Case Study 19: Prioritization, Delegation and Assignment

What is the most likely cause of the specks of blood in Rebecca's sputum? 1. A sign of pulmonary infection 2. A sign of bronchial remodeling 3. A sign of gastric irritation 4. A sign of gastrointestinal bleeding

1. A sign of pulmonary infection

The nurse performs a pain assessment. Charlie rates his pain as 4 of 10 on the Wong-Baker FACES® Pain Rating Scale. Which intervention should the nurse implement? 1. Administer 200 mg of ibuprofen. 2. Administer 5 mg of hydrocodone. 3. Administer 100 mg of acetaminophen. 4. Administer 10 mg of codeine.

1. Administer 200 mg of ibuprofen.

Which tasks related to the care of Sarah, Sam, and Ms. A can be delegated to the UAP? Select all that apply. 1. Assist the toddler to eat an age-appropriate meal. 2. Apply a supportive splint to the infant's arm. 3. Report any behavioral signs of child abuse. 4. Report any findings to Child Protective Services if appropriate. 5. Assist by holding one child while the other is being examined. 6. Accompany the infant to the radiology department.

1. Assist the toddler to eat an age-appropriate meal. 3. Report any behavioral signs of child abuse. 5. Assist by holding one child while the other is being examined. 6. Accompany the infant to the radiology department.

At the change of shift, the nurse reassesses Charlie. His NG tube is patent and drained 120 mL over 12 hours. His oral temperature is 99.5°F (37.5°C), heart rate is 80 beats/min, and respiratory rate is 17 breaths/min. Charlie appears groggy and confused. Charlie's muscle strength is 3 of 5 in his upper and lower extremities. Laboratory tests are ordered. Which results are most consistent with Charlie's clinical presentation? 1. K +, 3.3 mEq/L (3.3 mmol/L); Cl-, 95 mEq/L (95 mmol/L); pH, 7.55 2. K +, 3.3 mEq/L (3.3 mmol/L); Cl-, 110 mEq/L (110 mmol/L); pH, 7.55 3. K +, 5.2 mEq/L (5.2 mmol/L); Cl-, 110 mEq/L (110 mmol/L); pH, 7.20 4. K +, 3.3 mEq/L (3.3 mmol/L); Cl-, 95 mEq/L (95 mmol/L); pH, 7.20

1. K +, 3.3 mEq/L (3.3 mmol/L); Cl-, 95 mEq/L (95 mmol/L); pH, 7.55

What is the priority nursing concern for Terry, who is rubbing at his ears, acting fussy, refusing to suck, and has a temperature of 101.2°F (38.4°C)? 1. Pain 2. Poor nutrition 3. Recurrent ear infections 4. Elevated temperature

1. Pain Acute otitis media is painful, and the child is demonstrating behaviors indicative of pain. Symptoms are relieved with acetaminophen and application of a warm, moist towel to the outer ear.

The nurse reviews Rebecca's growth chart and determines her weight and BMI have consistently remained below the 5th percentile. Which collaborative intervention is the nurse most likely to anticipate when planning teaching? 1. Preparing the child and family for potential gastrostomy tube placement 2. Focusing on increasing the child's intake of protein and calories 3. Suggesting an increased dosage of pancreatic enzymes 4. Preparing the child and family for potential total parenteral nutrition

1. Preparing the child and family for potential gastrostomy tube placement

Which assessment finding for Billy is the most urgent and requires immediate intervention and notification of the pediatrician? 1. Sudden increase in respiratory rate and decreased breath sounds 2. Rattling cough productive of frothy, clear, gelatinous sputum 3. Crackles auscultated on inspiration in the lower lung fields 4. Restlessness and wheezing auscultated at the end of expiration

1. Sudden increase in respiratory rate and decreased breath sounds An increased respiratory rate and decreased breath sounds are ominous signs of airway obstruction. Respiratory arrest is imminent. A productive cough warrants close observation because the client is at risk for mucus plugs and bronchial spasm, which can cause an obstruction. Restlessness and wheezing are characteristic clinical manifestations of an asthma exacerbation and require attention but are not urgent.

What is the priority action for James (refer to question 11)? 1. Visually inspect the throat with a tongue blade and auscultate the lungs. 2. Administer humidified oxygen and have the child sit upright on a parent's lap. 3. Notify the pediatrician and prepare intubation equipment. 4. Reassure the parents the symptoms will resolve with breathing of cool moist air.

2. Administer humidified oxygen and have the child sit upright on a parent's lap. The child has an immediate need for oxygen. An upright position facilitates breathing, and parental comfort minimizes agitation and crying, which would increase oxygen consumption.

A mother brings her 12-month-old child to the clinic for an influenza vaccination. The RN tells the mother that the child is also due for doses of measles-mumps-rubella, varicella, and hepatitis A vaccines. The mother declines the nurse's advice because "he has already had enough of those." What is the priority action? 1. Encourage a follow-up appointment and notify Child Protective Services. 2. Assess the mother's concerns and current level of knowledge about immunization. 3. Emphasize the benefits of immunization; explain the purpose and schedule. 4. Respect the mother's decision and alert the pediatrician to the situation.

2. Assess the mother's concerns and current level of knowledge about immunization.

Six-year-old Billy woke last night with dyspnea, restlessness, wheezing, and cough. Mother and child spent the night in a reclining chair. His mother declares, "He is having an asthma attack. We are both exhausted. I'm tired of waiting forever to see the doctor!" What is the priority nursing concern? 1. Billy's poor sleep quality and restlessness 2. Billy's ongoing shortness of breath 3. Mother's report of feeling exhausted 4. Mother's frustration with health care system

2. Billy's ongoing shortness of breath The priority is the child's ongoing dyspnea, which indicates poor control of his asthma and possible hypoxemia. Additionally, restlessness is a clinical manifestation of impending respiratory failure. This requires rapid intervention.

What is the priority concern for James (refer to question 11)? 1. Fever 2. Drooling 3. Sore throat 4. Flushing

2. Drooling James has symptoms of epiglottitis and is at high risk for an airway obstruction. Drooling is a classic symptom of epiglottitis and indicates that airway obstruction may be imminent

Which laboratory value is consistent with clubbing of Rebecca's finger and toe nails? 1. Elevated white blood cell (WBC) count 2. Elevated red blood cell (RBC) count 3. Decreased hematocrit 4. Decreased mean corpuscular volume

2. Elevated red blood cell (RBC) count Clubbing occurs with chronic arterial desaturation. Chronic arterial desaturation can result in polycythemia (increased RBCs). This would result in increased hematocrit, not a decrease

Billy is to be transferred from the clinic to the hospital for his asthmatic condition. Which tasks are RN responsibilities and should not be delegated or performed by another member of the health care team? Select all that apply. 1. Give a report to the attending pediatrician at the receiving hospital. 2. Give a report to the charge nurse at the receiving hospital. 3. Help the parent and child to collect and bag up personal items. 4. Determine that the client's condition is stable enough for transport to the hospital. 5. Assess the response to treatment and document the client's condition. 6. Assist the client to transfer to the ambulance stretcher.

2. Give a report to the charge nurse at the receiving hospital. 5. Assess the response to treatment and document the client's condition.

Which pharmacologic intervention should the nurse anticipate at this time? 1. IV methylprednisolone 2. IV immunoglobulin 3. IV ibuprofen 4. IV infliximab

2. IV immunoglobulin IV immunoglobulin is the first line of treatment for children with Kawasaki disease because it has been demonstrated to reduce the incidence of coronary artery aneurysms (this is life threatening)

How would the nurse best interpret Rebecca's decreased FEV1? 1. Decreased oxygenation 2. Increased obstruction 3. Presence of infection 4. Pulmonary remodeling

2. Increased obstruction FEV1 measures the amount of air expired after 1 second of forced expiration. Hence, a decrease in FEV1 indicates obstruction.

What is the priority nursing concern in caring for the A family? (Refer to question 11 for a description of the A family's circumstances.) 1. Hygiene 2. Safety 3. Development 4. Growth

2. Safety

Charlie's parents ask the nurse if the NG tube can be removed because it is irritating Charlie's nose. What is the nurse's best response? 1. "The NG tube is necessary to prevent aspiration of the stomach contents into the lungs." 2. "The NG tube is necessary because Charlie will need to have feedings through it." 3. "The NG tube is necessary to keep Charlie's stomach empty, allowing the intestines to rest." 4. "The NG tube is necessary to prevent swallowed air from building up in the stomach."

3. "The NG tube is necessary to keep Charlie's stomach empty, allowing the intestines to rest." Charlie has decreased bowel sounds and perforated appendix, which places him at risk for ileus. Insertion of a NG tube is recommended for gastric decompression

A 9-month-old child arrives at the health center with his mother for immunizations. The child is fussy with rhinorrhea and has an axillary temperature of 100.4°F (38°C). The pediatrician has determined that the child has nasopharyngitis. What is the priority action? 1. Administer half of the immunizations and reschedule a subsequent appointment for the other half. 2. Advise the mother that fever is a contraindication for immunization and reschedule the appointment. 3. Administer acetaminophen to reduce fever and apply an anesthetic cream to the injection site. 4. Advise the mother that the child will likely need an antibiotic and reschedule the appointment.

3. Administer acetaminophen to reduce fever and apply an anesthetic cream to the injection site. Acetaminophen will reduce the child's fever, and an anesthetic cream will reduce pain at the injection site. By taking this action, the nurse is preparing to give the child the recommended immunizations. Fever and minor illnesses are not a contraindication for immunizations

For 7-month old Terry (refer to question 11), which task would be appropriate to assign to the LPN/LVN? 1. Teach parents that passive smoking and bottle feeding contribute to ear infections. 2. Explain the concept of "watchful waiting" for 72 hours for uncomplicated otitis. 3. Administer ordered dose of acetaminophen and apply a warm moist compress to pinna.

3. Administer ordered dose of acetaminophen and apply a warm moist compress to pinna.

The pediatrician examines James and determines that he should be taken immediately to the Children's Hospital emergency department (ED). The child is breathing slowly and quietly; humidified oxygen is being administered. What is the priority action? 1. Instruct the parents to drive the child to the hospital immediately and call the ED. 2. Contact a private ambulance service and prepare the client for transport. 3. Call 911, ask for advanced emergency medical services (EMS), and monitor the child. 4. Assist the pediatrician to intubate the child and then arrange for transport.

3. Call 911, ask for advanced emergency medical services (EMS), and monitor the child.

A parent calls in for advice because her 18-month-old toddler has stumbled and bumped his head on the coffee table. Which symptom is cause for the greatest concern? 1. A swelling the size of a golf ball that is tender to the touch 2. Two episodes of vomiting a small amount of undigested food 3. Continuous crying for 2 hours, unrelieved by familiar comfort measures 4. Gaping 1.5-inch (4-cm) laceration on the forehead, with bleeding controlled by pressure

3. Continuous crying for 2 hours, unrelieved by familiar comfort measures Inconsolable crying for 2 hours is excessive, prolonged, and abnormal and may be a sign of increased intracranial pressure (ICP). Instruct the parent to call 911. The swelling can be treated with ice packs. Vomiting can be a sign of increased ICP, but fewer than three episodes is usually associated with minor injuries

As the nurse cares for Billy and addresses his asthmatic condition, in what sequence should the following prescribed actions be implemented? 1. Administer IV methylprednisolone. 2. Contact the hospital about admission. 3. Give nebulized albuterol now and every 30 minutes. 4. Teach about measuring peak expiratory flow rate to determine personal best. 5. Obtain a chest radiograph and a complete blood count (CBC). 6. Administer humidified oxygen to maintain saturation above 90%. 7. Schedule a radioallergosorbent test.

3. Give nebulized albuterol now and every 30 minutes 6. Administer humidified oxygen to maintain saturation above 90%. 1. Administer IV methylprednisolone. 5. Obtain a chest radiograph and a complete blood count (CBC). 4. Teach about measuring peak expiratory flow rate to determine personal best. 7. Schedule a radioallergosorbent test.

To ensure efficient workflow of the clinic and maximize available expertise, which task should be assigned to the experienced LPN/LVN? 1. Perform triage for walk-in clients. 2. Perform physical assessment of walk-in clients. 3. Give routine immunizations. 4. Obtain weight and height measurements.

3. Give routine immunizations.

After a 14-day hospitalization, Bobby is discharged home on a regimen of long-term aspirin therapy. What advice should the nurse provide regarding influenza vaccination? 1. Influenza vaccine is indicated for children 4 months to 18 years of age. 2. Influenza vaccine should be postponed for 11 months after treatment. 3. Influenza vaccine is indicated for children receiving long-term aspirin therapy. 4. Influenza vaccine should be postponed in children receiving long-term aspirin therapy.

3. Influenza vaccine is indicated for children receiving long-term aspirin therapy.

The GN is preparing to give an antibiotic tablet to 7-month-old Terry. She checks a drug reference book, crushes the tablet, and then mixes it into 3 oz (84 grams) of applesauce. As the supervising nurse, what is the priority action? 1. Accompany her into the room and observe while she administers the drug. 2. Allow her to proceed independently and ask her to report on the outcome. 3. Suggest that she reconsider the client's circumstances and developmental needs. 4. Suggest that she recheck the drug reference book before administering the drug.

3. Suggest that she reconsider the client's circumstances and developmental needs.

The APN student and the pediatrician are at James' bedside. Which two additional team members would be the best combination to provide the initial care for James (refer to question 11)? 1. The experienced RN and the experienced LPN/LVN 2. The experienced RN and the UAP 3. The experienced RN and the GN 4. The experienced LPN/LVN and the GN

3. The experienced RN and the GN

Which nursing assessment is a priority? 1. Obtain a rectal temperature. 2. Auscultate the lungs. 3. Obtain a blood pressure. 4. Auscultate the heart.

4. Auscultate the heart. Kawasaki disease is one of the most common causes of vasculitis in children and may result in cardiac complications. Early indications of cardiac involvement include tachycardia out of proportion to fever and a gallop rhythm; therefore, auscultating the heart is the priority.

Daisy's mother arrives at the clinic, and she is relieved to find Daisy happy and smiling, but the mother bursts into tears and begins to yell at her neighbor and the nursing staff for "not taking care of her!" What is the best way to handle her anger and tears? 1. Remind the mother that the child is okay and that the neighbor was doing what she thought was best based on the information that she had. 2. Allow the mother to express her feelings and then take the neighbor aside and explain that the mother is just temporarily upset. 3. Teach the mother about ways to communicate the child's needs to all caregivers and help her make a list of specific instructions. 4. Direct the mother to a private area and encourage her to ventilate feelings; then gently assess how she typically manages Daisy's diabetes.

4. Direct the mother to a private area and encourage her to ventilate feelings; then gently assess how she typically manages Daisy's diabetes.

The pediatric social worker has just informed Ms. A that Child Protective Services has been notified and that a representative will arrive shortly to speak with her about the family's situation. Ms. A starts to cry and threatens to leave. What is the priority action? 1. Obtain an "against medical advice" (AMA) form and have her sign it. 2. Notify the pediatrician of the mother's intent to leave. 3. Inform the mother that the police will be notified if she leaves. 4. Encourage Ms. A to remain and to express feelings and fears.

4. Encourage Ms. A to remain and to express feelings and fears.

The nurse establishes that Rebecca has poor airway clearance. Which intervention is most important for the nurse to implement for this problem? 1. Increased fluid requirements 2. Inhaled corticosteroids 3. Oxygen therapy 4. Flutter valve with huffing

4. Flutter valve with huffing Forced expiration and huffing is an effective method to clear the airways. Children with cystic fibrosis do not have increased fluid requirements

. In the afternoon, several clients come to the clinic for walk-in care. Prioritize the following clients in the order in which they should be seen to ensure safe care and efficiently manage client load. 1. Daisy is 4 years old; she is alert and irritable with pale, sweaty skin. An older neighbor who was temporarily watching Daisy reports that she was running around and playing, and then she got "grumpy." Daisy has diabetes, but the neighbor "was not sure how to give her the insulin." 2. Sarah is 11 months old; she is dirty and crying, and her right arm is swollen and red. Sam is Sarah's 2-year-old brother; he is dirty and hungry and reaches out to be picked up. Ms. A, their mother, is 19 years old and single. She is thin and disheveled and seems somewhat confused. She is having trouble answering the nurse's questions. Ms. A says, "Those kids play too rough! The older one is always pushing the baby off the bed." 3. Terry is 7 months old; he rubs at both of his ears, acts fussy, refuses to suck, and has a temperature of 101.2°F (38.4°C). He has had three episodes of otitis media in the past. Social history includes being bottle-fed and having parents who are both smokers. 4. James is 3 years old. He awakened last night with a sore throat, difficulty swallowing, and a fever. He is flushed, anxious, and drooling. The nurse observes a thick, muffled quality to his voice and slow, quiet breathing. The nurse notes that James looks sick.

4. James is 3 years old. He awakened last night with a sore throat, difficulty swallowing, and a fever. He is flushed, anxious, and drooling. The nurse observes a thick, muffled quality to his voice and slow, quiet breathing. The nurse notes that James looks sick. 1. Daisy is 4 years old; she is alert and irritable with pale, sweaty skin. An older neighbor who was temporarily watching Daisy reports that she was running around and playing, and then she got "grumpy." Daisy has diabetes, but the neighbor "was not sure how to give her the insulin." 2. Sarah is 11 months old; she is dirty and crying, and her right arm is swollen and red. Sam is Sarah's 2-year-old brother; he is dirty and hungry and reaches out to be picked up. Ms. A, their mother, is 19 years old and single. She is thin and disheveled and seems somewhat confused. She is having trouble answering the nurse's questions. Ms. A says, "Those kids play too rough! The older one is always pushing the baby off the bed." 3. Terry is 7 months old; he rubs at both of his ears, acts fussy, refuses to suck, and has a temperature of 101.2°F (38.4°C). He has had three episodes of otitis media in the past. Social history includes being bottle-fed and having parents who are both smokers

Daisy (refer to question 11) has type 1 diabetes. She is currently alert but irritable. She looks pale and her skin is clammy. What is the priority action for Daisy? 1. Locate the mother to obtain a history and permission to treat. 2. Administer supplemental oxygen, alert the pediatrician, and establish IV access. 3. Ask the child to describe how she feels and use simple questions to obtain a history. 4. Perform blood glucose testing and then give the child a carton of milk.

4. Perform blood glucose testing and then give the child a carton of milk.

Which assessment should be most concerning to the nurse? 1. Oral temperature of 100.4°F (38°C) 2. Decreased bowel sounds in all quadrants 3. Urine output of 160 mL over 4 hours 4. Respiratory rate of 15 breaths per minute

4. Respiratory rate of 15 breaths per minute

A parent calls in for advice because "Missy is 5 years old, and she just won't sleep in her own bed. For the past 4 months, she wakes and comes to sleep with me and my husband. She cries and cries if we take her back to her own room." What is the priority action? 1. Send the mother a brochure of things she can try to assist the child to sleep independently. 2. Advise the mother that this is a normal behavior that will eventually pass with time. 3. Suggest that the child be put back into her own bed and allowed to cry herself to sleep. 4. Schedule an appointment with the APN student for assessment and management.

4. Schedule an appointment with the APN student for assessment and management.