ATI Nursing care of Children Practice B
A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first? 1. A toddler who has a concussion and an episode of forceful vomiting. 2. An adolescent who has infective endocarditis and reports having a headache. 3. An adolescent who was placed into halo traction 1 hr ago and reports pain as a 6 on a scale of 0-10. 4. A school-age child who has acute glomerulonephritis and brown-colored urine.
1. A toddler who has a concussion and an episode of forceful vomiting. (An episode of forceful vomiting is an indication of increased intracranial pressure). Headaches with infective endocarditis is expected.
School-aged child comes to the pediatric unit alert and responsive to stimuli., history of asthma. Capillary refill less than 3 seconds. O2 Sat 98% with nasal cannula. Resp regular and shallow. Mild intercostal retrations noted. Expiratory wheezes auscultated in the anterior and posterior lung bases. Abdomen is soft, flat and non distended. Within 2 hrs, child becomes restless, mod intercostal retractions. 92% on nasal cannula. Scattered rhonchi anterior bases with wheezing and noted n inhalation and exhalation. HR reg w/o murmurs, gallops or rubs. Radial and pedal pulses 2+ bilaterally. CBC: Hemoglobin 10 (10-15.5) Hematocrit 32% (32-44) WBC 11,000 (5,000-10,000) ABG: pH 7.49 (7.35-7.45) HCO3 24 mEq/L (21-28) PO2 92 mmHg (80-100 mmHg) What information based on the child's med rec will you provide to the HCP? 1. ABG 2. Cardiovascular assessment 3. WBC count 4. Hemoglobin 5. O2 sat level 6. Resp assessment
1. ABG (shows resp alkalosis, associated with complications of asthma such as hyperventilation and hypoxia). 3. WBC count 5. O2 sat level 6. Resp assessment (indicates increased resp distress as evidenced by tachypnea, retractions and increased wheezing)
Child with Hemophilia A presents with recent fall to the knee. Knee is tender, warm to touch, ecchymotic and edematous. Pain 8 on a FLACC scale of 0-10. Differential between anticipated and contraindicated orders: 1. Administer factor VII 2. Apply ice packs to the affected joints. 3. Perform passive ORM exercises during the first 12 hr following injury. 4. Elevate the affected joint(s).
1. Administer factor VII; anticipated; during this acute episode, there is a potential for internal bleeding into the joint spaces. Factor VII will help control bleeding. 2. Apply ice packs to the affected joints; anticipated; helps manage discomfort and decrease bleeding into the joint. 3. Perform passive ORM exercises during the first 12 hr following injury.; Contraindicated; Passive ROM can increased bleeding into the joint for the first 48hr following injury. Child should be encouraged to exercise the joint as tolerated. 4. Elevate the affected joint(s).; anticipated; helps decrease bleeding and swelling in the joint.
An adolescent with hx of asthma presents to ED after a car accident, conscious, normal vital signs, wearing a seat belt; 15 min later reports sharp pain in chest, pain 6 out of 0-10. Resp fast and shallow, O2 sat decreasing. Diminished breath sounds in left lung. S1 and S2 regular and rapid. Chest Xray-Air present in left pleural space. What actions would the nurse plan to take: 1. Apply supplemental oxygen 2. Place the adolescent in supine position. 3. Prepare for chest tube insertion. 4. Obtain consent for a pericardiocentesis 5. Admin a levalbuterol metered dose inhaler
1. Apply supplemental oxygen (d/t poss pneumothorax, O2 sat is decreasing, indicating hypoxia). 3. Prepare for chest tube insertion. (pneumothorax [presence of air in pleural cavity] results in decreased lung expansion. Could have dyspnea, tachypnea, tachycardia, hypoxia and pain which would require chest tube placement to remove air and fluid from the pleural space, allowing lung to re-expand).
A nurse is planning care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? 1. Avoid palpating the abdomen when bathing the child before surgery. 2. Refrain from auscultating the child's bowel sounds during the postop assessment. 3. Encourage the child to play with other children on the unit prior to surgery. 4. Explain to the child that their pain will be managed after surgery.
1. Avoid palpating the abdomen when bathing the child before surgery. (movement of the tumor can cause cancer cells to disseminate to other sites adjacent and distant to the tumor site).
A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? 1. Decreased edema 2. Increased abdominal growth 3. Decreased appetite 4. Increased protein in urine
1. Decreased edema (Child with nephrotic syndrome can experience edema d/t increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability which increases protein loss. Prednisone decreases glomerular permeability which causes fluid to shift from the extracellular spaces, resulting in decreased edema). With prednisone therapy, increased appetite and decreased protein in urine is seen.
A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? 1. Deep respirations of 32/min 2. Shallow respirations of 10/min 3. Paradoxic resp of 26/min 4. Periods of apnea lasting 20 seconds
1. Deep resp of 32/min (Kussmaul resp on a child is deep & rapid resp; body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis). Shallow resp seen in pts receiving opioids. Paradoxic resp expected in children with flail chests (fx of multiple ribs). Apnea lasting more than 20 sec seen in children with sleep apnea.
A nurse is admitting a 4 m.o infant who has HF. Reported 3 episodes of vomiting, 6 wet diapers in 24 hrs, consumes 3 oz. of concentrated formula every 3 hr. Temp 99.5 degrees Fahrenheit. HR 70/min. RR 30/min. Birth weight 7lb. Current weight 13 lb. Med admin record: Digoxin 0.5 mcg PO Q12H. Furosemide 20 mg PO Q12H. Which of the following findings is the nurse's priority? 1. Episodes of vomiting 2. Formula consumption 3. Weight 4. Temperature
1. Episodes of vomiting (can be an indicator of digoxin toxicity, PRIORITY). A 4 m.o with HF requires 3-4 oz of formula every 3 hr to adequately address caloric needs. A feeding schedule of every 2 hr does not allow sufficient rest time btwn feedings, and a feeding schedule every 4 hr requires consumption of a higher volume, which is often not tolerated by the infant. An intake of 3-4 oz of formula every 3 hr indicates that the infant is tolerating the current feeding schedule.
A nurse is assessing the pain level of a 3-y.o. Which of the following pain assessment scales should the nurse use? 1. FACES 2. Numeric 3. CRIES 4. Visual analog
1. FACES CRIES is for pain assessments of infants less than 40 weeks of age. Visual analog- for chikdren over 8 y.o; they mark their pain on a centimeter ruler.
A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? 1. Have the adolescent sign a consent form for treatment. 2. Instruct the adolescent to return with a guardian. 3. Obtain consent from the adolescent's guardian over the phone. 4. Treat the adolescent without a consent form.
1. Have the adolescent sign a consent form for treatment.
A nurse in the ED is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply) 1. Increased temp 2. Gingival hyperplasia 3. Xerophthalmia 4. Bradycardia 5. Cervical lymphadenopathy
1. Increased temp (usually unresponsive to antipyretics or antbx) 3. Xerophthalmia (ophthalmic manifestations include reddening of the conjuctiva and dryness of the eyes [xerophthalmia]) 5. Cervical lymphadenopathy (enlarged lymph nodes, nontender, >1.5 cm).
A nurse is teaching a group of parents about infections mononucleosis. Which of the following statements by a parent indicates an understanding of the teaching? 1. Mononucleosis is causes by an infection with the Epstein-Barr virus. 2. Mononucleosis us a bacterial infection requiring 14 days of antbx 3. A monospot is a throat culture used to diagnose mononucleosis. 4. Children who get mono will need to refrain from sports for 6 months.
1. Mononucleosis is causes by an infection with the Epstein-Barr virus. Mono is a self limiting virus with no known tx. Monospot is a blood test. Adjust activity according to level of fatigue. Contact sports should be avoided about 4 weeks or until splenomegaly is resolved.
A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? 1. Palpate the dorsum of the child's feet. 2. Weigh the child daily using the same scale. 3. Assess the child's skin turgor. 4. Observe the child for periorbital swelling.
1. Palpate the dorsum of the child's feet. (palpate for edema against a bony prominence with fingers for 5 sec). Weighing the child will indicate retained fluid, not for assessing peripheral edema. Periorbital swelling assess for generalizes edema.
A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following info should the nurse plan to include? 1. The child should be able to stand on the balls of their feet when sitting on the bike. 2. The child should ride their bike 2 ft to the side of other bikers. 3. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. 4. The child should ride the bike facing traffic when it is necessary to ride in the street.
1. The child should be able to stand on the balls of their feet when sitting on the bike.
Preschooler comes in with family history of atopic dermatitis with multiple small erythematous papules with some scaling on eyebrows, forearms and lower bilateral legs. Child is discharged with new medications. Which statement by the guardian indicates that the discharge teaching was effective? Select all that apply. 1. We should apply a skin emollient immediately after bathing our child. 2. We should keep our child's fingernails trimmed short. 3. We should rub the sores vigorously to remove scales. 4. We should allow our child to take a bubble bath prior to bed. 5. We should use a mild detergent for our laundry. 6. We should apply a large amount of the ointment to the sores.
1. We should apply a skin emollient immediately after bathing our child. 2. We should keep our child's fingernails trimmed short. 5. We should use a mild detergent for our laundry.
A nurse is providing dietary teaching to the guardian of a school-age child who has CF. Which of the following statements should the nurse make? 1. You should offer your child high-protein meals and snacks throughout the day. 2. You should decrease your child's dietary fat intake to less than 10% of their caloric intake. 3. You should restrict your child's intake to 1,200 per day. 4. You should give your child a multivitamin once weekly.
1. You should offer your child high-protein meals and snacks throughout the day. (will result in improved lung function and decreased risk of infection). Require 35%-40% of their calories to come from fats d/t decreased absorption from the intestines. Should consume at least 2,000 calories a day. Multivitamins should be taken daily.
A nurse is teaching the guardian of a 6 m.o infant about teething. Which of the following statements should the nurse make? 1. Your baby might pull at their ears when they are teething. 2. Rub your baby's gums w/aspirin to decrease discomfort. 3. Place a beaded teething necklace around your baby's neck. 4. Your baby's upper middle teeth will erupt first.
1. Your baby might pull at their ears when they are teething. Rubbing aspirin on gums will heighten risk of aspiration, infection or irritation of gums. Use cold teething rings or gently rub gums w/a cold cloth. Lower central incisors erupt first.
A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? 1. Use a kitchen teaspoon to measure the medication. 2. Brush the child's teeth after giving the medication. 3. Double the next dose if the child misses the dose. 4. Repeat the dose if the child vomits.
2. Brush the child's teeth after giving the medication. (prevents tooth decay caused by digoxin which comes in a sweetened liquid to enhance the taste). Digoxin should be administered at regular intervals, usually twice daily or every 12 hr. Do not double dose since it enhances the chances of digoxin toxicity. Nausea, vomiting and decreased appetite common manifestations of digoxin toxicity in children. Do not administer second dose, notify HCP.
A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? 1. Allow your child to play outside during the hours between 10:00am and 2:00 pm 2. Choose waterproof sunscreen with a min. SPF of 15 3. Dress your child in loose weave polyester fabric prior to sun exposure. 4. Reapply sunscreen every 4 hr
2. Choose waterproof sunscreen with a min. SPF of 15. Avoid playing outside between 1000-1400. Dress children in tight weave cotton fabric prior to sun exposure. Reapply sunscreen every 2-3 hr.
A nurse is assessing a 6 m.o. infant during a well-child visit. Which of the following findings should the nurse report to the HCP? 1. Presence of a central incisor tooth. 2. Presence of strabismus. 3. Presence of an open anterior fontanel. 4. Presence of external cerumen.
2. Presence of strabismus. (strabismus-crossing of the eyes- usually disappears 3-4 mo; if not corrected early can lead to blindness). Anterior fontanel usually closes ~12mo.
A nurse is caring for a 10 y.o. child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? 1. Urine specific gravity 1.045 2. Sodium 155 mEq/L 3. Blood glucose 45 mg/dL 4. Urine output 35mL/hr
2. Sodium 155 mEq/L (A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels ride above normal range of 136-145 mEq/L). Urine specific gravity normal range= 1.005-1.030; child with diabetes insipidus is more likely to have more diluted urine and a urine specific gravity below the expected reference range. Child with diabetes insipidus should have blood glucose within normal limits (70-110). Urinary output of 35mL/hr is within expected range of 33-58 mL/hr. Child with diabetes insipidus is expected to have polyuria.
A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? Select all that apply. 1. Steatorrhea 2. Vomiting 3. Lethargy 4. Constipation 5. Weight gain
2. Vomiting 3. Lethargy (lethargy is d/t severe pain episodes of severe pain during which the infant cried inconsolably, leading to exhaustion and decreased nutritional intake). Steatorrhea (bulky, fatty stools, manifested with CF). Infants with intussusception will have mucus-filled and red-jelly like diarrhea d/t blood mucus into the intestinal lumen. Infants will have weight loss d/t anorexia and episodes of vomiting and diarrhea.
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? 1. 1/2 cup whole milk 2. 1 cup of orange juice 3. 1/2 cup of raisins 4. 1 cup raw carrots
3. 1/2 cup of raisins. Whole milk contains high amounts of calcium. Orange juice has ascorbic acid which increases the amount of nonheme iron absorbed by the body.
A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first? 1. Check the child for a head injury 2. Observe for oral bleeding 3. Check the child's RR 4. Observe for extremity weakness
3. Check the child's RR (ABC; rescue breaths may be needed if low RR present). Tonic-clonic seizure is characterized by symmetric contraction and intense jerking movements of the child's body. If child is standing/sitting on chair, they will fall and head injury may occur. Important to check for head injury but not priority. During tonic-clonic seizure, child can lose muscle control and bite down on tongue. Important to check following seizure but not priority. Extremity weakness my proceed tonic-clonic seizure d/t intense jerking movements. Not priority.
A nurse is assessing a school-age child who has infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? 1. Hypotension. 2. Reports insomnia. 3. Difficulty concentrating 4. Tachycardia
3. Difficulty concentrating (irritability, inability to follow commands and difficulty concentrating are manifestations of increased intracranial pressure d/t decreased blood flow within the brain and pressure on the brainstem). Hypotension is a late manifestation of increased intracranial pressure d/t compression of the brain vessels. Somnolence and lethargy are symptoms of increased ICP. Bradycardia is a late manifestation of increased ICP.
A charge nurse is preparing to make a room assignment for a newly admitted school-aged child. Which of the following considerations is the nurse's priority. 1. Length of stay 2. Treatment schedule 3. Disease process 4. Self-care ability
3. Disease process
A nurse is proving discharge teaching to the parent of an 18 m.o who has dehydration d/t acute diarrhea. Which of the following statements by the parent indicated an understanding of the teaching? 1. I will offer my child small amounts of fruit juice frequently. 2. I will avoid giving my child solid foods until the diarrhea has stopped. 3. I will monitor my child's number of wet diapers. 4. I will give my child polyethylene glycol daily for 7 days.
3. I will monitor my child's number of wet diapers. (monitors adequate I&O). Fruit juice isn't recommended since it's high in carbohydrates, low in electrolytes and has a high osmolality value. Solids should be encouraged once rehydration is done Polyethylene glycol is an osmotic agent that pulls fluid into the bowel, increasing frequency of stools.
A nurse caring for a newly admitted school-aged child who has hypopituitarism. Which of the following meds should the nurse expect the provider to prescribe? 1. Desmopressin 2. Luteinizing hormone-releasing hormone 3. Recombinant growth hormone 4. Levothyroxine
3. Recombinant growth hormone (Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure). Desmopressin treats hyposecretion of antidiuretic hormones. Luteinizing hormone-releasing hormone is used to treat precocious puberty to slow prepubertal growth in children and in tx of advanced prostate cancer in adults. Levothyroxine treats various hypothyroid conditions.
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? 1. Reports an absence of nausea and vomiting 2. Reports experiencing an onset of loose stools within 15min of admin 3. Serum potassium level 4.1 mEq/L 4. BP 86/52 mm Hg
3. Serum potassium level 4.1 mEq/L (Sodium polystyrene sulfonate enema treats hypokalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4-4.7 mEq/L indicated the effectiveness of the med). Absence of nausea & vomiting indicates the effectiveness of an antiemetic med. Experiencing onset of loose stools within 15 min of admin is a side effect of sodium polystyrene sulfonate enema. BP of 86.52 is below the expected 90/60 BP for adolescents; monitoring of BP would continue
A nurse in the ED is assessing a 3 m.o. infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? 1. HR 124/min 2. Increased tear production 3. Sunken fontanel 4. Capillary refill 2 seconds.
3. Sunken fontanel Expected range of HR 106-186/min. The nurse should expect the infant who has moderate to severe dehydration to have tachycardia. An infants with moderate to severe dehydration is more likely to have delayed capillary refill of greater than 2 seconds.
A nurse is teaching a school-aged child and their parent about postop care following cardiac catheterization. Which of the following instructions should the nurse include? 1. Stay home from school for 1 week following the procedure. 2. Follow a diet that is low in fiber for 1 week. 3. Wait 3 days before taking tub bath. 4. Apply pressure dressing to the site for 3 days.
3. Wait 3 days before taking tub bath. (Avoiding immersing surgical site in water will reduce risk of infection). Child can attend school next day but should avoid strenuous activities to prevent bleeding at incision site. Resume a regular diet after procedure. Pressure dressing can be removed the day after the procedure and should apply a new adhesive bandage strip daily to the site for at least the next 2 days.
A nurse is providing discharge teaching to the parents of a 6 m.o infant who is postop following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? 1. You may bathe your infant in an infant bathtub when you go home. 2. Apply hydrocortisone cream to your infant's penis daily. 3. You should clamp your infant's stent twice daily. 4. Allow the stent to drain directly into your infant's diaper.
4. Allow the stent to drain directly into your infant's diaper. (it will prevent kinking or twisting that can interfere with urine flow). Submersion of water should be avoided to prevent infection. Prophylactic antbx is ordered in the prevention of infection. Avoid occluding stent to prevent urinary stasis that can potentially injure the patient
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? 1. An 18 m.o who has unintelligible speech. 2. A 3 m.o who has an exaggerated startle response. 3. A 4 y.o preschooler who prefers playing w/ others rather than alone. 4. An 8 m.o infant who is not yet making babbling sounds.
4. An 8 m.o infant who is not yet making babbling sounds. (should be making babbling sounds by 7 m.o). Refer 24 m.o who does not have intelligible speech. Refer >4m.o if they lack startle response Refer preschoolers that prefer to play alone and avoid interactions
A nurse is providing discharge teaching to the parents of a 3 m.o. infant following a cheiloplasty. Which of the following instructions should the nurse include? 1. Clean your baby's sutures daily with a mix of chlorhexidine and water 2. Expect your baby to swallow more than usual over the next few days. 3. Inspect your baby's tongue for white patches using a tongue depressor every 8 hrs. 4. Apply a thin layer of antibiotic on your baby's suture line daily for the next 3 days.
4. Apply a thin layer of antibiotic on your baby's suture line daily for the next 3 days. (Cheiloplasty; sx reconstruction of lips; cleft lip).
A nurse is planning care for a newly admitted school-age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? 1. Ensure that a padded tongue blade is at the child's bedside. 2. Allow the child to play video games on a tablet computer. 3. Allow the child to take a tub bath independently. 4. Ensure the oxygen source is functioning in the child's room.
4. Ensure the oxygen source is functioning in the child's room. (maintaining airway is priority during a seizure). Nothing should be places in the child's mouth during or after a seizure. Bright/flashing lights can trigger seizures. Someone available should be present during a tub bath.
A nurse is discussing organ donation with the parents of a school-age child who has sustained brain death to a bicycle crash. Which of the following actions should the nurse take first? 1. Inform the parents that written consent is required prior to organ donation. 2. Provides written information to the parents about organ donation. 3. Ask the provider to explain misconceptions of organ donation to the parents. 4. Explore the parent's feelings and wishes regarding organ donation.
4. Explore the parent's feelings and wishes regarding organ donation.
A nurse is creating a plan of care for a newly-admitted adolescent who has bacterial meningitis. How should the nurse plan to maintain the adolescent in droplet precautions? 1. Until the adolescent is afebrile. 2. For 7 days following admin to the facility. 3. Until the adolescent has a neg blood culture 4. For 24 hr following antimicrobial therapy.
4. For 24 hr following antimicrobial therapy. (no longer contagious at this time).
A nurse is planning care to address nutritional needs for a preschooler who has CF. Which of the following interventions should the nurse include in the plan? 1. Amin pancreatic enzymes 2 hr after meals. 2. Discontinue the use of pancreatic enzymes if steatorrhea develops. 3. Limit fluid intake to 750 mL/day 4. Increase fat content in the child's diet to 40% of total calories
4. Increase fat content in the child's diet to 40% of total calories. (CF pts cannot properly digest fats d/t fibrosis of the pancreas and limited secretions of pancreatic enzymes). Pancreatic enzymes should be admin 30min before meals and snacks to replace enzymes lost w/ CF. Steatorrhea (Fatty stools) shows the need of possibly increasing the dosage of pancreatic enzymes. Fluid intake should be encouraged to prevent the loss of sodium and chloride through perspiration.
A nurse is caring for a preschooler who has CHF. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? 1. Furosemide 2. Captopril 3. Regular insulin 4. Potassium chloride
4. Potassium chloride (CHF pts can develop electrolyte imbalances such as hyper/hypokalemia. Child is exhibiting signs of hyperkalemia). Furosemide is a loop diuretic that excretes potassium, prevents fluid overload from HF. Pt showing signs of hyperkalemia; safe to admin. HF pts require meds that cause vasodilation, such as ACE inhibitors (Captopril), to reduce cardiac afterload. Regular insulin appropriate since the heightened risk of electrolyte imbalances require insulin to help w/the movement of potassium into the cells.
A nurse is planning care for a school-age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan? 1. Use sterile scissors to remove the dressing from the site. 2. Irrigate each lumen weekly with 10mL of 0.9% sodium chloride solution when not in use. 3. Access the site using a noncoring angled needle. 4. Use a semipermeable transparent dressing to cover the site.
4. Use a semipermeable transparent dressing to cover the site. (reduces risk of infection). Avoid use of scissors to reduce risk of cutting catheter. Each lumen of the catheter should be flushed with a heparin solution daily when not in use. Angled/straight needle is for accessing an implanted port.
Wheezes description
High-pitched, musical or whistle-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways.
Crackles description
High-pitched, short and noncontinuous sounds usually heard at the end of inspiration. Occurs when air expands deflated alveoli or when the passage of air through small airways is disrupted.
Pleural friction rub description
Loud, rough, gratins sounds that can be heard during inspiration or expiration; occurs when the pleurae are inflamed and the surfaces rub together
Rhonci description
Low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration; occurs when the larger airways are obstructed
Preschooler admitted with the following labs: Hemoglobin 8.8 (9.5-14 g/dL) Hematocrit 28% (30-40) WBC count 8,000 (5,000-10,000) Platelets 100,000 (150,000-400,000) BUN 20 mg/dL (5-18) Creatinine 0.8 mg/dL (0.2-0.5) Total protein 6.4 g/dL (6.2-8) Total cholesterol 202 mg/dL (120-200) Match findings with nephrotic syndrome, acute poststreptococcal glomerulonephritis or hemolytic uremic syndrome.
Nephrotic Syndrome- Elevated BP (indicating narrowing of blood vessels), slightly elevated cholesterol (may be d/t diet or increased liver production of lipoproteins to compensate for proteins lost. Acute poststreptococcal glomerulonephritis- May present with low-grade fever. A streptococcal infection invades the inner membranes of the kidney, which affects filtration and blood flow. Elevated BP & elevated BUN (d/t impairment of kidney function). Hemolytic uremic syndrome- High fever causing hallucinations and lethargy. Intravascular coagulation occurs in the endothelium of the glomeruli of the kidneys, which impairs filtration and blood flow due to the aggregation of platelets; thrombocytopenia is seen. Elevated BP & elevated BUN (d/t impairment of kidney function).
A child with anemia enters the unit with low O2 sat, Joint swelling and fever, pain (8 out of 10), dry mucus membranes and low H&H. The nurse should first address:
Oxygen saturation followed by the child's pain. (Vaso-occlusive crisis can cause severe pain d/t tissue ischemia from sickled cells obstructing blood flow. Joint swelling, low grade fever, low H&H and dehydration are all seen in vaso-occlusive crisis but not priority.
