Chapter 31: Medication Administration and Intravenous Therapy

The nurse is caring for an 8-year-old girl who requires medication that is only available in an enteric tablet form. The nurse is teaching the mother how to help the girl swallow the medication. Which statement indicates a need for further teaching?

"I can pinch her nose to make it easier to swallow." The mother should be advised to never pinch the child's nose as it increases the risk for aspiration. The other statements are correct.

The nurse knows additional teaching is needed if a parent makes which comment?

"I keep the medications in a drawer under papers." The nurse would need to provide additional teaching if the medication is kept in a drawer under papers, as children are curious and will look inside drawers that are not locked. It is best to teach parents to keep medication in a locked drawer or cabinet. Keeping it in a high cabinet is also appropriate. Refrigerated medications should be kept on the highest shelf in the refrigerator.

A nurse has just given instructions to the parents of a 12-year-old about administering a prescribed otic medication. Which statement by the parents would indicate the need for further education concerning the medication?

"I will make sure that I pull her outer ear down and back before administering the medication." The proper technique to instill ear drops in a child over age 3 involves pulling the pinna of the ear up and back. Do not administer otic medication if it is cold. Cold medication may cause discomfort and produce vomiting or vertigo in the child. If an otic medication must be refrigerated, it should be warmed to room temperature in the palms of the hands. Proper otic administration technique involves holding the dropper one-half inch above the ear canal and being careful not to touch the dropper to the ear to prevent contamination of the dropper with microorganisms. For children under 3, pull the pinna up and back.

The primary health care provider prescribed ketoconazole for a child with ringworm. Which statement by the parents indicates the nurse needs to provide additional teaching on the prescription?

"I will wrap the skin tightly after applying the medication." Ketoconazole is an antifungal used to treat tinea infections. The nurse would teach to avoid covering treated skin areas with tightly. The area needs to allow for air to circulate to the skin in order to limit side effects. All other statements indicate correct understanding.

The pediatric nurse is teaching a class of graduate nurses about fluid and electrolyte balance. The nurse knows that teaching has been effective when the new graduate states:

"Infants and children become dehydrated more quickly than adults because the increased BSA relative to the body fluid volume is 2 or 3 times that of adults." Answer B: Infants and children can become dehydrated in a short amount of time. Dehydration occurs because of a greater fluid exchange caused by the rapid metabolic activity associated with infants' growth. Large quantities of fluid are lost through the skin and BSA is 2 to 3 times that of an adult. Incorrect A,C,D: children and infants become dehydrated more quickly, the water and extracellular fluid lost from the body is increased and the BSA is 2-3 times that of the adult, not 4-5 times that of an adult.

The nurse educator is teaching the class of nurses about infusion control in children. The nurse knows that more education is needed when the student nurse states:

"No special pumps are needed for the pediatric patient; I can use the same one that we use with adult patients." Pediatric IV medications can be given directly into the IV tubing or via volume control chamber, syringe pump, or a volume control chamber. They are used to avoid overloading of the cardiopulmonary system. The amount of fluid needs to be monitored and accurately documented to avoid overloading the infant/child's circulation.

The nurse is providing teaching on how to administer nasal drops. Which response by the parents indicates a need for further teaching?

"She needs to remain still for at least 10 minutes after administration." Once the drops are instilled, the child should remain in hyperextension for at least 1 minute to ensure the drops have come in contact with the nasal membranes. Ten minutes would be excessive. The other statements are correct.

A mother of a newborn brings her child to the well child clinic the week after birth. The mother asks the nurse if the child will get any "shots" at the next appointment. The best response from the nurse would be:

"Yes, your child will get 3 shots next time. They will be the polio vaccine (called IPV), Haemophilus influenza B vaccine (called Hib), and hepatitis B vaccine. They will be given in the thigh." In older children, the deltoid muscle and the ventrogluteal are acceptable sites. For infants under walking age, use the vastus lateralis for IM injections.

A 5-year-old child is to receive long-term IV antibiotics. The mother is concerned about what type of administration method will be used. Which medication administration route may be the most easily accepted?

A peripherally inserted central catheter (PICC) line in an antecubital space If IV antibiotic therapy is going to be needed for an extended period of time, a type of longer-term device needs to be used as opposed to a peripheral IV. A peripheral IV would need to be changed often and the risks of dislodgement or inflammation are much greater. Peripherally inserted central catheters (PICCs) are placed in the upper arm under ultrasound guidance. If maintained properly they can remain for many months. This means no IV sticks for the time the child would need IV therapy. It also leaves the hands free to use. A port must be surgically implanted into the child's chest. It can remain for many months. This would not be warranted for a one-time treatment of antibiotic therapy. A Hickman catheter is inserted via sterile procedure by a surgeon. This catheter is placed near the heart and has an increased risk of infection. An intraosseous line is not a route for long-term administration. It is used for emergent situations.

A 3-year-old child with asthma and a respiratory tract infection is prescribed an antibiotic and a bronchodilator. The nurse notes the following during assessment: oral temperature 100.2°F (37.9°C), respirations 52 breaths/minute, heart rate 90 beats/minute, O2 saturation 95% on room air. Which action will the nurse take first?

Administer the bronchodilator via a nebulizer. The nurse would first administer the bronchodilator to open the child's airway and facilitate breathing. Once the airway was open, the nurse could administer oxygen, if indicated. At this time, the child's saturation level is normal but it should be monitored. The nurse would then administer the antibiotic medication. The heart rate is within normal range for a child of this age (65 to 110 beats/minute); therefore, a cardiac monitor is not needed at this time.

A neonate is to receive a hepatitis B vaccine within a few hours after birth. What is the best approach for the nurse to take when giving this medication?

Administer the medication in the neonate's vastus lateralis with a 25-gauge needle. The vastus lateralis site is a safe choice for intramuscular (IM) injections in a neonate. A 22- to 25-gauge needle is recommended for neonates, but the nurse must assess the neonate's size before determining needle size to use. The 25-gauge needle is recommended for neonates. The dorsogluteal site should not be used until school age. Neither the deltoid muscle nor the dorsogluteal muscle are recommended IM sites for neonates. These muscles should not be used until toddler age or older. The volume of the medication should not exceed 0.5 ml per injection until the child is preschool age.

The nurse is preparing to give an oral medication to an 11-year-old client. Which of the following is the best approach for the nurse to take?

Allow independence from the parent in the process of medication administration. Allowing a patient in middle childhood independence from the parent is an appropriate approach. Abstract rationales are too advanced for this age group and are better suited to adolescents. Allowing preparation through play is better suited to a child in early childhood. Introducing a bottle is better suited for an infant.

The nurse is administering a liquid medication to a 3-year-old using an oral syringe. Which action would be most appropriate?

Allow the child time to swallow the medication in between amounts. When using an oral syringe to administer liquid medications, give the drug slowly in small amounts and allow the child to swallow before placing more medication in the mouth. The syringe is directed toward the posterior side of the mouth. The toddler or young preschooler may enjoy helping by squirting the medication into his or her mouth.

The nurse enters the room to give a subcutaneous injection of insulin to a 6-year-old female who is diabetic. What is the best method of medication administration?

Ask her where she would like to have the injection. Asking the client to choose where to receive the injection gives a degree of control. Announcing that it is time for the medication does not give any sense of control to the child. Asking permission to give a medication to a child is not appropriate—a child should not be given the opportunity to decline a medication. It is not appropriate to tell a child not to cry during a painful procedure. The child should be given permission to yell out or cry if he or she feels the need to.

The nurse is planning to provide a preschool-age client with an oral medication. Which approach should the nurse use to gain the child's cooperation?

Ask the child if a cup or oral syringe is preferred to take the medicine. The child should be offered choices to provide a sense of control. Asking if a cup or oral syringe is preferred is the best approach for the nurse to use to gain the child's cooperation. Medicine should never be compared to chocolate. The child might eat a fatal amount of the medicine when unattended. Offering to play a game is bribing the child and should not be done. The medicine should not be left at the bedside stand. The child might forget to take it and another child might swallow it.

David, age 2, is diagnosed with stomach flu and is suffering from vomiting and diarrhea. What is the most important factor in determining the correct dosage for his infection?

Body surface area A drug dose for a child can be determined by using the standard formula for finding the body surface area of the child. The ratio of the body surface area to weight is inversely proportional to its length. Body surface area also can be determined by using a nomogram. Drug dosages cannot be based on age or memorized because child weights may vary considerably. Child dosage cannot be based on adult dosage, because a child's body is small and immature.

A child is receiving intravenous fluids for dehydration. The nurse notes coarse breath sounds and increased pulse and blood pressure. What does the nurse do first?

Discontinue the IV infusion. Signs of fluid overload are those of congestive heart failure and include coarse breath sounds, increased pulse rate, and increased blood pressure. These are not symptoms of extravasation because this would be swelling of fluid around the IV site. The nurse would need to stop the IV infusion, then assess weight, intake, and output. The nurse would then contact the health care provider.

A toddler requires 1.5 ml (.05 oz) of an antibiotic given intramuscularly (IM). How will the nurse administer this medication?

Divide the dose. Administer 0.75 ml (0.25 oz) IM in each vastus lateralis. The recommended amount of solution a toddler should receive in one IM injection should not exceed 1 ml (0.33 oz). Dividing the dose is necessary even though two injections will cause additional stress. These could be given simultaneously by two nurses. Seeking an oral route could be explored, but may not be feasible. The manufacturer's directions regarding the amount of diluent should be followed to ensure safety.

A nurse is preparing a dose of insulin to give the client. Which action takes priority when preparing and administering this medication?

Double-check the dose with another RN before giving. Insulin is a high-alert medication and the dosage must be checked with another RN before administering. All rights of medication administration should be adhered to. Insulin dosages come in units and the prescription is to administer a specific number of units; thus, no calculations of dosages are needed. Insulin injections do not have to be witnessed. Insulin is not known for having adverse reactions, but it is always a good practice to ask the client if he or she has experienced any problems receiving insulin.

A nurse is preparing to start an IV for a 3-year-old child. Which nursing action(s) is appropriate for a child this age? Select all that apply.

Explain the procedure using positive language. Allow the child to touch safe equipment in the treatment room. Have another nurse hold the child during the procedure. Give the child a sticker when finished. It is important to explain the procedure to the child using positive, age-appropriate language. It helps to take the child to a treatment room if possible so that the child's hospital room remains a safe place and to allow the child to touch equipment in the room as long as it is safe. Having another nurse hold the child is helpful if the child is frightened. Stickers are always fun rewards for children, especially after a difficult procedure. The antecubital vein is not the best site for toddlers because they are very active and likely to dislodge it. It is often helpful to have the parent in the room to distract or soothe the child.

The nurse is identifying a diagnosis appropriate for a preschool-age child who began to cry after learning about needing intravenous fluid therapy. Which diagnosis should the nurse select to address this specific reaction?

Fear related to intravenous infusion After learning about needing an intravenous infusion, the child began to cry. The most appropriate diagnosis would be fear related to intravenous infusion. The infusion has not started, so the child may or may not experience discomfort related to the infusion. The child did not ask the nurse to explain the infusion or the actions and effects of fluid therapy.

A child is prescribed multiple intravenous medications. Which nursing action demonstrates the best practice to maintain medication safety?

Flush the intravenous line between each medication. Two nurses are not necessarily needed to transcribe or review health care provider orders. Pharmacists review all pediatric medication orders for accuracy. Diluents and fluids should always be checked for compatibility with the medications. Thus, the best practice when giving multiple IV medications to a child is to flush the IV line between each medication.

The nurse is giving discharge instructions to a mother of a 3-month-old infant who will be receiving oral medication at home. Which of the following would the nurse include in the teaching plan?

Give the medication with a syringe and squirt a small amount at a time beside the tongue while holding the infant upright. Infants should be given oral medications with a syringe. Squirt a small amount at a time onto the side of the tongue while holding the infant upright in order to prevent aspiration. Medications should never be mixed with an infant's formula or breast milk since this is their primary source of nutrition and the infant could develop an aversion to it. Infants should be positioned upright or with the head of the bed elevated when giving oral medications. Infants are obligatory nose breathers therefore holding shut the nose is contraindicated. Medication should be squirted beside the tongue.

The clinical nurse educator who oversees the emergency department in a children's hospital has launched an awareness program aimed at reducing drug errors. What measure addresses the most common cause of incorrect doses in the care of infants and children?

Having nurses check their math calculations with a colleague before administering a drug Of all the problems that may contribute to an incorrect dose, the most common involve errors in math during dosage calculation. Dosage calculation can involve several steps, and a mathematical error can occur at each step. Documentation in multiple locations, rigorous assessment, and avoidance of IV administration are not practices that appreciably reduce the potential for incorrect doses.

The nurse has prepared an IM injection to give a 13-year-old child. After some searching, the nurse locates the child in the playroom in front of a video game. Which action is best for the nurse to take?

Inform the child that it is time for an injection. Explain why the injection is needed and have the child move to the treatment room. Explaining the reason for a medication is appropriate for a 13-year-old child. The medication should not be given in the playroom. The playroom is a safe area for clients. Painful procedures should be done in a treatment room. Asking the child to take a break from the game sounds like the nurse is asking permission to give the medication. A child should not be given the opportunity to refuse a medicine.

A 5-year-old boy is receiving an analgesic intravenously while in the hospital. What should the nurse do to determine whether the drug is being properly excreted from this child?

Monitor the child's fluid intake and output. Monitoring intake and output is important in children receiving drugs to be certain urine excretion or an outlet for drug metabolites is adequate. The other interventions listed are not typically used to determine whether drug excretion is occurring.

The nurse is administering a crushed tablet to an 18-month-old infant. What is a recommended guideline for this intervention?

Mix the crushed tablet with a small amount of applesauce. If a tablet or capsule is the only oral form available for children younger than 6 years, it needs to be crushed or opened and mixed with a pleasant-tasting liquid or a small amount (generally no more than a tablespoon) of a nonessential food such as applesauce. The crushed tablet or inside of a capsule may taste bitter, so it should never be mixed with formula or other essential foods. Otherwise, the child may associate the bitter taste with the food and later refuse to eat it.

While working in the emergency room, the nurse receives a call that a 3-year-old child sustained extensive burns in a house fire. Assuming all of the following actions are included in the standing burn-care protocol, which action should be the nurse perform first?

Obtain a weight. A burn victim will require large amounts of fluid hydration to replace fluid losses. Obtaining a weight provides a base for calculating the fluid that will need to be replaced. Nasogastric tube placement and/or drinking milk are not actions to take at this point. Tetanus can be given later and is not critical to active management.

The nurse is preparing to give a 4-month-old an oral medication. Which technique demonstrates the nurse's accurate knowledge of the infant's developmental level?

Position the infant upright, offer the infant a bottle of formula, remove the bottle and squirt the medication on the side of the tongue toward the cheek, then offer the infant the bottle again. Proper medication administration for an infant includes the following: Position the infant upright, present a pleasant- or neutral-tasting substance to ensure that the child is awake and swallowing, give the medication slowly enough to allow the child to swallow and prevent any risk of aspirating, and give a pleasant-tasting "chaser." An infant should not be placed supine since this would increase the risk of aspiration. Medications should not be placed in a client's staple food to avoid an aversion to the food in the future.

A child with gastroenteritis has been unable to keep oral medication down. What nursing intervention would be appropriate for this client?

Request an intravenous form of the medication. Absorption is the transfer of the drug from its point of entry into the bloodstream, and vomiting and diarrhea interfere with absorption because the drug does not remain in the gastrointestinal tract long enough to be absorbed. Distribution is not affected by vomiting and diarrhea, as it involves movement of the drug through the bloodstream. Metabolism involves conversion of the drug into an active or inactive form, and is unaffected by gastroenteritis. Excretion is the elimination of the drug from the body, usually through the kidneys. This is also unaffected by vomiting and diarrhea.

A child reports pain at the IV insertion site. The nurse suspects infiltration based on which assessment finding?

The area is cool to the touch. Signs of infiltration are coolness and swelling. If the area is red and hot with hard veins on palpation, this is usually phlebitis. Purulent drainage is usually an infection.

The nurse is preparing to administer regular insulin to a child following lunch. Which finding will cause the nurse to question administering the medication?

The client received insulin aspart 2 hours ago. The nurse would question administer another short-acting insulin to the client as this could result in hypoglycemia. A glucose level of 125 mg/dl (6.94 mmol/L) indicates a need for insulin. An elevated temperature alone is not reason to hold insulin. Clients do not have to eat their entire meals for insulin to be administered. The nurse would monitor the client following administration when limited meal consumption occurs.

The nurse is instructing a parent on administering ear drops to a 6-year-old. Which parental action demonstrates an understanding of teaching?

The parent has the child sit down and pulls the pinna upward and back The nurse should pull the pinna upward and back for children 3 years of age and older. The nurse should pull the pinna downward and back for children younger than 3 years of age. Medication should not be instilled cold and should not be heated in the microwave. A 6 year old is not able to instill ear drops independently.

What is the most important reason for administering a medication at the correct time?

To maintain the desired blood level of the medication Administering a drug at the correct time helps to maintain the desired blood level of the drug. When giving a PRN medication, always check the last time it was given and clarify how much has been given during the past 24 hours.

The nurse is preparing to administer an IV antibiotic to a 10-year-old child. After calculating the recommended dose with the patient's weight, the nurse discovers the ordered dose exceeds the safe dose range in a pediatric drug reference. The medication has been given to the child at this dose for three days. Which of the following should the nurse's next action be?

Verify the dose with the prescribing practitioner Medication calculations should always be checked before giving the dose. When a medication dose is found to be outside of the safe dose range, the dose should be verified with the prescribing practitioner. Doses that exceed the recommended range should always be verified, even if they have been given before. The parents did not prescribe this medication. Even if the medication had been given for three days, it does not make the dose correct. Calling the pharmacy can only verify if the dose is out of the safe range. The pharmacy did not prescribe the medication, nor do they know the medical background of the patient.

If a medication is being administered by the otic route, it will be administered in which way?

Warmed to room temperature and dropped into the ear Otic means ear. Be sure that the ear drops are at room temperature. If necessary, roll the container between the palms of your hands to help warm the drops. Using cold ear drops can cause pain and possibly vertigo or vomiting when they reach the eardrum. If the medication were to be placed in the rectum the instructions would say "for rectal use only." A ophthalmic drug would be placed in the eye. Medications in a syringe could be for injection or a liquid for oral use.

A mother is told that her child will receive total parenteral nutrition. She asks the nurse what this means. The nurse bases her response on knowledge that total parenteral nutrition is:

administration of fluids, electrolytes, amino acids, lipids, dextrose, and minerals through an IV. Total parenteral nutrition is an IV fluid that contains dextrose, amino acids, lipids, electrolytes, vitamins, and minerals through an IV. A peripheral IV might be used short term, but in most cases the fluid will be administered through a central IV line. TPN is not administered IM or through a nasogastric tube, and it includes more nutrients that those contained in Ringer's lactate.

A medical/surgical nurse has been floated to the pediatric unit. Which action by the float nurse would require the pediatric nurse to intervene?

asking the child his or her name prior to giving medications To prevent errors, the nurse should never ask children their names for identification. This action would require the pediatric nurse to intervenes. Instead, nurses must read or scan the bar code on clients' identification arm bands and compare them with the medication sheet or electronic record. It is important to include both the parents and child in teaching about a medication. Calculating pediatric doses is not something medical/surgical nurses do on a regular basis, so it would be appropriate for the float nurse to have a pediatric nurse double-check the calculations.

The new graduate nurse is preparing to administer medication to a 4-year-old client. When would it be appropriate for the supervising nurse to intervene? The new graduate:

had two whole tablets to administer to the child. Many children do not have enough coordination to swallow tablets or pills until they are 6 or 7 years of age. Therefore, the supervising nurse would need to intervene. The other actions are correct. The nurse should explain why the medication is being administered. Medications in children are dosed according to body weight (milligrams per kilogram) or body surface area (BSA) (milligrams per square meter). The vastus lateralis is a good location for an IM injection in a 4-year-old child.

The charge nurse is assisting the new graduate nurse in administering eye drops to a child. The charge nurse would stop the new graduate if which action was observed?

holds the eyelids apart for about 30 seconds To prevent the conjunctiva from drying, the nurse should not hold the eyelids apart any longer than necessary. Therefore, the charge nurse would need to stop the new nurse. It is best to use the supine position. Instill the correct number of drops into the conjunctiva of the lower lid. Allow the eyelid to close. Avoid placing the drops directly on the cornea because that can be painful. To prevent the conjunctiva from drying, do not hold the eyelids apart any longer than necessary. After the child has blinked 2 or 3 times, allow the child to sit up.

A parent must administer a medication in syrup form to a 2-month-old infant. The nurse suggests:

placing the syrup in an medicine syringe. The young infant should naturally and easily suck the medicine through a medicine syringe. Formula and rice cereal are essential foods for the infant and the desirability of them should not be altered by the taste of the medication. In addition, a 2-month-old infant is not developmentally ready for spoon feeding of rice cereal or medication from a medicine spoon.

A 4-year-old child is admitted to the hospital for surgery. Before the nurse administers medicine, the best way to identify the child would be to:

read the child's armband. A child may answer to the wrong name or deny his or her identity to avoid an unpleasant situation or if scared of the unknown. If the child is avoiding the situation he or she may fail to answer. Using the child's nickname is okay in conversation but it is not a legal identification of the child. To verify the correct identity the nurse should verify the child's armband and the correct name with the child's caregiver. Bar code scanning the child's armband would also be a correct method of identification.

A nurse is administering subcutaneous deferoxamine to a client as a treatment for sickle cell anemia. The nurse should monitor the client for several potential side effects. Which side effect requires the nurse's immediate attention?

tachycardia When administering deferoxamine the nurse must monitor for side effects such as tachycardia, respiratory distress, urinary tract infection, visual changes, and injection site reactions. However, tachycardia is a side effect that will require the nurse's immediate attention.

After administering eye drops to a child, the nurse applies gentle pressure to the inside corner of the eye at the nose for which reason?

to ensure the medication stays in the eye Punctal occlusion, or gentle pressure to the inside corner of the eye at the nose, helps to slow systemic absorption and ensure that the medication stays in the eye. Having the head lower than the body aids in dispersing the medication over the cornea. Placing the heel of the hand on the child's forehead and then retracting the lower lid helps to stabilize it.