LIPPINCOTT respiratory problems
20. When developing a teaching plan for the mother of an asthmatic child concerning measures to reduce allergic triggers, which of the following suggestions should the nurse include? 1. Keep the humidity in the home between 50% and 60%. 2. Have the child sleep in the bottom bunk bed. 3. Use a scented room deodorizer to keep the room fresh. 4. Vacuum the carpet once or twice a week.
20. 1. To help reduce allergic triggers in the home, the nurse should recommend that the humidity level be kept between 50% and 60%. Doing so keeps the air moist and comfortable for breathing. When air is dry, the risk for respiratory infections increases. Too high a level of humidity increases the risk for mold growth . Typically, the child with asthma should sleep in the top bunk bed to minimize the risk of exposure to dust mites. The risk of exposure to dust mites increases when the child sleeps in the bottom bunk bed because dust mites fall from the top bed, settling in the bottom bed. Scented sprays should be avoided because they may trigger an asthmatic episode . Ideally, carpeting should be avoided in the home if the child has asthma. However, if it is present, carpeting in the child's room should be vacuumed often, possibly daily, to remove dust mites and dust particles.
51. A 21-month-old child admitted with the diagnosis of croup now has a respiratory rate of 48 breaths/ minute, a heart rate of 120 bpm, and a temperature of 100.8 ° F (38.2 ° C) rectally. The nurse is having difficulty calming the child. Which of the following should the nurse do next? 1. Administer acetaminophen (Tylenol). 2. Notify the primary care provider immediately. 3. Allow the toddler to continue to cry. 4. Offer clear fluids every few minutes.
51. 2. The nurse may be having difficulty calming the child because the child is experiencing increasing respiratory distress. The normal respiratory rate for a 21-month-old is 25 to 30 breaths/ min. The child's respiratory rate is 48 breaths /min. Therefore the primary care provider needs to be notified immediately. Typically, acetaminophen is not given to a child unless the temperature is 101 ° F (38.6 ° C) or higher. Letting the toddler cry is inappropriate with croup because crying increases respiratory distress . Offering fluids every few minutes to a toddler experiencing increasing respiratory distress would do little, if anything, to calm the child. Also, the child would have difficulty coordinating breathing and swallowing, possibly increasing the risk of aspiration.
52. A child has viral pharyngitis. The nurse should advise the parents to do which of the following? Select all that apply. 1. Use a cool mist vaporizer. 2. Offer a soft-to-liquid diet. 3. Administer amoxicillin. 4. Administer acetaminophen. 5. Place the child on secretion precautions.
52. 1, 2, 4. Viral pharyngitis is treated with symptomatic, supportive therapy. Treatment includes use of a cool mist vaporizer, feeding a soft or liquid diet, and administration of acetaminophen for comfort. Viral infections do not respond to antibiotic administration. The child does not need to be on secretion precautions because viral pharyngitis is not contagious.
53. A father brings his 3-month-old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and "just doesn't seem to be acting right." Which of the following actions should the nurse do first? 1. Check the infant's heart rate. 2. Weigh the infant. 3. Assess the infant's oxygen saturation. 4. Obtain more information from the father.
53. 3. In an infant with these symptoms, the first action by the nurse would be to obtain an oxygen saturation reading to determine how well the infant is oxygenating, which is valuable information for an infant having trouble breathing. Because the father probably can provide no other information, checking the heart rate would be the second action done by the nurse. Then the nurse would obtain the infant's weight.
54. While the nurse is working in a homeless shelter, assessment of a 6 -month-old infant reveals a respiratory rate of 52 breaths/ min, retractions, and wheezing. The mother states that her infant was doing fine until yesterday . Which of the following actions would be most appropriate? 1. Administer a nebulizer treatment.2. Send the infant for a chest radiograph. 3. Refer the infant to the emergency department. 4. Provide teaching about cold care to the mother.
54. 3. Based on the assessment findings of increased respiratory rate, retractions, and wheezing , this infant needs further evaluation, which could be obtained in an emergency department. Without a definitive diagnosis, administering a nebulizer treatment would be outside the nurse's scope of practice unless there was a prescription for such a treatment. Sending the infant for a radiograph may not be in the nurse's scope of practice. The findings need to be reported to a primary care provider who can then determine whether or not a chest radiograph is warranted. The infant is exhibiting signs and symptoms of respiratory distress and is too ill to send out with just instructions on cold care for the mother.
55. An infant is being treated at home for bronchiolitis. Which of the following should the nurse teach the parent about home care? Select all that apply. 1. Offering small amounts of fluids frequently. 2. Allowing the infant to sleep prone. 3. Calling the clinic if the infant vomits. 4. Writing down how much the infant drinks. 5. Performing chest physiotherapy every 4 hours. 6. Watching for difficulty breathing.
55. 1, 6. An infant with bronchiolitis will have increased respirations and will tire more quickly, so it is best and easiest for the infant to take fluids more often in smaller amounts. The parents also would be instructed to watch for signs of increased difficulty breathing, which signal possible complications. Healthy infants and even those with bronchiolitisshould sleep in the supine position. Calling the clinic for an episode of vomiting would not be necessary. However, the parents would be instructed to call if the infant cannot keep down any fluids for a period of more than 4 hours. Parents would not need to record how much the infant drinks. Chest physiotherapy is not indicated because it does not help and further irritates the infant.
56. In preparation for discharge, the nurse teaches the mother of an infant diagnosed with bronchiolitis about the condition and its treatment . Which of the following statements by the mother indicates successful teaching? 1. "I need to be sure to take my child's temperature every day." 2. "I hope I don't get a cold from my child." 3. "Next time my child gets a cold I need to listen to the chest." 4. "I need to wash my hands more often."
56. 4. Handwashing is the best way to prevent respiratory illnesses and the spread of disease. Bronchiolitis, a viral infection primarily affecting the bronchioles, causes swelling and mucus accumulation of the lumina and subsequent hyperinflation of the lung with air trapping. It is transmitted primarily by direct contact with respiratory secretions as a result of eye-to-hand or nose-to-hand contact or from contaminated fomites. Therefore, handwashing minimizes the risk for transmission. Taking the child's temperature is not appropriate in most cases. As long as the child is getting better, taking the temperature will not be helpful. The mother's statement that she hopes she doesn't get a cold from her child does not indicate understanding of what to do after discharge. For most parents, listening to the child's chest would not be helpful because the parents would not know what they were listening for. Rather, watching for an increased respiratory rate, fever, or evidence of poor eating or drinking would be more helpful in alerting the parent to potential illness.
57. The nurse observes an 18-month-old who has been admitted with a respiratory tract infection (see figure). The nurse should first: 1. Position the child supine. 2. Call the rapid response team. 3. Offer the child a carbonated drink. 4. Place the child in a croup tent.
57. 4. The child is in respiratory distress and is sitting in a position to relieve the airway obstruction; the nurse should provide a humidified environment with a croup tent with cool mist to facilitate breathing and liquefy secretions. The child should remain sitting to facilitate breathing; the nurse should allow the child to determine the most comfortable position. After the child is breathing normally, the nurse can offer fluids; the primary care provider also may prescribe intravenous fluids. The nurse can call therapid response team if the respiratory distress is not relieved by using a croup tent or changes in other vital signs indicate further distress.
61. A nurse administers cefazolin instead of ceftriaxone to an 8-year-old with pneumonia. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action from reporting the error. The charge nurse should tell the nurse: 1. "If you do not report the error, I will have to." 2. "Reporting the error helps to identify system problems to improve client safety." 3. "Notify the client's primary care provider to see if she wants this reported."4. "This is not a serious mistake so reporting it will not affect your position."
61. 2. Client safety is enhanced when the emphasis on medication errors is to determine the root cause. All errors should be reported so systems can identify patterns that contribute to errors. Here, the similar names probably contributed to the error. The nurse who commits the error knows all the relevant information and is in the best position to report it. While the primary care provider should be notified, it is a nursing responsibility to report errors, not a primary care provider choice. Relating mistakes to a nurse's position focuses on personal blame.
63. The triage nurse in the emergency room must prioritize the children waiting to be seen. Which of the following children is in the greatest need of emergency medical treatment? 1. A 6-year-old with a fever of 104 ° F (40 ° C), a muffled voice, no spontaneous cough, and drooling. 2. A 3-year-old with a fever of 100 ° F (37.8 ° C), a barky cough, and mild intercostal retractions. 3. A 4-year-old with a fever of 101 ° F (38.3 ° C), a hoarse cough, inspiratory stridor, and restlessness. 4. A 13-year -old with a fever of 104 ° F (40 ° C), chills, and a cough with thick yellow secretions.
63. 1. This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency due to the risk of complete airway obstruction. The 3- and 4-year-olds are exhibiting signs and symptoms of croup. Symptoms often diminish after the child has been taken out in the cool night air. If symptoms do not improve, the child may need a single dose of dexamethasone. Fever should also be treated with antipyretics. The 13-year-old is exhibiting signs and symptoms of bronchitis. Treatment includes rest, antipyretics, and hydration.
8. After insertion of bilateral tympanostomy tubes in a toddler, which of the following instructions should the nurse include in the child's discharge plan for the parents? 1. Insert ear plugs into the canals when the child bathes. 2. Blow the nose forcibly during a cold. 3. Administer the prescribed antibiotic while the tubes are in place. 4. Disregard any drainage from the ear after 1 week.
8. 1. Placing ear plugs in the ears will prevent contaminated bathwater from entering the middle ear through the tympanostomy tube and causing an infection. Blowing the nose forcibly during a cold causes organisms to ascend through the eustachian tube, possibly leading to otitis media. It is not necessary to administer antibiotics continuously to a child with a tympanostomy tube. Antibiotics are appropriate only when an ear infection is present . Drainage from the ear may be a sign of middle ear infection and should be reported to the health care provider.
19. A 7-year-old child with a history of asthma controlled without medications is referred to the school nurse by the teacher because of persistent coughing. Which of the following should the nurse do first? 1. Obtain the child's heart rate. 2. Give the child a nebulizer treatment. 3. Call a parent to obtain more information. 4. Have a parent come and pick up the child.
19. 3. Because persistent coughing may indicate an asthma attack and a 7-year -old child would be able to provide only minimal history information, it would be important to obtain information from the parentAlthough determining the child's heart rate is an important part of the assessment, it would be done after the history is obtained. More information needs to be obtained before giving the child a nebulizer treatment. Although it may be necessary for the parent to come and pick up the child, a thorough assessment including history information should be obtained first.
40. Which of the following breathing rates should the nurse use when performing rescue breathing during cardiopulmonary resuscitation for a 5-year-old? 1. 10 breaths/ min. 2. 12 breaths/ min. 3. 15 breaths/ min. 4. 20 breaths/ min.
40. 1. Rescue breaths should be delivered slowly at a volume that makes the chest rise and fall. For a 5-year-old child, the rate is 10 breaths per minute. If the nurse is also administering chest compressions, the rate is 2 breaths for every 15 compressions.
11. After teaching the parents of an 18-month-old who was treated for a foreign body obstruction about the three cardinal signs indicative of choking, the nurse determines that the teaching has been successful when the parents state that a child is choking when he or she cannot speak, turns blue, and does which of the following? 1. Vomits. 2. Gasps. 3. Gags. 4. Collapses.
11. 4. The three cardinal signs indicating that a child is truly choking and requires immediate life-saving interventions include inability to speak, blue color (cyanosis ), and collapse. Vomiting does not occur while a child is unable to breathe. Once the object is dislodged, however, vomiting may occur . Gasping, a sudden intake of air, indicates that the child is still able to inhale . When a child is choking , air is not being exchanged, so gagging will not occur.
13. An 11- year-old is admitted for treatment of an asthma attack. Which of the following indicates immediate intervention is needed?1. Thin, copious mucous secretions. 2. Productive cough. 3. Intercostal retractions. 4. Respiratory rate of 20 breaths/ minute.
13. 3. Intercostal retractions indicate an increase in respiratory effort, which is a sign of respiratorydistress. During an asthma attack, secretions are thick, the cough is tight, and respiration is difficult (and shortness of breath may occur). If mucous secretions are copious but thin, the client can expectorate them , which indicates an improvement in the condition. If the cough is productive it means the bronchospasms and the inflammation have been resolved to the extent that the mucus can be expectorated. A respiratory rate of 20 breaths/ min would be considered normal and no intervention would be needed.
6. An adolescent female is prescribed amoxicillin (Amoxil) for an ear infection. The nurse should teach the adolescent about the risks associated with her concurrent use of:1. Antacids. 2. Oral contraceptives. 3. Multiple vitamins. 4. Protein shakes.
6. 2. When a person is taking amoxicillin as well as an oral contraceptive it renders the contraceptive lesseffective. Because pregnancy can occur in such a situation, the nurse should advise the client to use additional means of birth control during the time she is taking the antibiotic. There are no risks associated with the concurrent use of amoxicillin and antacids , vitamins, or food.
47. When teaching the parents of an infant how to perform back slaps to dislodge a foreign body, which of the following should the nurse tell the parents to use to deliver the blows? 1. Palm of the hand. 2. Heel of the hand. 3. Fingertips. 4. Entire hand.
47. 2. Back slaps are delivered rapidly and forcefully with the heel of the hand between the infant's shoulder blades. Slowly delivered back slaps are less likely to dislodge the object. Using the heel of the hand allows more force to be applied than when using the palm or the whole hand, increasing the likelihood of loosening the object. The fingertips would be used to deliver chest compressions to an infant younger than 1 year of age.
7. A toddler is scheduled to have tympanostomy tubes inserted . When approaching the toddler for the first time, which of the following should the nurse do? 1. Talk to the mother first so that the toddler can get used to the new person. 2. Hold the toddler so that the toddler becomes more comfortable. 3. Walk over and pick the toddler up right away so that the mother can relax. 4. Pick up the toddler and take the child to the play area so that the mother can rest.
7. 1. Toddlers should be approached slowly, because they are wary of strangers and need time to get used to someone they do not know. The best approach is to ignore them initially and to focus on talking to the parents. The child will likely resist being held by a stranger, so the nurse should not pick up or hold the child until the child indicates a readiness to be approached or the mother indicates that it is okay.
9. After teaching the parents of a toddler about commonly aspirated foods, which of the following foods, if identified by the parents as easily aspirated, would indicate the need for additional teaching? 1. Popcorn. 2. Raw vegetables. 3. Round candy. 4. Crackers.
9. 4. Crackers, because they crumble and easily dissolve, are not commonly aspirated. Because children commonly eat popcorn hulls or pieces that have not popped, popcorn can be easily aspirated . Toddlers frequently do not chew their food well , making raw vegetables a commonly aspirated food . Round candy is often difficult to chew and comes in large pieces, making it easily aspirated.
16. Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply. 1. Coughing. 2. Respiratory rate of 35 breaths/ min. 3. Heart rate of 95 beats/ min. 4. Restlessness. 5. Malaise. 6. Diaphoresis.
16. 1, 2, 4, 6. Coughing, especially at night and in the absence of an infection, is a common symptom of asthma. Early signs of respiratory distress include restlessness, tachypnea, tachycardia, and diaphoresis. Other signs also include hypertension, nasal flaring , grunting, wheezing, and intercostal retractions. A heart rate of 95 bpm is normal for a toddler. Malaise
10. A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. Theparents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating separation anxiety involving which of the following? 1. Protest. 2. Despair. 3. Regression. 4. Detachment.
10. 1. Young children have specific reactions to separation and hospitalization. In the protest stage, the toddler physically and verbally attacks anyone who attempts to provide care. Here, the child is fussing and crying and visibly pushes the nurse away. In the despair stage, the toddler becomes withdrawn and obviously depressed (eg, not engaging in play activities and sleeping more than usual). Regression is a return to a developmentally earlier phase because of stress or crisis (eg, a toddler who could feed himself before this event is not doing so now). Denial or detachment occurs if the toddler's stay in the hospital without the parent is prolonged because the toddler settles in to the hospital life and denies the parents ' existence (eg, not reacting when the parents come to visit).
12. The father of a 2-year-old phones the emergency room on a Sunday evening and informs the nurse that his son put a bead in his nose. What is the most appropriate recommendation made by the nurse? 1. "Try to remove the bead at home as soon as possible; you might try using a pair of tweezers." 2. "Be sure to take your child to the pediatrician in the morning so the pediatrician can remove the bead in the office." 3. "You should bring your child to the emergency room tonight so the bead can be removed as soon as possible." 4. "Ask your child to blow his nose several times; this should dislodge the bead."
12. 3. The bead should be removed by a health care professional as soon as possible to prevent the risk of aspiration and tissue necrosis. Unskilled individuals should not attempt to remove an object from the nose as they may push the object further increasing the risk for aspiration. Two-year- old children are not skilled at blowing their nose and may breathe in, further increasing the risk of aspiration.
14. A 12-year-old with asthma wants to exercise. Which of the following activities should the nurse suggest to improve breathing? 1. Soccer. 2. Swimming. 3. Track. 4. Gymnastics.
14. 2. Swimming is appropriate for this child because it requires controlled breathing, assists in maintaining cardiac health, enhances skeletal muscle strength, and promotes ventilation and perfusion . Stop-and-start activities, such as soccer, track, and gymnastics, commonly trigger symptoms in asthmatic clients.
39. On finding a child who is not breathing, the nurse has someone activate the emergency medical system and then does which of the following first? 1. Clear the airway. 2. Begin mouth-to-mouth resuscitation. 3. Initiate oxygen therapy. 4. Start chest compressions.
39. 4. The 2010 CPR guidelines call for a CAB approach. When breathlessness is determined, the priority nursing action is checking a pulse and beginning compressions. After 30 compressions, the nurse opens the airway and gives 2 breaths. Oxygen therapy would not be initiated at this time, because the child is not breathing. Also, administering oxygen therapy would interfere with providing mouth- to-mouth resuscitation.
15. When preparing the teaching plan for the mother of a child with asthma, which of the following should the nurse include as signs to alert the mother that her child is having an asthma attack? 1. Secretion of thin, copious mucus. 2. Tight, productive cough. 3. Wheezing on expiration. 4. Temperature of 99.4 ° F (37.4 ° C).
15. 3. The child who is experiencing an asthma attack typically demonstrates wheezing on expiration initially. This results from air moving through narrowed airways secondary to bronchoconstriction. The child's expiratory phase is normally longer than the inspiratory phase. Expiration is passive as the diaphragm relaxes. During an asthma attack , secretions are thick and are not usually expelled until the bronchioles are more relaxed. At the beginning of an asthma attack the cough will be tight but not productive. Fever is not always present unless there is an infection that may have triggered the attack.
28. At a follow-up appointment after being hospitalized, an adolescent with a history of cystic fibrosis (CF) describes his stools to the nurse. Which of the following descriptions should the nurse interpret as indicative of continued problems with malabsorption? 1. Soft with little odor. 2. Large and foul-smelling.3. Loose with bits of food. 4. Hard with streaks of blood.
28. 2. In children with CF, poor digestion and absorption of foods, especially fats, results in frequent bowel movements that are bulky, large, and foul -smelling. The stools also contain abnormally large quantities of fat, which is called steatorrhea. An adolescent experiencing good control of the disease would describe soft stools with little odor. Stool described as loose with bits of food indicates diarrhea. Stool described as hard with streaks of blood may indicate constipation.
29. When developing a recreational therapy plan of care for a 3-year-old child hospitalized with pneumonia and cystic fibrosis, which of the following toys would be appropriate? 1. 100-piece jigsaw puzzle. 2. Child's favorite doll. 3. Fuzzy stuffed animal. 4. Scissors, paper, and paste.
29. 2. The child's favorite doll would be a good choice of toys. The doll provides support and is familiar to the child. Although a 3-year-old may enjoy puzzles, a 100-piece jigsaw puzzle is too complicated for an ill 3-year -old child. In view of the child's lung pathology, a fuzzy stuffed animal would not be advised because of its potential as a reservoir for dust and bacteria, possibly predisposing the child to additional respiratory problems. Scissors, paper, and paste are not appropriate for a 3-year-old unless the child is supervised closely.
4. After teaching the parents of a preschooler who has undergone a tonsillectomy and adenoidectomy about appropriate foods to give the child after discharge, which of the following, if stated by the parents as appropriate foods, indicates successful teaching? 1. Meat loaf and uncooked carrots. 2. Pork and noodle casserole. 3. Cream of chicken soup and orange sherbet. 4. Hot dog and potato chips.
4. 3. For the first few days after a tonsillectomy and adenoidectomy, liquids and soft foods are best tolerated by the child while the throat is sore. Children typically do not chew their food thoroughly , and solid foods are to be avoided because they are difficult to swallow. Although meat loaf would be considered a soft food, uncooked carrots would not be. Pork is frequently difficult to chew. Foods that have sharp edges, such as potato chips, are contraindicated because they are hard to chew and may cause more throat discomfort.
41. The nurse begins CPR on a 5-year-old unresponsive client. When the emergency response team arrives, the child continues to have no respiratory effort but has a heart rate of 50 with cyanotic legs. The team should next: 1. Discontinue compressions but continue administering breaths with a bag-mask device. 2. Establish an intravenous line with a large bore needle while preparing the defibrillator. 3. Begin 2-person CPR at a ratio of 2 breaths to 15 compressions. 4. Begin 2-person CPR at a ratio of 2 breaths to 30 compressions.
41. 3. CPR is done on children for heart rate of less than 60 with signs of poor perfusion. Rescuers should use a 15: 2 compression to ventilation ratio for 2-rescuer CPR for a child. Breaths without compressions are indicated only for respiratory arrests where the heart rate remains above 60. The AED/ defibrillator should be used as soon as it is ready, but rescuers should not discontinue compressions until the device is ready for use. The ratio for 2-person CPR in adults is 30: 2.
42. As part of a health education program, the nurse teaches a group of parents CPR. The nurse determines that the teaching had been effective when a parent states: 1. "If I am by myself , I should call for help before starting CPR." 2. "I should compress the chest using 2 to 3 fingers." 3. "I should deliver chest compression at a rate of 100 per minute." 4. "If I can't get the breaths to make the chest rise, I should administer abdominal thrusts."
42. 3. To maintain the best perfusion, it is recommended that compressions be given at a rate of 100 per minute in a ratio of 30 compressions to 2 breaths for 1-rescuer CPR. Children still are more likely to have had a respiratory arrest than a cardiac arrest and are more likely to respond to opening the airway and rescue breaths. Therefore, it is recommended that unless the collapse was witnessed , a sole rescuer should attempt 5 cycles of CPR before leaving to call for help. Using 2 to 3 fingers for chest compressions is recommended for infant CPR only . Abdominal thrusts are no longer recommended for unconscious victims.
36. When planning a visit to the parents of an infant who died of sudden infant death syndrome (SIDS) at home, the nurse should visit the parents at which of the following times? 1. A few days after the funeral. 2. Two weeks after the funeral. 3. As soon as the parents are ready to talk. 4. As soon after the infant's death as possible.
36. 4. The community health nurse should visit as soon after the death as possible, because the parents may need help to deal with the sudden, unexpected death of their infant. Parents often have a great deal of guilt in these situations and need to express their feelings to someone who can provide counseling.
62. A 12-year -old with cystic fibrosis is being treated in the hospital for pneumonia. The primary care provider is calling in a telephone prescription for ampicillin. The nurse should do which of the following? Select all that apply. 1. Ask the unit clerk to listen on the speaker phone with the nurse and write down the prescription. 2. Ask the primary care provider to come to the hospital and write the prescription on the chart. 3. Repeat the prescription to the primary care provider. 4. Ask the primary care provider to confirm that the prescription is correct as understood by the nurse. 5. Ask the nursing supervisor to cosign the telephone prescription as transcribed by the nurse.
62. 3, 4. To ensure client safety in obtaining telephone prescriptions, the prescription must be received by a registered nurse. The nurse should write the prescription , read the prescription back to the primary care provider, and receive confirmation from the primary care provider that the prescription is correct. It is not necessary to ask the unit clerk to listen to the prescription, to require the primary care provider to come to the hospital to write the prescription on the chart, or to have the nursing supervisor cosign the telephone prescription.
60. The nurse is preparing to administer the last dose of ceftriaxone (Rocephin) before discharge to a 1-year-old but finds the IV has occluded. The nurse should: 1. Restart the IV. 2. Administer the medication intramuscularly. 3. Arrange for early discharge. 4. Contact the prescriber to request a prescription change.
60. 4. Restarting an IV for one dose of a medication may not be in the infant's best interest when the medication can be given in an alternate form. The prescriber should be contacted to determine IM or PO options. Rocephin may be given IM, but changing the route of a medication administration requires a prescription. Failing tocomplete an entire course of antibiotics contributes to the emergence of antibiotic resistance and would rarely be the best option.
43. When performing cardiopulmonaryresuscitation (CPR), which of the following indicates that external chest compressions are effective? 1. Mottling of the skin. 2. Pupillary dilation. 3. Palpable pulse. 4. Cool, dry skin.
43. 3. With CPR, effectiveness of external chest compressions is indicated by palpable peripheral pulses, the disappearance of mottling and cyanosis, the return of pupils to normal size, and warm, dry skin. To determine whether the victim of cardiopulmonary arrest has resumed spontaneous breathing and circulation, chest compressions must be stopped for 5 seconds at the end of the first minute and every few minutes thereafter.
58. A teaching care plan to prevent the transmission of respiratory syncytial virus (RSV) should include which of the following? Select all that apply.1. The virus can be spread by direct contact. 2. The virus can be spread by indirect contact. 3. Palivizumab (Synagis) is recommended to prevent RSV for all toddlers in day care. 4. The virus is typically contagious for 3 weeks. 5. Older children seldom spread RSV. 6. Frequent handwashing helps reduce the spread of RSV.
58. 1, 2, 6. RSV can be spread through direct contact such as kissing the face of an infected person, and it can be spread through indirect contact by touching surfaces covered with infected secretions . Handwashing is one of the best ways to reduce the risk of disease transmission. Palivizumab can prevent severe RSV infections but is only recommended for the most at-risk infants and children. RSV is typically contagious for 3 to 8 days. RSV frequently manifests in older children as cold-like symptoms. Infected school-age children frequently spread the virus to other family members.
1. The nurse is inspecting the child's throat (see figure). The nurse should: 1. Remove the tongue blade from the child's hands after he has experienced what it feels like in his mouth. 2. Ask the child to hold the tongue blade with both hands in his lap while the nurse uses another tongue blade. 3. Have the parent hold the child with arms restrained. 4. Guide the tongue blade while the child is holding it to depress the tongue to visualize the throat.
1. 4. If the child does not stick out his tongue so the nurse can visualize the throat, it is appropriate to use a tongue blade. Having the child participate by holding the tongue blade while the nurse guides it to facilitate visualization of the throat is appropriate technique. It is not useful to remove the tongue blade or have the child hold it because the nurse will need to use the tongue blade to depress the tongue. It is preferable to engage the child's cooperation before asking the parent to restrain the child.
17. A 10-year-old child who is 5′ 4″ (138 cm) tall with a history of asthma uses an inhaled bronchodilator only when needed. He/ she takes no other medications routinely. His/ her best peak expiratory flow rate is 270 L/ min. The child's current peak flow reading is 180 L/ min. The nurse interprets this reading as indicating which of the following? 1. The child's asthma is under good control, so the routine treatment plan should continue. 2. The child needs to use his/ her short-acting inhaled beta2-agonist medication. 3. This is a medical emergency requiring a trip to the emergency department for treatment.4. The child needs to use his /her inhaled cromolyn sodium (Intal).
17. 2. The peak flow of 180 L/ min is in the yellow zone, or 50% to 80% of the child's personal best. This means that the child's asthma is not well controlled, thereby necessitating the use of a short-acting beta2-agonist medication to relieve the bronchospasm. A peak flow reading greater than 80% of the child's personal best (in this case, 220 L/ min or better) would indicate that the child's asthma is in the green zone or under good control. A peak flow reading in the red zone, or less than 50% of the child's personal best (135 L/ min or less), would require notification of the health care provider or a trip to the emergency department. Cromolyn sodium (Intal) is not used for short-term treatment of acute bronchospasm. It is used as part of a long-term therapy regimen to help desensitize mast cells and thereby help to prevent symptoms.
18. An adolescent with chest pain goes to the school nurse . The nurse determines that the teenager has a history of asthma but has had no problems for years. Which of the following should the nurse do next? 1. Call the adolescent's parent. 2. Have the adolescent lie down for 30 minutes. 3. Obtain a peak flow reading. 4. Give two puffs of a short-acting bronchodilator.
18. 3. Problems of chest pain in children and adolescents are rarely cardiac . With a history of asthma, the most likely cause of the chest pain is related to the asthma. Therefore, the nurse should check the adolescent's peak flow reading to evaluate the status of the air flow. Calling the adolescent's parent would be appropriate, but this would be done after the nurse obtains the peak flow reading and additional assessment data. Having the adolescent lie down may be an option, but more data need to be collected to help establish a possible cause. Because the adolescent has not experienced any asthma problems for a long time, it would be inappropriate for the nurse to administer a short-acting bronchodilator at this time.
2. The nurse has identified a problem of anxietyfor a 4-year-old preparing for a tonsillectomy. The nurse should tell the child: 1. "You won't have so many sore throats after your tonsils are removed." 2. "The doctor will put you to sleep so you don't feel anything." 3. "Show me how to give the doll an IV." 4. "When it is done you will get to see your mommy and get a Popsicle."
2. 4. When preparing a child for a procedure the nurse should use neutral words, focus on sensory experiences, and emphasize the positive aspects at the end. Being reunited with parents and having an ice pop would be considered pleasurable events. Children this age fear bodily harm. To reduced anxiety, the nurse should use the word "fixed" instead of "removed" to describe what is being done to the tonsils. Using the terms "put to sleep" and "IV" maybe threatening. Additionally, directing a play experience to focus on IV insertion may be counterproductive as the child may have little recollection of this aspect of the procedure.
3. After a tonsillectomy and adenoidectomy, which of the following findings should alert the nurse to suspect early hemorrhage in a 5-year-old child? 1. Drooling of bright red secretions. 2. Pulse rate of 95 bpm. 3. Vomiting of 25 mL of dark brown emesis. 4. Blood pressure of 95/ 56 mm Hg.
3. 1. After a tonsillectomy and adenoidectomy, drooling bright red blood is considered an early sign of hemorrhage. Often, because of discomfort in the throat, children tend to avoid swallowing; instead , they drool . Frequent swallowing would also be an indication of hemorrhage because the child attempts to clear the airway of blood by swallowing. Secretions may be slightly blood-tinged because of a small amount of oozing after surgery. However, bright red secretions indicate bleeding. A pulse rate of 95 bpm is within the normal range for a 5-year-old child, as is a blood pressure of 95/ 56 mm Hg. A small amount of blood that is partially digested , and therefore dark brown, is often present in postoperative emesis.
35. Parents bring their child to the emergency department because the child has stopped breathing. A nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which of the following questions should the nurse ask the parents first? 1. "Was the infant sleeping while wrapped in a blanket?" 2. "Was the infant lying on his stomach?" 3. "What did the infant look like when you found him?" 4. "When had you last checked on the infant?"
35. 3. Because this is an especially disturbing and upsetting time for the parents, they must be approached in a sensitive manner. Asking what the infant looked like when found allows the parents to verbalize what they saw and felt, thereby helping to minimize their feelings of guilt without implying any blame, neglect, wrongdoing, or abuse. Asking if the child was wrapped in a blanket or lying on his stomach, or when the parents last checked on the infant, implies that the parents did something wrong or failed in their care of the infant, thus blaming them for the event.
37. When developing the ongoing plan of care for the parents whose infant died of sudden infant death syndrome ( SIDS), the nurse should plan to accomplish which of the following on the second home visit? 1. Allow the parents to express their feelings. 2. Have the parents gain an understanding of the disease. 3. Assess the impact of the infant's death on their other children. 4. Deal with issues such as having other children.
37. 1. The goal of the second home visit is to help the parents express their feelings more openly. Manyparents are reluctant to express their grief and need help. The goal of the first visit is to help the parents understand the disease and what happened. The first visit also provides time to help the parents understand that they are not to blame. Although it is important to assess the impact of SIDS on siblings, this is not the primary goal for the second visit . However, the nurse must be flexible in case problems involving this area arise. Typically, parents are unable to deal with decisions such as having other children during the second visit because they are grieving for the child that they lost. This topic may be discussed later in the course of care.
64. A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with the recommendation for:1. Starting oxygen. 2. Providing sedation. 3. Transferring to PICU. 4. Prescribing a chest CT scan.
64. 1. The infant is experiencing signs and symptoms of respiratory distress indicating the need for oxygen therapy. Sedation will not improve the infant's respiratory distress and would likely cause further respiratory depression. If the infant's respiratory status continues to decline, she may need to be transferred to the PICU. Oxygen should be the priority as it may improve the infant's respiratory status. A chest CT is not indicated. However, a CXR would be another appropriate recommendation for this infant.
5. A nurse is teaching the parents of a preschooler about the possibility of postoperative hemorrhage after a tonsillectomy and adenoidectomy. The nurse should explain that the risk is greatest at which of the following times? 1. 1 to 3 days after surgery. 2. 4 to 6 days after surgery. 3. 7 to 10 days after surgery. 4. 11 to 14 days after surgery.
5. 3. The risk of hemorrhage from a tonsillectomy is greatest when the tissue begins sloughing and the scabs fall off. This typically happens 7 to 10 days after a tonsillectomy.
22. An 8-year-old child with asthma states, "I want to play some sports like my friends. What can I do?" The nurse responds to the child based on the understanding of which of the following? 1. Physical activities are inappropriate for children with asthma. 2. Children with asthma must be excluded from team sports. 3. Vigorous physical exercise frequently precipitates an asthmatic episode. 4. Most children with asthma can participate in sports if the asthma is controlled.
22. 4. Physical activities are beneficial to asthmatic children, physically and psychosocially. Most children with asthma can engage in school and sports activities that are geared to the child's condition and within the limits imposed by the disease. The coach and other team members need to be aware of the child's condition and know what to do in case an attack occurs. Those children who have exercise-induced asthma usually use a short-acting bronchodilator before exercising.
50. The father of a 16-month-old child calls the clinic because the child has a low-grade fever, cold symptoms, and a hoarse cough. Which of the following should the nurse suggest that the father do? 1. Offer extra fluids frequently.2. Bring the child to the clinic immediately. 3. Count the child's respiratory rate. 4. Use a hot air vaporizer.
50. 1. The toddler is exhibiting cold symptoms. A hoarse cough may be part of the upper respiratory tract infection. The best suggestion is to have the father offer the child additional fluids at frequent intervals to help keep secretions loose and membranes moist. There is no evidence presented to suggest that the child needs to be brought to the clinic immediately. Although having the father count the child's respiratory rate may provide some additional information, it may lead the father to suspect that something is seriously wrong, possibly leading to undue anxiety . A hot air vaporizer is not recommended. However, a cool mist vaporizer would cause vasoconstriction of the respiratory passages , making it easier for the child to breathe and loosening secretions.
31. Which of the following outcome criteria would the nurse develop for a child with cystic fibrosis who has ineffective airway clearance related to increased pulmonary secretions and inability to expectorate? 1. Respiratory rate and rhythm within expected range. 2. Absence of chills and fever. 3. Ability to engage in age-related activities. 4. Ability to tolerate usual diet without vomiting.
31. 1. After treatment, the client outcome would be that respiratory status would be within normal limits , as evidenced by a respiratory rate and rhythm within expected range. Absence of chills and fever, although related to an underlying problem causing the respiratory problem (eg, the infection), do not specifically relate to the respiratory problem of ineffective airway clearance . The child's ability to engage in age-related activities may provide some evidence of improved respiratory status. However, this outcome criterion is more directly related to activity intolerance. Although the child's ability to tolerate his or her usual diet may indirectly relate to respiratory function, this outcome is more specifically related to an imbalanced nutrition that may or may not be related to the child's respiratory status. CN: Physiological adaptation; CL: Evaluate
32. A school-age child with cystic fibrosis asks the nurse what sports she can become involved in as she becomes older. Which of the following activities would be appropriate for the nurse to suggest? 1. Swimming. 2. Track. 3. Baseball. 4. Javelin throwing.
32. 1. Swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport. Because track events, baseball , and javelin throwing usually are performed outdoors, the child would be breathing in large amounts of dust and dirt, which would be irritating to her mucous membranes and pulmonary system. The strenuous activity and increased energy expenditure associated with track events, in conjunction with the dust and possible heat, would play a role in placing the child at risk for an upper respiratory tract infection and compromising her respiratory function.
33. When explaining to parents how to reduce the risk of Sudden Infant Death Syndrome (SIDS) the nurse should teach about which of the following measures? Select all that apply. 1. Maintain a smoke-free environment. 2. Use a wedge for side-lying positions. 3. Breast-feed the baby. 4. Place the baby on his back to sleep. 5. Use bumper pads over the bed rails. 6. Have the baby sleep in the parent's bed.
33. 1, 3, 4. Exposure to environmental tobacco increases the risk for SIDS. Sleeping on the back and breast-feeding both decrease the risk of SIDS. Theside-lying position is not recommended for sleep. It is recommended that babies be dressed in sleepers and that cribs are free of blankets, pillows, bumper pads, and stuffed animals. Co- bedding with parents is not recommended as parents may roll on the child.
38. A child has just ingested about 10 adult-strength acetaminophen (Tylenol) pills. The mother brings the child to the emergency department. What should the nurse do? Place the interventions in the order of priority from first to last. 1. Administer activated charcoal. 2. Assess the airway. 3. Reassure the mother. 4. Check serum acetaminophen levels. 5. Obtain a history of the incident. 6. Complete a physical examination.
2. Assess the airway. 1. Administer activated charcoal. 3. Reassure the mother. 6. Perform a physical exam. 5. Obtain a history of the incident. 4. Check serum acetaminophen levels.Immediate care of the child who has ingested acetaminophen is to ensure airway, breathing, and circulation. Next, the nurse should administer activated charcoal. Acetylcysteine (Mucomyst) may also be used as an antidote. When the child is stable, the nurse should reassure the mother. Next, the nurse should perform a physical exam to assess the child for other health problems, and then obtain further information about how the child obtained the aspirin. The serum acetaminophen level should be obtained 4 hours after ingestion.
21. After discussing asthma as a chronic condition, which of the following statements by the father of a child with asthma best reflects the family's positive adjustment to this aspect of the child's disease? 1. "We try to keep him happy at all costs; otherwise, he has an asthma attack." 2. "We keep our child away from other children to help cut down on infections." 3. "Although our child's disease is serious, we try not to let it be the focus of our family."4. "I'm afraid that when my child gets older, he won't be able to care for himself like I do."
21. 3. Positive adjustment to a chronic condition requires placing the child's illness in its proper perspective. Children with asthma need to be treated as normally as possible within the scope of the limitations imposed by the illness. They also need to learn how to manage exacerbations and then resume as normal a life as possible . Trying to keep the child happy at all costs is inappropriate and can lead to the child's never learning how to accept responsibility for behavior and get along with others. Although minimizing the child's risk for exposure to infections is important , the child needs to be with his or her peers to ensure appropriate growth and developmentChildren with a chronic illness need to be involved in their care so that they can learn to manage it. Some parents tend to overprotect their child with a chronic illness. This overprotectiveness may cause a child to have an exaggerated feeling of importance or later, as an adolescent, to rebel against the overprotectiveness and the parents.
23. A 9-month-old child with cystic fibrosis does not like taking pancreatic enzyme supplement with meals and snacks. The mother does not like to force the child to take the supplement. The most important reason for the child to take the pancreatic enzyme supplement with meals and snacks is: 1. The child will become dehydrated if the supplement is not taken with meals and snacks. 2. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins. 3. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear. 4. The child will experience severe diarrhea if the supplement is not taken as prescribed.
23. 2. The child must take the pancreatic enzyme supplement with meals and snacks to help absorb nutrients so he can grow and develop normally. In cystic fibrosis, the normally liquid mucus is tenacious and blocks three digestive enzymes from entering the duodenum and digesting essential nutrients. Without the supplemental pancreatic enzyme, the child will have voluminous , foul, fatty stools due to the undigested nutrients and may experience developmental delays due to malnutrition. Dehydration is not a problem related to cystic fibrosis. The pancreatic enzymes have no effect on the viscosity of the tenacious mucus. Diarrhea is not caused by failing to take the pancreatic enzyme supplement.
59. A charge nurse is making assignments for a group of children on a pediatric unit. The nurse should most avoid assigning the same nurse to care for a 2-year-old with respiratory syncytial virus (RSV) and: 1. An 18-month-old with RSV. 2. A 9-year-old 8 hours post-appendectomy. 3. A 1-year-old with a heart defect. 4. A 6-year-old with sickle cell crisis.
59. 3. RSV may be spread through both direct and indirect contact . While contact and standard precautions should be employed, a measure to further decrease the risk of nosocomial infections is to avoid assigning the same nurse caring for an RSV client to a client at risk for infection. A private room is preferred, but if this is not an option the nurse should understand that children 2 years of age and younger are most at risk for RSV, especially if they have other chronic problems such as a heart defect. From an infection control perspective, pairing two clients with RSV is ideal. RSV infections are less likely to pose a serious problem in older children.
46. A 6-month-old infant has had a cardiac arrest and the rapid response team has been paged. The nurse arrives in the client's room and observes a licensed practical nurse (LPN) administering CPR to an infant (see figure). To assist the LPN with CPR, the nurse should: 1. Take over rescue breaths with a rate of 1 breath per 5 compressions using a bag-mask device while the LPN continues compressions. 2. Take over compressions using one hand whilethe LPN uses a mask device to administer rescue breaths. 3. Take over rescue breaths using a rate of 2 breaths per 15 compressions using a bag-mask device while the LPN delivers compressions. 4. Take over compressions at 80 compressions a minute while the LPN uses a bag-mask device to administer rescue breaths.
46. 2. The nurse should first obtain a bag-mask device and assist with CPR by giving breaths at 2breaths/ 15 compressions. The LPN is using correct technique by using two to three fingers on the chest to administer chest compressions. The encircling hand technique may also be used during two-person infant CPR. The heel of both hands is used for older children and adolescents. The compression rate is at least 100/ min.
30. Which of the following, if described by the parents of a child with cystic fibrosis (CF), indicates that the parents understand the underlying problem of the disease? 1. An abnormality in the body's mucus-secreting glands. 2. Formation of fibrous cysts in various body organs. 3. Failure of the pancreatic ducts to develop properly. 4. Reaction to the formation of antibodies against streptococcus.
30. 1. CF is characterized by a dysfunction in the body's mucus-producing exocrine glands. The mucus secretions are thick and sticky rather than thin and slippery. The mucus obstructs the bronchi , bronchioles, and pancreatic ducts. Mucus plugs in the pancreatic ducts can prevent pancreatic digestive enzymes from reaching the small intestine, resulting in poor digestion and poor absorption of various food nutrients. Fibrous cysts do not form in various organs. Cystic fibrosis is an autosomal recessive inherited disorder and does not involve any reactionto the formation of antibodies against streptococcus.
48. While the nurse is delivering abdominal thrusts to a 6-year-old who is choking on a foreign body, the child begins to cry. Which of the following should the nurse do next? 1. Tap or gently shake the shoulders. 2. Deliver back slaps. 3. Perform a blind finger sweep of the mouth. 4. Observe the child closely.
48. 4. Crying indicates that the airway obstruction has been relieved. No additional thrusts are needed. However, the child needs to be observed closely for complications, including respiratory distress. Tapping or shaking the shoulders is used initially to determine unresponsiveness in someone who appears unconscious. Delivering chest or back slaps could jeopardize the child's now-patent airway. Because the obstruction has been relieved, there is no need to sweep the child's mouth. Additionally, blind finger sweeps are contraindicated because the object may be pushed further back, possibly causing a complete airway obstruction.
49. A 3 -year-old is brought into the emergency department in her mother's arms. The child's mouth is open and she is drooling and lethargic. Her mother states that she became ill suddenly within the past 2 hours. What should the nurse do first? 1. Draw blood cultures for complete blood count. 2. Start an intravenous line. 3. Inspect the child's throat with a tongue blade. 4. Maintain the child in an undisturbed, upright position.
49. 4. This child is in severe respiratory distress with the potential for complete airway obstruction. The nurse should refrain from disturbing the child at this time to avoid irritating the epiglottis and causing it to completely obstruct the child's airway. The child may be intubated or undergo a tracheotomy. However, initially, the child should be kept as calm aspossible with as little disruption as possible. Any attempt to restrain the child, draw blood, insert an IV, or examine her throat could result in total airway obstruction.
44. A nurse walks into the room just as a 10-month-old infant places an object in his mouth and starts to choke. After opening the infant's mouth , which of the following should the nurse do next to clear the airway? 1. Use blind finger sweeps. 2. Deliver back slaps and chest thrusts. 3. Apply four subdiaphragmatic abdominal thrusts. 4. Attempt to visualize the object.
44. 2. The nurse should use mechanical force—back slaps and chest thrusts— in an attempt to dislodge the object. Blind finger sweeps are not appropriate in infants and children because the foreign body may be pushed back into the airway. Subdiaphragmatic abdominal thrusts are not used for infants aged 1 year or younger because of the risk of injury to abdominal organs. If the object is not visible when opening the mouth, time is wasted in looking for it. Action is required to dislodge the object as quickly as possible.
45. When preparing to deliver back slaps to an infant who is choking on a foreign body, in which of the following positions should the nurse position the infant? 1. Head down and lower than the trunk. 2. Head up and raised above the trunk. 3. Head to one side and even with the trunk lower than the head. 4. Head parallel to the nurse and supported at the buttocks.
45. 1. To deliver back slaps, the nurse should place the infant face down, straddled over the nurse's arm, with the head lower than the trunk and the head supported. This position, together with the back slaps, facilitates dislodgment and removal of a foreign object and minimizes aspiration if vomiting occurs . Placing the infant with the head up and raised above the trunk would not aid in dislodging and removing the foreign object. In addition, this position places the infant at risk for aspiration should vomiting occur . Placing the head to one side may minimize the risk of aspiration. However , it would not help with removal of an object that is dislodged by the back slaps. Placing the infant with the head parallel to the nurse and supported at the buttocks is more appropriate for burping the infant.
24. A client's diagnosis of cystic fibrosis was made 13 years ago, and he/ she has since been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive . Which nursing actions are most important initially?1. Placing the client on bed rest and prescribing a blood gas analysis. 2. Prescribing a high-calorie, high-protein, low-fat, vitamin-enriched diet and pancreatic granules. 3. Applying an oximeter and initiating respiratory therapy. 4. Inserting an IV line and initiating antibiotic therapy.
24. 3. Clients with cystic fibrosis commonly diefrom respiratory problems. The mucus in the lungs is tenacious and difficult to expel, leading to lung infections and interference with oxygen and carbon dioxide exchange. The client will likely need supplemental oxygen and respiratory treatments to maintain adequate gas exchange, as identified by the oximeter reading. The child will be on bed rest due to respiratory distress. However, although blood gases will probably be prescribed, the oximeter readings will be used to determine oxygen deficit and are, therefore, more of a priority. A diet high in calories , proteins, and vitamins with pancreatic granules added to all foods ingested will increase nutrient absorption and help the malnutrition; however, this intervention is not the priority at this time. Inserting an IV to administer antibiotics is important, and can be done after ensuring adequate respiratory function.
34. Which one of the following children is at most risk for sudden infant death syndrome (SIDS)? 1. Infant who is 3 months old. 2. 2-year-old who has apnea lasting up to 5 seconds. 3. First-born child whose parents are in their early forties. 4. 6-month-old who has had two bouts of pneumonia.
34. 1. The highest incidence of SIDS occurs in infants between ages 2 and 4 months. About 90% of SIDS occurs before the age of 6 months. Apnea lasting longer than 20 seconds has also been associated with a higher incidence of SIDS. SIDS occurs with higher frequency in families where a child in the family has already died of SIDS, but the age of the parents has not been shown to contribute to SIDS. A respiratory infection such as pneumonia has not been shown to cause a higher incidence of SIDS.
25. A child with cystic fibrosis is receiving gentamicin. Which of the following nursing actions is most important? 1. Monitoring intake and output. 2. Obtaining daily weights. 3. Monitoring the client for indications of constipation. 4. Obtaining stool samples for hemoccult testing.
25. 1. Monitoring intake and output is the most important nursing action when administering an aminoglycoside, such as gentamicin, because a decrease in output is an early sign of renal damage. Daily weight monitoring is not indicated when the client is receiving an aminoglycoside. Constipation and bleeding are not adverse effects of aminoglycosides.
26. When developing the plan of care for a child with cystic fibrosis (CF) who is scheduled to receive postural drainage, the nurse should anticipate performing postural drainage at which of the following times? 1. After meals. 2. Before meals. 3. After rest periods. 4. Before inhalation treatments.
26. 2. Postural drainage, which aids in mobilizing the thick, tenacious secretions commonly associated with CF, is usually performed before meals to avoid the possibility of vomiting or regurgitating food . Although the child with CF needs frequent rest periods, this is not an important factor in scheduling postural drainage. However, the nurse would not want to interrupt the child's rest period to perform the treatment. Inhalation treatments are usually given before postural drainage to help loosen secretions.
27. When teaching the parents of an older infant with cystic fibrosis (CF) about the type of diet the child should consume, which of the following would be appropriate? 1. Low-protein diet. 2. High-fat diet. 3. Low-carbohydrate diet. 4. High-calorie diet.
27. 4. CF affects the exocrine glands. Mucus isthick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion and absorption, a high- calorie, high-protein, high-carbohydrate, moderate-fat diet is indicated.
