. blood pressure

b. skin color and heart rate Explanation: Infants less than 2 months (or premature) may display periodic breathing. The infant who is experiencing period breathing looks pink and has a normal heart rate and the nurse would not need to intervene further. The infant's birth weight, Apgar scores, lung fields, and blood pressure are important to assess, but not specifically to the infant with period breathing.

Which medication would not be administered through a tracheal tube? a. lidocaine b. sodium bicarbonate c. epinephrine d. naloxone

b. sodium bicarbonate Explanation: To remember which drugs can be administered via tracheal tube the nurse should remember the mnemonic LEAN. This includes the drugs lidocaine, epinephrine, atropine, and naloxone. When administering these drugs via tracheal tube the nurse should check to see if the dosage needs to be adjusted for that route. After administration the tube should be flushed with 5 ml saline followed by 5 consecutive positive pressure breaths to ensure drug delivery. Sodium bicarbonate cannot be administered via tracheal tube.

A 9-year-old has suffered a severe anaphylactic reaction and dies. The nurse is providing support for the grieving parents. Which comment would best help them cope? a. "You would be more comfortable here in the lounge." b. "Would you like to see the chaplain?" c. "How can I help you get through this?" d. "Can I get you something to eat?"

c. "How can I help you get through this?" Explanation: The experience of an emergency situation and an unexpected death is very frightening to parents. The nurse plays a key role in providing empathy and support. Using open-ended questions elicits the parents' thoughts and fears and helps the nurse assess the issues at hand. Questions that can be answered with "yes" or "no" are less effective. The nurse should provide honest answers in a reassuring manner and never give false reassurances such as "It's going to be all right." That is something that cannot be promised. Parents should be encouraged to stay with the child until they are ready to leave. Moving them to the lounge may cause more emotional distress. Calling the chaplain is a good support for the family but only if the family wishes chaplaincy services. Eating would be the least thought for parents shortly after their child has died. The nurse offering this to the parents may be very uncomfortable in the situation and can only offer a tangible solution for an emotional problem.

The nurse notes absent breath sounds in the right upper, middle, and lower lung fields of a 24-month-child. What question by the nurse to the parents of the child would be most appropriate? a. "Has your child been diagnosed with asthma?" b. "Is your child allergic to environmental allergens?" c. "Was your child playing with a toy with small parts?" d. "When did your child last receive immunizations?"

c. "Was your child playing with a toy with small parts?" Explanation: Breath sounds that are absent on one side only are indicative of a pneumothorax or foreign body aspiration. The nurse would further assess the child for choking hazards. The nurse would ask the parent about asthma, allergies, and immunizations, but not specifically in relationship to an absent breath sound on one side (unilateral absent breath sound).

Which assessment finding would indicate to the health care team that a child would need to be reintubated due to improper placement of the endotracheal tube? a. Symmetrical chest rise is observed. b. There's water vapor on the inside of the tube. c. Breath sounds are heard over the abdominal area. d. Oxygen saturation rises from 78% to 93% after intubation.

c. Breath sounds are heard over the abdominal area. Explanation: Indications the tube is accidentally inserted into the esophagus include auscultation of breath sounds over the abdominal region. Indications the tracheal tube is correctly placed include symmetrical chest rise, water vapor on the inside of the tube, and a rise in oxygen saturation.

A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 bpm. Which intervention is priority? a. Give three doses of epinephrine. b. Administer two consecutive defibrillator shocks. c. Initiate cardiac compressions. d. Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR).

c. Initiate cardiac compressions. Explanation: The American Heart Association (AHA) emphasizes the importance of cardiac compressions in pulseless clients with arrhythmias, making this the priority intervention in this situation. Current AHA recommendations are for defibrillation to be administered once followed by five cycles of CPR. The AHA now recommends against using multiple doses of epinephrine because they have not been shown to be helpful and may actually cause harm to the child.

The nurse is assessing a 10-year-old child with tachypnea and increased work of breathing. Which finding demonstrates the child is in the late stages of shock? a. stable blood pressure and cool extremities b. increased heart rate with weak distal pulses c. hypotension and capillary refill time greater than 5 seconds d. cool and clammy extremities

c. hypotension and capillary refill time greater than 5 seconds Explanation: Compensated shock occurs when poor perfusion exists without a decrease in blood pressure. Once the child in shock is hypotensive, organ perfusion is dramatically impaired and a dire clinical scenario ensues. Commonly, the heart rate will increase in the early stages of shock, but as the heart becomes compromised as a result of poor perfusion, the child will become bradycardic. During compensated shock, the body can maintain some level of blood flow to the vital organs. Peripheral vasoconstriction, the body's compensatory response to diminished blood flow, often results in the child's ability to maintain a normal or near-normal blood pressure, but distal perfusion will be diminished, thereby resulting in cool extremities.

A child has fallen from a swing at the playground and the parent states that the child became groggy. After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next? a. Obtain a full set of vital signs. b. Obtain blood glucose. c. Provide pain management. d. Assess the level of consciousness.

d. Assess the 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 (exposure) to assess for underlying signs of illness or injury. Next, full vital signs are taken while facilitating the family's 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. Capillary blood glucose should be obtained to rule out hypoglycemia as the cause of mental status change.

The parents of a preschool child are distraught as they carry their limp child into the emergency room. The parents report the child fell approximately 10 feet from a large slide and hit his head "hard enough to knock him out." What is the nurse's next action? a. Apply a cervical collar and request a cervical exam. b. Assess the child's breathing by using a pulse oximeter. c. Ask the child to rate the pain from 0-10 or use a picture scale. d. Perform a jaw-thrust technique to assess the patency of the airway.

d. Perform a jaw-thrust technique to assess the patency of the airway. Explanation: The nurse would first evaluate the airway, assessing its patency. Position the airway in a manner that promotes good air flow. Since cervical spine injury is a possibility, do not use the head tilt-chin lift maneuver; use only the jaw-thrust technique for opening the airway. The description of the injury would be suspicious for cervical injury. The nurse would evaluate the child's airway before evaluating pain scale and managing cervical concerns, although the nurse is managing cervical concerns by not performing a head tilt-child lift maneuver. A pulse oximeter measurement would not be the priority.