Vsim Sabina Vasquez (Complex) Pre/Post

The nurse is caring for a patient who is showing signs of respiratory distress. List the interventions in the order that they should be performed.

1)Elevate the head of the bed and reposition the patient. 2)Encourage the patient to cough to clear the airway. 3)Apply oxygen and titrate flow as needed. 4)Collect sputum to send to the lab for culture. 5)Administer an antipyretic and antibiotics as ordered. Rationale:The priority is to consider airway, breathing, and circulation. Elevating the head of the bed, assisting the patient into a position of comfort, and encouraging the patient to cough will help to open the airway. Oxygen administration will ease the overall work of breathing. It is important to obtain any cultures prior to administering antibiotics or antipyretics.

When teaching Sabina's mother how to recognize respiratory distress, what is the best way to determine whether the teaching has been effective?

Have the mother point to areas on the body and describe what she is looking for. Rationale:Return demonstration, or reteaching of knowledge, is the most effective way to ensure that patients and families understand the information provided.

The nurse is preparing a 5-year-old for a chest x-ray. Which of the following statements would be the nurse's best explanation of this procedure to the patient?

I am sending you to have a big camera take pictures of your body. Rationale:It is important to explain procedures to a child in simple terms that are nonthreatening. The terms stretcher, x-ray, and test may be too technical or confusing, causing the child to misunderstand what is going to occur. When explaining time frames to small children, it is important to use points of reference that are familiar to them (i.e., the length of a cartoon or the time after dinner) as they may not have a firm understanding of the concept of time.

The nurse is caring for a patient hospitalized with an asthma exacerbation secondary to pneumonia. Which of the following is the highest priority nursing diagnosis for this patient?

Impaired gas exchange related to excess mucous production and carbon dioxide retention Rationale:The highest priority nursing diagnosis for a child with asthma exacerbation and pneumonia is impaired gas exchange. The other nursing diagnoses are appropriate but are not the highest priority.

A nurse must administer maintenance fluid intravenously to a patient weight 43 lb. What is the daily maintenance fluid requirement for this patient?

1,475 mL/day Rationale:Daily maintenance fluid requirement is calculated using the 100-50-20 formula. Convert pounds to kilograms: 43 ÷ 2.2 = 19.5 kg. Multiply 100 by the first 10 kg: 100 × 10 = 1,000. Multiply 50 by the second 10 kg: 50 × 9.5 = 475. Add the sum of the calculations together to get the daily fluid maintenance: 1,000 + 475 = 1,475.

Which of the following children should receive the pneumococcal vaccine? (Select all that apply.)

2-month-old who is at a well-child checkup,4-year-old with congenital heart disease who has received an age-appropriate series,3-year-old who has not received any immunizations,6-month-old who was born at 25 weeks gestation Rationale:The pneumococcal conjugate vaccine (PCV13) should be given to all infants at 2, 4, and 6 months of age, with a booster dose at 12 through 15 months of age. Previously unvaccinated, healthy children 24 months through 4 years of age only need to receive one dose of the vaccine. Additional doses of PCV13 may be recommended, depending on the child's age and health status, such as presence of congenital heart disease. The pneumococcal polysaccharide vaccine is recommended for use in children who are 2 years and older and at high risk for diseases, such as those with immune deficiencies or other chronic conditions like sickle-cell disease.

The provider has given an order for acetaminophen suspension 240 mg orally every 4 - 6 hr as needed for fever. Which of the following considerations does the nurse need to remember when administering acetaminophen?

Acetaminophen can affect laboratory test results for white blood cell count, hemoglobin, and hematocrit. Rationale:Acetaminophen can affect laboratory test results, causing decreases in the following: glucose, hemoglobin, hematocrit, and neutrophil levels and white blood cell, red blood cell, and platelet counts. Acetaminophen does not cause gastrointestinal upset and can be given without regard to food. Excessive doses of acetaminophen can have a hepatotoxic, not nephrotoxic, effect and can cause liver, not renal, failure. Adult doses of acetaminophen should not exceed 4,000 mg daily. Maximum dosing of acetaminophen for pediatrics varies by age and weight, but dosing should not exceed five doses in a 24-hour period.

The nurse is planning care for a preschooler hospitalized with pneumonia. Which of the following are appropriate choices to offer when administering oral medications? (Select all that apply.)

After you take your medicine, would you like a puppy sticker or a heart sticker?,Which do you want to take first: the pink medicine or the yellow medicine?,Who do you want to squirt the medicine in your mouth, you or me?,Do you want to drink water or apple juice with your medicine? Rationale:When administering medications to preschoolers, provide simple choices that are possible. Do not offer a choice when one is not available. Remediation:

A patient arrives at the emergency department in respiratory distress with a history of asthma. Upon assessment, the nurse notes that the patient sits forward with intercostal retractions, has a productive cough, and wheeze upon auscultation. Which of the following interventions is most appropriate for the nurse to implement at this time?

Elevate the head of the bed and allow the patient to assume a position of comfort Rationale:The priority is to consider airway, breathing, and circulation. Elevating the head of the bed and assisting the patient into a position of comfort will help to open the airway and aid in the work of breathing. A throat culture is not needed, as the symptoms indicate a lower airway condition. Expectorants are contraindicated for asthma exacerbations as further airway irritation and bronchoconstriction may occur. Patients in respiratory distress should limit oral intake to reduce the risk of aspiration. Measuring the patient's oxygen saturation and having the patient lie down to conserve energy are not priority interventions at this time for a patient in respiratory distress. Having the patient lie down can cause further respiratory distress.

After giving discharge instructions, which response by Sabina's mother indicates that teaching has been effective?

Even if she is feeling better, Sabina must finish taking her oral antibiotics as ordered. Rationale:Completion of the entire course of antibiotics is key to prevent antibiotic resistance and recurrence of infection. Pneumonia is a self-limiting disorder. The patient may tire easily for up to 2 weeks, but activity should be encouraged as able. Oral hydration is important, but if the patient experiences tachypnea or increased work of breathing, limited fluids should be given by mouth to avoid aspiration.

A nurse observes that a preschooler who is hospitalized appears stressed. Which of the following is the most likely stressor for this child?

Fear of mutilation Rationale:While preschoolers may experience other stressors related to hospitalization, the primary stressor is fear of mutilation and invasive procedures as they do not understand the body's integrity. Separation anxiety, loss of control, and disruption in autonomy are more characteristic of toddlers than of preschoolers

During assessment the pediatric patient reports good control of asthma symptoms with no interference in daily activities and one incidence of nighttime cough in the past month. The patient uses a rescue inhaler occasionally during the week for asthma exacerbations. The patient would be classified as having which of the following levels of asthma severity?

Mild intermittent Rationale:Asthma severity is classified based on the following: type, frequency, and timing of symptoms reported; lung function; interferences with normal activities of daily living; and frequency of use of short-acting β2-agonists for symptom control. Patients with mild intermittent asthma experience daily symptoms 1 or 2 times a week and nighttime symptoms 1 or 2 times a month. Forced expiratory volume is greater than or equal to 80% of predicted values. The patient experiences no interferences with normal activity and uses short-acting β2-agonists 1 or 2 days a week.

What techniques can the nurse employ when providing care for Sabina and her family to reduce the overall stress of hospitalization? (Select all that apply.)

Provide copies of written materials in both English and Spanish.,Use a certified medical interpreter to aid in communication.,Involve the family in daily care and give the patient simple choices when possible. Rationale:An interpreter should be used for all medical communication, not family members and visitors. This helps ensure that the patient and family can read and understand all written and translated materials. It is important to provide patients and families with written handouts and visuals in both English and their primary language to help reinforce communication and teaching. Including the patient and family in daily care allows them to have a sense of control during hospitalization. All communication and teaching including discharge education should be provided in small increments throughout hospitalization and reinforced as necessary to avoid information overload.

The nurse is preparing Sabina for her nebulized albuterol treatment. Which of the following demonstrates that the nurse understands developmentally appropriate communication?

Some kids say the breathing treatment makes them feel a little shaky. Rationale:It is important to explain procedures to a child in simple terms that are nonthreatening but that will identify any sensations they may experience, such as feeling shaky. The use of terms such as OK or asking whether the patient wants to do something offers the illusion of a choice when there is not one available. When explaining time frames to small children, it is important to use points of reference that are familiar to them (i.e., the length of a cartoon or the time after dinner) as they may not have a firm understanding of the concept of time. Avoid terms that are too technical or confusing causing the child to misunderstand what is going to occur. Hearing "smoke" may cause the child to think that something will be burning or on fire.

A nurse is explaining the pathophysiology of asthma and asthma exacerbation to a group of nursing students at a workshop. Which of the following statements would be most accurate for the nurse to make? (SATA)

The smooth muscles of the airway increases in responsiveness, causing bronchoconstriction. Chronic inflammation contributes to irreversible airway changes and decreased lung function. Exposure to bacterial and viral infections increases airways responsiveness and inflammation. Rationale: The acute inflammatory process in asthma consists of acute bronchoconstriction, airway edema, and increased mucus production. Chronic inflammation results from repeated exposure to triggers, causing hypersensitive airways and permanent remodeling. Both processes result in decreased pulmonary function and decreased ability to compensate when exposed to viral or bacterial respiratory infections.

A nurse is administering medications and fluids intravenously to a pediatric patient. Which of the following must the nurse do to prevent complications?

Use standard precautions when assessing the insertion site and handling tubing per institution protocol. Rationale:Adherence to standard precautions is crucial to reduce the risk of contamination and associated complications. Transparent dressings and intravenous houses keep the device secure while allowing for easy visualization and assessment. The insertion site should be inspected every 1 to 2 hours, not once per day, for patency and signs of complications. In pediatrics, the time frame for site rotations is extended to when clinically indicated and may be adjusted to minimize the patient's exposure to repeated trauma of insertion.

Sabina was discharged with instructions to complete the course of oral azithromycin started during her hospitalization. The next day, her mother calls asking how to prepare the medication for administration. How would the nurse instruct the mother to prepare 3.8 mL of this medication for administration?

Use the calibrated syringe provided to draw up the medication and check dose at eye level. Rationale:The most accurate way to prepare the ordered amount of medication is to have the parent measure it using a calibrated oral syringe. A medication cup will not be as accurate when preparing the ordered dose. Household cups and measuring spoons are not calibrated and may deliver an incorrect dose. If the medication is mixed into an entire glass of juice and then the patient does not drink the full amount, the parent will be unable to determine how much medication the patient has ingested.

A patient weighting 43 lb has an order fro intravenous cefuroxime 475 mg Q8 hr. The safe dose range is 50 to 100 mg/kg/day. Is the order safe?

Yes, the safe range is 975 to 1,950 mg/day Convert pounds to kilograms: 43 ÷ 2.2 = 19.5 kg. Multiply low end of dosage range by weight: 50 × 19.5 = 975 mg/day. Multiply high end of dosage range by weight: 100 × 19.5 = 1,950 mg/day. Safe dosage range equals 975 to 1,950 mg/day. Divide daily safe dosage range by frequency of administration per day: 975 ÷ 3 = 325 mg/dose; 1,950 ÷ 3 = 650 mg/dose. The ordered dose of cefuroxime 475 mg falls within the range of 325 to 650 mg/dose, so the ordered dose is safe to administer.