GO OVER: Nursing Care During a Pediatric Emergency
A 10-year-old boy with congenital heart disease is in shock. Which nursing intervention would be most appropriate for this child? a) Assessing for changes in mental status and alertness b) Monitoring urine output with a goal of 1 to 2 mL/kg/hour c) Palpating for pulses and capillary refill d) Assessing for pulmonary edema from fluid overload
Assessing for pulmonary edema from fluid overload
Cardiopulmonary resuscitation (CPR) is in progress on an 8-year-old boy who is in shock. Which nursing intervention is priority? a) Drawing a blood sample for arterial blood gas analysis b) Using a large bore catheter for peripheral venous access c) Attaining central venous access via the femoral route d) Inserting an indwelling urinary catheter to measure urine output
Attaining central venous access via the femoral route
The parents of a 7-month-old boy with a broken arm agree on how the accident happened. Which account would lead the nurse to suspect child abuse? a) "The gate was open and he fell down three steps." b) "He was climbing out of his crib and fell." c) "He fell out of a shopping cart in the store." d) "Mom turned and he fell from changing table."
"He was climbing out of his crib and fell."
The nurse is providing support to the parents of a 10-year-old boy receiving emergency care. The boy is their foster child. Which comment will be most effective? a) "Since you are not his biological parents, you must wait outside." b) "Your child is hypovolemic and needs fluid." c) "Hold your child's hand while this is going on." d) "I think you had better stay out here and wait to hear from us."
"Hold your child's hand while this is going on."
The child's physician requests that the nurse should notify her if the child's urine output is less than 1 mL/kg of body weight each hour. The child weighs 56 lb (25.46 kg). Calculate the minimum amount of urine output the child should produce each hour. Record your answer using a whole number. _________ mL/hour
25 mL/hour
The nurse is assisting with the intubation of a 6-year-old child and is gathering the necessary equipment. The nurse determines that the child needs which size tracheal tube? a) 5.0 b) 4.0 c) 4.5 d) 5.5
5.5
The child needs a tracheal tube placed. The child is 8 years old. Calculate the size, in millimeters, of the tracheal tube that should be used for this child. Record your answer using a whole number. ___________ mm
6 8/4=2+4=6
A 10y/o child in respiratory distress requires intubation. Which sizes of tracheal tubes wil the nurse prepare? 1. 9.5mm/10mm 2. 8.5mm/9.0mm 3. 6.0mm/6.5mm 4. 6.5mm/7.0mm
6.0mm/6.5mm ...10/4=2.5+4=6.5 also one tube smaller just in case
The nurse has administered IV adenosine as ordered to a child with supraventricular tachycardia. Which action would the nurse do next? a) Monitor for ventricular arrhythmias. b) Administer a rapid generous saline flush. c) Set up a continuous infusion for administration of adenosine. d) Give five positive-pressure ventilations.
Administer a rapid generous saline flush.
A 3-year-old child who is breathing very rapidly and shallowly has an oxygen saturation level of 90%. The child is also very apprehensive. Which of the following would be most appropriate? a) Offer the child a drink of her favorite fluid. b) Have the child sit up straight in a chair next to her parent. c) Administer oxygen via a mask made out of a paper cup. d) Have the parent hold a mask in place to administer a nebulizer treatment.
Administer oxygen via a mask made out of a paper cup.
A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which treatment is most likely appropriate in the immediate treatment of the girl's poisoning? a) Gastric lavage b) Inducing vomiting c) Administration of activated charcoal d) Intravenous rehydration
Administration of activated charcoal
When assessing a child with a traumatic injury, what would be the priority assessment? a) Level of consciousness and papillary reaction b) Airway patency and airflow c) Breathing effectiveness and breath sounds d) Pulse rate and skin color
Airway patency and airflow
The nurse is caring for a 7-year-old child with suspected basilar head trauma. Which of the following interventions is most likely to be required? a) Beginning hyperventilation of the child b) Administering small doses of morphine c) Intubation and mechanical ventilation d) Providing blow-by oxygenation
Intubation and mechanical ventilation
A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in teaching parents about how to protect a toddler from accidental poisoning? a) Keep cleaning solutions locked up. b) Closely monitor the toddler's activity. c) Do not leave the toddler alone. d) Label poisonous solutions.
Keep cleaning solutions locked up.
The nurse is assessing the neurologic status of an infant. What would the nurse identify as a nonreassuring finding? a) Vigorous crying b) Lack of interest in surroundings c) Making eye contact with the nurse d) Soft flat anterior fontanel
Lack of interest in surroundings
A 6-year-old girl in shock is receiving dobutamine. What would the nurse most likely do? a) Give adequate fluids prior to administration. b) Monitor for hypotension or seizures. c) Monitor for ventricular arrhythmias. d) Assess for shortness of breath and dyspnea.
Monitor for ventricular arrhythmias.
A 14-year-old child is brought to the emergency department. His parents state that they think he took "too many of his pain pills." The child had been prescribed oxycodone every 4 hours for pain secondary to a bone infection. Which agent would the nurse expect to be administered to counteract the analgesics? a) Naloxone b) Atropine c) Lidocaine d) Ketamine
Naloxone
A group of nursing students are reviewing information about tachyarrhythmias in children. The students demonstrate a need for additional review when they identify this as a characteristic of sinus tachycardia in children: a) Beat-to-beat variability in rhythm b) Presence of P waves c) Narrow QRS complex d) Heart rate below 180 beats per minute
Narrow QRS complex
A 2-year-old boy is in respiratory distress. Which nursing assessment finding would suggest the child aspirated a foreign body? a) Auscultating a low-pitched, grating breath sound b) Hearing dullness when percussing the lungs c) Noting absent breath sounds in one lung d) Hearing a hyperresonant sound on percussion
Noting absent breath sounds in one lung
A 16-year-old boy is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries from what cause? a) Automobile accidents b) Falls from beds c) Play-related injuries d) Falls from staircases
Automobile accidents
A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? a) Provide only partial baths to the toddler. b) Teach the child that water is dangerous. c) Instruct the toddler not to go near the pool. d) Avoid unattended baths for the toddler.
Avoid unattended baths for the toddler.
A 14-year-old girl arrives at the hospital in a comatose state. Her father, who found her comatose in her room, tells you that she has an opiate addiction. Which of the following would confirm that the coma was caused by opiate intoxication? a) Both pupils are pinpoints b) One pupil dilated and the other deviated downward c) Both pupils are dilated d) One pupil dilated and the other normal
Both pupils are pinpoints
When a poison has been ingested by a child, what should the parents do first? a) Call the local poison control center. b) Administer an emetic. c) Induce vomiting. d) Get the child to an emergency facility.
Call the local poison control center.
The condition of an 11-year-old boy who is on mechanical ventilation begins to deteriorate. What action would the nurse do next? a) Check to see if the tracheal tube is displaced. b) Confirm that the ventilator is working properly. c) Suction the tube to remove a mucus plug. d) Examine the child for signs of pneumothorax.
Check to see if the tracheal tube is displaced.
The nurse is caring for a 4-year-old boy who is receiving mechanical ventilation. Which intervention is the priority when moving this child? a) Monitoring the pulse oximeter for oxygen saturation b) Auscultating the lungs for equal air entry c) Checking the CO2 monitor for a yellow display d) Watching for disconnections in the breathing circuit
Checking the CO2 monitor for a yellow display
An unconscious client is brought to the emergency department after ingesting too much prescribed medication. What is the highest priority nursing intervention? a) Administer antacids. b) Establish IV access. c) Establish a patent airway. d) Call family members.
Establish a patent airway.
A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which action should the nurse take first? a) Provide oral analgesics as ordered. b) Establish a suitable IV site. c) Begin hyperventilation. d) Draw blood for type and cross-match.
Establish a suitable IV site.
A strain is a ligament injury. a) True b) False
False A strain is a muscle-tendon injury. A sprain is a ligament injury.
A young client in the intensive care unit is in a coma after a severe head injury. The primary nurse is teaching a nursing student how to assess the client's level of consciousness using a coma scale. What type of scale could be used for this purpose? a) Apgar scale b) Visual analogue scale c) Wong-Baker FACES scale d) Glasgow scale
Glasgow scale
A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 bpm. Which intervention is priority? a) Give three doses of epinephrine b) Administer two consecutive defibrillator shocks c) Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR) d) Initiate cardiac compressions
Initiate cardiac compressions
The nurse is caring for a 10-month-old infant with signs of respiratory distress. Which is the best way to maintain this child's airway? a) Employing the jaw-thrust maneuver b) Placing the hand under the neck c) Using the head tilt chin lift technique d) Inserting a small towel under shoulders
Inserting a small towel under shoulders
A 5-year-old girl is breathing spontaneously but is unable to maintain an airway. What action would be the priority? a) Placing a towel under her shoulders b) Inserting an oropharyngeal airway c) Positioning her using head tilt/chin lift d) Assisting with tracheal tube insertion
Inserting an oropharyngeal airway
The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern? a) The child is crying and looking around fearfully. b) Inspection shows a sluggish pupillary reaction. c) The child's eyes remain closed unless she is spoken to. d) Palpation of the head reveals a closed posterior fontanel.
Inspection shows a sluggish pupillary reaction.
A 7-year-old girl is in the intensive care unit following a bicycle accident. Which would be most helpful in providing support to the girl's parents? a) Providing honest answers in a reassuring manner b) Giving them brief explanations of procedures c) Encouraging them to read to their daughter d) Describing the treatment plan for their daughter
Providing honest answers in a reassuring manner
Which nursing diagnosis would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub? a) Noncompliance b) Risk for suffocation c) Risk for falls d) Risk for imbalanced body temperature
Risk for suffocation
The nurse is ventilating a 9-year-old girl with a bag valve mask. Which action would most likely reduce the effectiveness of ventilation? a) Pressing down on the mask below the mouth b) Checking the tail for free flow of oxygen c) Setting the oxygen flow rate at 15 L/minute d) Referring to Broselow tape for bag size
Setting the oxygen flow rate at 15 L/minute
The nurse is examining a 10-year-old boy with tachypnea and increased work of breathing. Which finding is a late sign that the child is in shock? a) Delayed capillary refill with cool extremities b) Blood pressure slightly less than normal c) Significantly decreased skin elasticity d) Equally strong central and distal pulses
Significantly decreased skin elasticity
A 4-year-old girl, injured in an automobile accident, is suspected of having a head injury. What would be the priority action? a) Opening the airway using the jaw thrust maneuver b) Hyperventilating the child with a bag-valve-mask c) Providing manual stabilization of the head and neck d) Stabilizing the head and neck with a pediatric backboard
Opening the airway using the jaw thrust maneuver
The nurse is examining a 10-month-old girl who has fallen from the back porch. Which assessment will directly follow evaluation of the "ABCs?" a) Observing skin color and perfusion b) Palpating the abdomen for soreness c) Auscultating for bowel sounds d) Palpating the anterior fontanel
Palpating the anterior fontanel
A 10-year-old boy who was in a car wreck has been brought to the emergency room for evaluation. He appears to have suffered abdominal trauma due to his seat belt. He has tenderness in the left upper quadrant of the abdomen, especially on deep inspiration. Given these circumstances, the nurse should suspect injury to which of the following organs? a) Liver b) Pancreas c) Spleen d) Stomach
Spleen
The nurse is caring for a 2-year-old who has been rushed to the clinic immediately after swallowing an unknown number of acetaminophen tablets. Which of the following is the priority intervention? a) Start IV fluid replacement. b) Administer N-acetylcysteine. c) Perform a gastric lavage. d) Initiate chelation therapy.
Perform a gastric lavage.
A 3-year-old child has sustained injuries from a fall. Once the airway is secured, what interventions would be next? a) Administer 100% oxygen. b) Check mouth for debris. c) Set up antecubital IV access. d) Stabilize the cervical spine.
Stabilize the cervical spine.
The nurse has performed an across-the-room assessment of an 8-year-old child and has classified her as emergent. Which sign or symptom has the nurse seen? a) The child is asleep on the mother's lap. b) The child is scratching a rash. c) There is a blue color to the lips. d) The child is guarding one hand.
There is a blue color to the lips.
The nurse is attempting to establish peripheral vascular access in child requiring pediatric advanced life support. The decision to use the intraosseous route would be made if the nurse were unsuccessful after how many attempts within 90 seconds? a) Five b) Four c) Two d) Three
Three
The effect of the bite of a rattlesnake, copperhead, or cottonmouth moccasin (all pit vipers) is the almost immediate failure of the blood coagulation system. a) True b) False
True
A 9-year-old boy nearly drowned when he fell through the ice while skating on a pond. The child is exhibiting bradycardia. What would the nurse expect to implement to resolve the child's bradycardia? a) Giving intravenous isotonic fluids b) Providing 100% oxygen via face mask c) Administering epinephrine as ordered d) Using a convective air warming blanket
Using a convective air warming blanket
Assessment of a 12y/o who crashed his bicycle without a helmet reveals the following: temp 99.2F, pulse 100, RR 24 with easy work of breathing, BP 102/70. What is the priority action by the nurse? 1. assess neurologic status while observing for obvious injuries 2. administer IV fluid bolus or NS 20mL/kg 3. remove the cervical collar if he complains that it bothers him 4. listen for bowel sounds while assessing for pain
assess neurologic status while observing for obvious injuries
An 18m/o child is BIBA to ED after an accidental ingestion. What is the priority nursing action? 1. get vitals 2. give oral syrup of ipecac 3. insert NG tube 4. start an IV line
get vitals
A preschooler presents to the ED with a Hx of vomiting, diarrhea, and fever over the past few days. She is receiving 100% O2 via nonrebreather mask. Vital signs are temp 104.5F, Pulse 144, RR 22, BP 70/50. She is listless and difficult to arouse and has weak peripheral pulses and prolonged cap refill. What nursing intervention takes priority? 1. administer acetaminophen rectally for the high fever 2. administering IV antibiotics for the infection 3. preparing the child for tracheal intubation 4. giving an IV bolus of NS 20mL/kg
giving an IV bolus of NS 20mL/kg
An unresponsive toddler is brought to the emergency department. Assessment reveals mottled skin color, respiratory rate of 10bpm, and a brachial pulse of 52bpm. What is the priority nursing action? 1. prepare the defibrillator and draw up code medications 2. provide 100% O2 BVM and start compressions 3. start chest compression and provide 100% O2 nonrebreather mask 4. begin and IV fluid infusion and administer epinephrine IV
provide 100% O2 BVM and start compressions
The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of: a) neurologic trauma. b) respiratory failure. c) underlying heart disease. d) lethal arrhythmia.
respiratory failure.
The nurse is caring for a child in an emergency situation. The child has a tracheal tube in place. The nurse is aware which medications may be given via the tracheal tube if no intravenous access is available. Select all that apply. a) Atropine b) Lidocaine c) Sodium bicarbonate d) Epinephrine e) Glucose
• Atropine • Epinephrine • Lidocaine
After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next? a) Assess level of consciousness. b) Remove the child's clothing. c) Obtain a full set of vital signs. d) Provide pain management.
Assess level of consciousness.
A 4-year-old girl is brought to the emergency room following ingestion of large amounts of acetaminophen (Tylenol). Which of the following interventions does the nurse expect? a) Stimulation of vomiting b) Assessing for consciousness c) Administration of acetylcysteine d) Performing hands-only CPR
Administration of acetylcysteine
A child is to undergo synchronized cardioversion. The child weighs 44 lbs (20 kg). The nurse would expect how many joules to be delivered? a) 10 to 20 joules b) 2 to 4 joules c) 5 to 10 joules d) 30 to 40 joules
10 to 20 joules
When developing the plan of care for a 10-month-old infant in septic shock, which intervention would the nurse most likely include? a) Administering intravenous saline as ordered b) Giving blood if saline provides inadequate response c) Inserting a urinary catheter for monitoring urinary output d) Administering intravenous dopamine as ordered
Administering intravenous dopamine as ordered
An 8-year-old girl with tachycardia is alert, breathing comfortably, and exhibiting signs of adequate tissue perfusion. Which nursing intervention would be most appropriate for this child? a) Applying ice to the child's face b) Initiating cardiac compressions c) Oxygenating and ventilating the child d) Administering epinephrine as ordered
Applying ice to the child's face
Administration of which medication reverses the histamine release and hypotension that are seen in anaphylaxis? a) Zantac b) Epinephrine c) Atropine d) Benadryl
Epinephrine
The nurse is preparing to insert an oropharyngeal airway. Which action would be most appropriate to determine the proper size? a) Measuring distance from end of nose to tragus of ear b) Inspecting the child's fifth digit to estimate the diameter c) Placing the airway next to the cheek with tip pointing down d) Measuring from the tip of the nose to earlobe to middle of xiphoid process
Placing the airway next to the cheek with tip pointing down
A 14-month-old trauma victim has arrived in the emergency department. What challenges will the nurse need to address first a) Inadequate systemic perfusion b) Increased metabolic demands c) Risks from reduced core temperature d) Possible tissue damage from hypoxia
Possible tissue damage from hypoxia
A 10-year-old boy has just arrived by ambulance at the emergency room following a motor vehicle accident, and a nurse is assessing him. Which three body systems should the nurse evaluate fist? a) Respiratory, cardiovascular, and neurologic b) Respiratory, cardiovascular, and skeletal c) Neurologic, cardiovascular, and endocrine d) Cardiovascular, gastrointestinal, and neurologic
Respiratory, cardiovascular, and neurologic
A 3-year-old girl had a near-drowning incident when she fell into a wading pool. Which intervention is the highest priority? a) Covering the child with warming blankets b) Suctioning the upper airway to ensure airway patency c) Assuring the child stays still during an X-ray d) Inserting a nasogastric tube to decompress stomach
Suctioning the upper airway to ensure airway patency
Fever increases the basal metabolic rate resulting in: a) Decreased oxygen demand b) Bradycardia c) Bradypnea d) Tachypnea
Tachypnea
When assessing a young child who is experiencing decompensated shock, what would the nurse expect to find? a) Normal blood pressure b) Tachycardia c) Tachypnea d) Irritability
Tachypnea
A 13-year-old girl suffered a serious fall while hiking with friends and injured her head. She is now being evaluated by a nurse in the emergency room. The nurse notices clear fluid flowing from the girl's nose. The girl's friend said that she had been suffering from pollen allergy recently. Which of the following interventions should the nurse implement to determine whether the fluid is cerebrospinal fluid (CSF) or rhinitis from an allergy? a) Test the fluid with a glucose reagent strip b) Evaluate the client's level of consciousness c) Perform a skull x-ray d) Assess the client's blood pressure
Test the fluid with a glucose reagent strip
Which finding from the history of a child with extensive burns would make you most alert to assess for respiratory complications? a) Firemen found the child sobbing silently. b) The child's clothing was burned. c) The fire was caused by burning weeds. d) The child was trapped in a closed burning bedroom.
The child was trapped in a closed burning bedroom.
