PEDS: Chapter 13 Key Pediatric Nursing Interventions
The child weighs 47 pounds. How many kilograms does the child weigh? Record your answer using one decimal place.
21.4 There are 2.2 lb per kg. 47 lb x 1 kg/2.2 pounds = 21.363636 kg. When rounded to the tenths place, the answer is 21.4 kg. pg 376
The nurse is preparing to administer an oral dose of Reglan to a 5-year-old child who weighs 40 pounds. The order reads Metoclopramide (Reglan) 0.8 mg/kg/day to be given in 4 oral doses. How many milligrams of Reglan would you give per dose?
3.65 mg per dose The patient's weight in pounds must be converted to kilograms first: 40 divided by 2.2 equals 18.2 kilograms. Then multiply 0.8 mg by 18.2 kg, which equals 14.6 mg per day for the patient's weight. Divide 14.6 mg by 4, the number of doses each day, to arrive at 3.65 mg per dose. pg 377
The nurse has been caring for a 12-year-old boy during his five-day hospitalization. The child's IV has infiltrated, and the care provider is getting ready to change the intravenous line site. Which statement made by the nurse would be appropriate in supporting the child?
"The client is left-handed and likes to draw; an IV site in his right arm would be best." The staff nurse may serve as the child's advocate when the care provider comes to start an infusion. The staff nurse who has cared for the child has the child's confidence and knows the child's preferences. pg 391
The nurse is preparing to administer an intramuscular immunization to a 5-year-old child. What statement to the child is appropriate for inclusion in the preadministration period?
"This will help prevent you from getting sick." When providing teaching to a child it is important to be open, honest and provide developmentally appropriate information. Explaining that this will prevent later illness is something a child can understand. Saying that pain may result if movement occurs is a scare tactic and counterproductive. Yes, this is an immunization but this is terminology that is too complex for a child. Using the word "shot" is scary for the child and should not avoided if possible. pg 376
An infant 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 infant's vastus lateralis with a 25-gauge needle. The vastus lateralis site is a safe choice for IM injections in an infant. A 25-gauge needle is recommended for infants. The dorsogluteal site should not be used until the child has been walking for one year. The deltoid muscle is not a recommended IM site for infants. pg 384
The nurse is caring for a child with an intravenous device in his hand. Which sign would alert the nurse that infiltration is occurring?
Cool, puffy skin Signs of infiltration included cool, puffy, or blanched skin. Warmth, redness, induration, and tender skin are signs of inflammation. pg 393
The nurse administers an antipyretic rectal suppository. The child has a bowel movement 15 minutes later. What is the appropriate nursing action?
Examine the stool for the presence of the suppository. The stool should be examined for the suppository that may have been expelled with the bowel movement. If it is found, the physician or nurse practitioner can be notified to determine if the suppository should be repeated. The nurse should not administer another dose without examining the stool or contacting the physician or nurse practitioner. Rechecking the child's temperature would provide little useful information since only a very limited time has elapsed since the temperature was last checked.
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. pg 31
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 Obtaining a weight provides a base for calculating the fluid that will need to be replaced. NG 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. pg 392
The nurse is administering a PRN pain medication to a child. What is the highest priority for the nurse in this situation?
The nurse checks the last time the medication was given. 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 other choices are important but checking when and how much the child has had are the priorities.
The nurse is administering a tube feeding to a child. The nurse aspirates the stomach contents as part of the process for checking placement of the tube. Which action is correct for the nurse to do with the aspirated stomach contents?
The nurse should measure and replace the residual stomach contents. Aspirate, measure, and replace the residual stomach contents at the beginning of the procedure. pg 398
The nurse is administering a gavage feeding through a nasogastric feeding tube. Which nursing intervention is the highest priority?
The nurse verifies the position of the feeding tube. Verify position of tube to ensure that the tube is in the stomach by aspirating stomach contents is the highest priority because of the danger of aspiration if the tube is not in the stomach but rather in the esophagus or the lung. pg 397
A nurse is preparing to administer an ordered IM injection to an infant. The nurse knows that the most appropriate injection site for this child is which muscle?
Vastus lateralis The preferred injection site for infants is the vastus lateralis muscle. An alternative site is the rectus femoris muscle. The dorsogluteal is not a recommended site for the infant. The deltoid muscle, which is a small muscle mass, is used as an IM injection site in children after the age of 4 to 5 years of age due to the small muscle mass. pg 382
A nursing student is preparing to give an intramuscular (IM) injection to an infant. Which site does the nurse identify as mandatory for this administration?
Vastus lateralis muscle For IM injections in infants, the mandatory site for administration is the vastus lateralis muscle of the anterior thigh. Using the gluteal muscle is hazardous. The deltoid muscle is used for older children as well as for adults, or a ventrogluteal site should be used. pg382
To gain a preschooler's cooperation to swallow an oral medication, your best approach would be to:
ask if he would like to take his medicine in a cup or through an oral syringe. Ask if he would like to take his medicine in a cup or through an oral syringe. Medicine never should be compared to candy. Children cannot be depended on to take medicine without supervision; bribing is also ineffective. pg 378
A nursing instructor is teaching students the importance of understanding how drugs are absorbed, distributed, metabolized, and excreted. This concept is referred to as the study of:
pharmacokinetics The study of a drug's absorption, distribution, metabolism, and excretion is known as pharmacokinetics. pg 375
Apply adhesive bandages generously after venipuncture or finger punctures as young children find bandages comforting.
true Apply pressure to the site with a dry gauze dressing and then cover with a small adhesive bandage. If possible, allow the child to choose the bandage. pg 394
The nurse is showing the student nurse how to flush a pediatric client's peripherally inserted central catheter (PICC) line. The nurse prepares a 3-mL normal saline flush using a 5-mL syringe. The student asks the nurse why the flush was prepared this way. What is the most accurate response by the nurse?
"Using a larger-volume syringe exerts less pressure on the PICC line." Using a larger-volume syringe (i.e., 5 mL or larger) exerts less pressure on the PICC, thereby reducing the risk of rupture. pg 393
The nurse is caring for a child who weighs 31 kg. A medication is ordered for this child with a dosage range of 20 to 40 mg per kg of body weight per dose. Which dosage would be appropriate for the nurse to administer to this child in one dose?
1,000 mg per dose If a dosage range of 20 to 40 mg per kg of body weight is a safe dosage range and a child weighs 31 kg, the low dose of this medication would be 31 X 20 = 620. The high dose of this medication would be 31 X 40 = 1240. Therefore, a dose of 1,000 mg per dose would be appropriate.
A nurse is caring for a child who requires intravenous maintenance fluid. The child weighs 30 kg. Which is the child's daily maintenance fluid requirement?
1,700 mL The child's daily intravenous fluid maintenance is 1,700 mL. The child requires 100 mL/kg for the first 10 kg, plus 50 mL/kg for the next 10 kg, plus 20 mL/kg for each kg more than 20 kg. This equals the number of kg required for 24 hours. (10 x 100) + (10 x 50) + (10 x 20) = 1,700. pg 391-392
The adolescent weighs 113 lb (51.36 kg). The nurse closely monitors the child's urine output. How many milliliters of urine is the least amount that the adolescent should make during an 8-hour shift? Record your answer using a whole number
411 The child weighs 113 lb (51.36 kg). 51.36 kg x 1 mL/1 kg = 51.36 mL/hour. 51.36 x 8 hours = 410.90. Rounded to the nearest whole number = 411 mL
The nurse is caring for a 12-year-old post-appendectomy client who weighs 86 pounds. The child has a temperature of 38.5 ºC (101.3 ºF). The nurse prepares to give the client a dose of oral Tylenol. The order reads "Tylenol 15mg/kg/dose every 4 to 6 hours PO PRN for fever or pain." How many milligrams of Tylenol should the nurse give the client?
587 milligrams The child's weight must first be converted to kilograms by dividing 86 by 2.2. The result is 39.1 kilograms. Next, the 39.1 kilograms must be multiplied by 15 milligrams. This answer is 587 milligrams. pg 377
A 5-year-old girl is to receive long-term 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 Since PICC lines are typically inserted in the arm, parents and children may view this as more of a regular intravenous line and be more accepting of this. An intraosseous line is not a route for long-term administration.
The nurse is caring for a 7-year-old with a low-profile gastrostomy tube placed 6 months ago. Which is the priority intervention to prevent irritation of the skin at the insertion site?
Cleaning the surrounding skin with soap and water daily plus keeping the area dry Daily cleansing with soap and water and keeping the area dry are essential. Moisture can create irritation and encourage the growth of organisms in the warm, moist climate created. Alcohol can sting if used on the area plus remove protective skin oils, promoting excess drying, which can lead to skin breakdown. Cleaning under the bumper or disc with hydrogen peroxide is not recommended because it is irritating and damaging to skin cells. Rotating the gastrostomy tube or button daily is important to prevent adherence in the tract, but keeping the skin clean and dry is the priority. pg 399
A child is having difficulty swallowing pills. What is the best action for the nurse to take at this time to help this child swallow medications?
Put the pills in some ice cream or applesauce. A useful technique when children cannot swallow pills is to put them into some ice cream or applesauce. Do not use candy for practice, because you do not want to suggest that medicine is the same as candy. Never crush medications if it is contraindicated. The nurse should always administer a prescribed medication, even if doing so may be difficult. pg 378
Included in the nursing care plan for the child receiving total parenteral nutrition (TPN) will be which intervention?
Regularly monitoring the child's blood glucose Monitoring the blood glucose is important with TPN since the glucose content of the solution is high and can cause hyperglycemia. The need for a stool softener would be determined on an individual basis. Children receiving TPN may or may not be taking food and fluids orally. The catheter delivering the TPN solutions will be centrally placed to accommodate the concentrated TPN solution (larger vessel with more rapid blood flow). page 401
The nurse has finished completing a client education program for parents on proper medication administration to children. Which statement by a parent would indicate a need for further education?
"If my toddler won't swallow her medication, I will hold her nose until she has to swallow." Proper medication administration includes placing a pill in applesauce or ice cream to help a child learn how to swallow it. When giving medications to an infant or small child, always have them in an upright position to avoid aspiration. Allowing a toddler or preschooler to squirt medication into their own mouth. You should never force medication into a child's mouth or pinch their nose. This increases the risk for aspiration and interferes with developing a trusting relationship. pg 386
The nurse is caring for a 4-year-old who requires a venipuncture. To prepare the child for the procedure, which explanation is most appropriate?
"The doctor will look at your blood to see why you are sick." The nurse should provide a description of and reason for the procedure in age-appropriate language. The nurse should avoid the use of terms such as culture or strep throat as it is not age appropriate for a 4-year-old. The nurse should also avoid confusing terms like "take your blood" that might be interpreted literally. pg 390
A father believes his 2-year-old son is frightened by seeing an intramuscular (IM) medication injected into his thigh and requests that the child's "butt" be used. What will be the nurse's response?
"The muscle in his butt is not well enough developed to receive this injection until he has walked for 1 year." Muscle development follows use, and 1 year of walking allows for full development of the gluteus and less likelihood of injury to the sciatic nerve. Since most children do little walking at 12 months, it is not likely the child has been walking for a year. The other explanations do not address muscle development or are inaccurate statements. pg 382
A child needs a peripheral IV start as well as a venous blood sample for a laboratory test. The nurse will take what action?
Coordinate placing the peripheral IV and the lab blood draw. Coordinate the IV placement and lab blood draw to minimize the number of venipunctures for the child. Gaining venous access for each purpose separately does not do this and is not necessary. Having a well-hydrated child makes venous access easier, but oral hydration will take some time, thus delaying needed treatment. pg 390
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. pg 384
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 towards 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 patient's staple food to avoid an aversion to the food in the future. pg 379
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 nurse give 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 they feel the need to. pg 377
Prior to administering an intermittent tube feeding, which action should be performed?
Assess tube placement. Checking for tube placement is a priority before administering any intermittent tube feeding and periodically during continuous tube feedings, regardless of the type of tube being used. pg 398
The nurse is preparing a subcutaneous insulin injection for a preschooler. How and where should the nurse administer the insulin?
At a 45- to 90-degree angle into the elevated tissue of the upper arm Subcutaneous administration distributes medication into the fatty layers of the body. It is used for insulin administration. Preferred subcutaneous sites include anterior thigh, buttocks, upper arms, and abdomen. The rest of the sites are intramuscular ones and not appropriate for insulin administration. pg 384
Which assessment is the most important for determining an accurate dose of a pediatric medication?
Body surface area Body surface area (BSA) is the most accurate measure for dosing medications for children. In pediatrics, there are no standard amounts of a drug given per age; rather, dosage is based on weight using an established amount of the drug per body weight. Body mass index is not considered when determining pediatric medication dosing. pg 377
The nurse is preparing to administer an IV antibiotic to a child. After calculating the recommended dose with the child's weight, she discovers the ordered dose exceeds the safe dose range in a pediatric drug book. The medication has been given to the child at this dose for three days. What 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 child's medical background. pg 375
Immediately following administering a medication by enteral tube, the nurse will:
flush the tube with water. It is important to flush the tube to ensure all of the medication reaches the child's digestive tract and to prevent occlusion of the tube. Right (not left) side-lying position will aid in stomach emptying, although it was not specified that the enteral tube was located in the stomach. Elevating the head of the bed is done prior to placing material in the gastrointestinal tract. Checking for signs of nausea and vomiting is always important but not the immediately following nursing action in this situation. pg 398
The site most often used when administering a medication using the intradermal route is the:
forearm. Intradermal injections are most often used for tuberculosis screening and allergy testing. The forearm is the site most often used. The anterior thigh, lateral upper arms, and abdomen are the preferred sites for subcutaneous administration. pg 384
A 4-year-old child is admitted to the hospital for surgery. Before you administer medicine, the best way to identify the child would be to
read the child's armband. Children may answer to the wrong name to please an adult. For this reason, checking the armband is the best method to identify a child. pg 375
The nurse is educating the parents of a 5-month-old on how to administer an oral antibiotic. Which response indicates a need for further teaching?
"We can mix the antibiotics into his formula or food." Never mix a medication with formula or food. The child may associate the bitter taste with the food and later refuse to eat it. pg 387
A child is being discharged from the hospital and the nurse has completed discharge teaching regarding prescribed liquid medications. Which comments by the parent demonstrates understanding of discharge instructions for safe medication administration? Select all that apply.
"I need to make sure to use the medicine dropper the pharmacy gives me instead of the syringe I use for my B12 injections." "I shouldn't use a liquid dropper from my kitchen because it may be a different measurement than one from the pharmacy." "I will be sure to not give too much of the liquid medication at one time." Only droppers given by the pharmacy for the specific medication should be used. Different syringes may have different measurements than pediatric oral syringes. Mixing medication syringes is avoided if a dropper is packaged with a certain medication since the drop size may vary from one dropper to another. Giving small amounts of liquid avoids aspiration. Pinching the child's nose increases the risk for aspiration and interferes with the development of a trusting relationship.
A nurse has just given otic medication instructions to the parents of a 12-year-old. Which statement would indicate that the parents need further education concerning the medication?
"I will pull the outer ear down and back before administering the medication." The proper technique to instill ear drops involves pulling the outer 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. pg 381
The nurse is caring for a child who weighs 42 lbs. The medication ordered for the child has a therapeutic dosage range of 33 mg/kg per day to 48 mg/kg per day. The medication ordered is to be given three times a day. Which dosage would be appropriate for the nurse to administer to this child in one dose?
250 mg per dose One kilogram equals 2.2 lbs.; therefore, a child weighing 42 lbs. weighs 19 kg. The low dose of this medication would be 19 X 33 = 627 divided by three times a day equals 209 mg per dose. The high dose of this medication would be 19 X 48 = 912 divided by three times a day equals 304 mg per dose. Therefore, a dose of 250 mg per dose would be appropriate.
The nurse is calculating the urinary output for the infant. The infant's diaper weighed 40 grams prior to placing the diaper on the infant. After removal of the wet diaper, the diaper weighed 75 grams. How many milliliters of urine can the nurse document as urinary output? Record your answer using a whole number.
35 The diaper must be weighed before being placed on the infant and after removal to determine urinary output. For each 1 gram of increased weight, this is the equivalent of 1 milliliter of fluid. 75 grams - 40 grams = 35 grams = 35 mL pg 392
A nurse is caring for a child having an arm laceration sutured. What intervention can the nurse provide that will help the child not consider the procedure as a totally negative experience?
Allow the child to choose a treat from the drawer. Children given a treat or a small toy after an uncomfortable procedure tend to remember the experience as not totally bad. pg 402
The nurse is caring for a child with an ileostomy. What nursing intervention will be included in this child's plan of care?
Check for leakage around the stoma. An ileostomy is made by bringing a part of the small intestine through the abdominal wall to create an outlet for fecal material. The drainage from the ileostomy contains digestive enzymes, so the stoma must be fitted with a collection device to prevent skin irritation and breakdown. A colostomy is a similar opening in the colon that allows fecal material to be eliminated. A new colostomy may be left open to the air; alternatively a bag, pouch, or other appliance may be used to collect the stool. A urostomy may be created to help in the elimination of urine. Ostomy bags should be checked for leakage, emptied frequently, and changed when needed. pg 399
The pediatric nurse recognizes that what statement is true regarding medications administered via the intravenous route?
Giving medications through the intravenous route is less traumatic than other routes. Delivering medications intravenously is actually less traumatic than administering multiple intramuscular injections. pg 385
The nurse has prepared an IM injection to give a 13-year-old. After some searching, the nurse locates the 13-year-old in the playroom in front of a video game. Which action is the best one for the nurse to take?
Inform the child that it is time for an injection. Explain why the injection is needed and have him move to the procedure room. Explaining the reason for a medication is appropriate for a 13-year-old. The medication should not be given in the playroom. The playroom is a safe area for clients. Painful procedures should be done in a procedure 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. pg 377
To give eardrops to a 4-year-old, what would be the best technique to use?
Pull the pinna of the ear up and back. Pulling the pinna up and back straightens the ear canal in the child over 3 years of age. pg 381
The nurse is preparing to give a diphtheria, pertussis, and tetanus (DPT) immunization to a child in an acute care setting before discharge. The label on the DPT bottle indicates the immunization expired yesterday. What is the correct nursing action to take?
Return the bottle to the pharmacy and request a replacement. The expired immunization bottle should be returned to the pharmacy and a replacement should be requested. Never give expired medications. Simply discarding the bottle does not solve the problem and it is not necessary to inform the prescribing practitioner. pg 388
A client's mother informs the nurse that she has a hard time getting her 6-year-old son to take medication at home. Which would be the best suggestion for the nurse to offer this mother to help correct this problem?
Tell the mother to state firmly, "It's time for you to drink your medicine." The best guideline for the mother to help in getting a child to take his medication is to state firmly, "It's time to take your medication." Asking or pleading with the child does not work. Firmness is required. Adults also should never refer to medicine as candy. If a child happens to like a medicine, he or she may help themselves to it, and consuming too much can be fatal. pg 377
When administering medications to an infant, what information would be most important for the nurse to consider?
The oral medication should be directed toward the posterior side of the mouth when using a syringe or dropper. A syringe or dropper should be directed toward the posterior side of the mouth with the infant in the upright position when administering an oral medication. pg 379
A parent must administer a medication in syrup form to a 2-month-old infant. The nurse suggests:
placing the medicine in an empty nipple without an attached bottle The young infant should naturally and easily suck the medicine through an empty nipple, getting the entire dose. 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 is not developmentally ready for spoon feeding of rice cereal or medication from a medicine spoon.
A nurse is educating the parents how to administer daily oral medication to their 5-year-old boy. Which response indicates a need for further teaching?
"He needs to take his medicine or he will lose a privilege." The nurse should emphasize that the parents should never threaten the child in order to make him take his medication. It is more appropriate to develop a cooperative approach that will elicit the child's cooperation since he needs ongoing, daily medication. The other statements are correct. pg 387
A child who is receiving TPN has developed the need to have insulin injections. The child's mother questions thia and states that her child does not have diabetes. What is the appropriate response by the nurse?
"The feedings are high in sugar and insulin is needed to manage this." Glucose levels may be elevated when TPN is administered. While illness can impact serum glucose levels this is not an appropriate response. Telling the parent there is no need to worry minimizes concerns and is not a correct response. The child does not have diabetes but warrants insulin coverage.
The nurse is preparing to remove an IV device from the arm of a 6-year-old girl. Which approach is best for minimizing fear and anxiety?
"The first step is for you to help me remove this dressing from your IV." The nurse should explain what is to occur and enlist the child's help in the removal of the tape or dressing. This provides the child with a sense of control over the situation and also encourages his or her cooperation. The nurse should avoid using scissors to remove the tape or dressing and the comment regarding cutting may be perceived as threatening and/or frightening. Telling the child to be a big girl is inappropriate and does not teach. Telling the child the procedure will not hurt and using the terms tug and pinch could increase the child's fear and lead to misunderstanding. pg 393
A family the nurse is working with administers cycled total parenteral nutrition (TPN) over a 12-hour period at night to free their teenage son for activities during the day. In teaching this family, what areas would the nurse stress? Select all that apply.
Administering the solution at half-rate during the first and last hour of the infusion Inspecting the insertion site of the catheter regularly Infusing cycled TPN at half-rate during the first and last hour of the infusion prevents hyper- and hypoglycemia. Risk for infection is always present, and the insertion site needs regular care and inspection. TPN should be stored in the refrigerator and infused by pump (not gravity) for precise rate control. Weighing the teen twice daily is not necessary. Monitoring weight weekly is sufficient for most.
As the nurse prepares to administer a medication to a preschooler, she realizes that the child is extremely underweight for her age. What action would the nurse take?
Measure her height and weight, and check whether the dose is correct for her. Before any medicine is administered, it should be confirmed that the dose is correct for the child's weight and height because of the great variability in these areas. pg 376
The student nurse is preparing to care for a recently placed gastrostomy tube. Which action would prompt further instruction from the overseeing nurse?
The student obtains an antimicrobial soap to clean the area surrounding the tube. The skin around a gastrostomy tube requires cleaning at least once a day. Routine site care includes gentle cleansing with sterile water or saline for newly placed tubes, or for established tubes, soap and water followed by rinsing or cleaning with water alone. To clean under an external disc or bumper, a cotton-tipped applicator may be used.
The nurse is caring for a child who weighs 75 lb. The medication ordered for the child has a therapeutic dosage range of 33 mg/kg per day to 48 mg/kg per day. The medication ordered is to be given four times a day. Which dosages would be appropriate for the nurse to administer to this child in one dose?
375 mg per dose One kilogram equals 2.2 lb.; therefore, a child weighing 75 lb. weighs 34 kg. The low dose of this medication would be 34 X 33 = 1122 divided by four times a day equals 280.5 mg per dose. The high dose of this medication would be 34 X 48 = 1632 divided by four times a day equals 408 mg per dose. Therefore, a dose of 375 mg per dose would be appropriate. pg 377
The nurse is preparing to administer a PO medication to a 6-year-old in the hospital for an exacerbation of asthma. The nurse notes that the child is due for an oral dose of Prevacid in one hour. What is the most important action for the nurse to take before administering this medication to the client?
Clarify the order, since there is no apparent link between the client's diagnosis and the medication. There is no clear link between this client's diagnosis and the Prevacid administration. The nurse should clarify a medication order that does not have a clear link to the client's diagnosis before giving the medication. Asking the mother how she usually gives the medication is a good idea; however, it is not the priority nursing action in this scenario. Parental permission is not required to administer this medication. Consent to treat is signed upon admission to the hospital.
The nurse is assessing a child who is receiving TPN. The nurse determines the TPN bag was hung 24 hours ago. What initial action by the nurse is indicated?
Hang a new bag of TPN. TPN bags should not hang over 24 hours. The nurse should discontinue the current bag and hang a new one. There is no need to notify the physician. The rate of the TPN should never be changed without a physician's order. pg 401
The nurse is administering an oral liquid medication to a 5-year-old child. What would be the most appropriate for the nurse to do when administering this medication?
Let the child hold the medication cup. Medication cups and spoons can be used to administer liquid medications to the older child. The child can hold the medication cup and drink the liquid medication. pg 378
The nurse is administering medications to a 10-year-old girl who takes medications at home for a chronic condition. The child's mother is at the bedside. What are some guidelines for medication administration? Select all that apply.
The nurse compares the child's ID band with the medication record. The nurse reads the label on the side of the medication bottle. The nurse documents the medication administration after giving the medication. Check the drug label to confirm that it is the correct drug. Do not use a drug that is not clearly labeled. Check the identification bracelet each time that a medication is given to confirm identification of the client. Always double-check the dose by calculating the dosage according to the child's weight. Have another qualified person double-check any time that a divided dosage is to be given or for insulin, digoxin, and other agents governed by the facility's policy. Recording the administration of the medication, especially PRN medications, is critical to avoiding potential errors in medication administration.
An infant is to have a scalp-vein intravenous infusion begun. What is an advantage of this insertion site?
The scalp veins are easily visualized. The scalp veins are easily visualized, being covered only by a thin layer of subcutaneous tissue. These veins do not have valves, so the device may be inserted in either direction, although the preference would be in the direction of blood flow. pg 388
The nurse is caring for a 13-year-old boy with cystic fibrosis. The nurse prepares and verifies several medications and brings them and the medication administration record to the client's room. The nurse observes that the client is not wearing an identification band. Which action is the correct one for the nurse to take?
Ask the client to recall their name and date of birth. If the child does not have an identification band in place, the nurse must first identify the child before administering any medication. A parent should identify a baby or a younger child. Ask an older child his or her name and date of birth or other identifier. There is no need to notify the prescribing physician. Admitting may be called at a later time to obtain a new identification band. Locating another RN to identify the client is not necessary.
The nurse is preparing to administer medication to a 10-year-old who weighs 70 lb (32 kg). The prescribed single dose is 3 to 4 mg/kg per day. Which dose range is appropriate for this child?
96 to 128 mg The nurse should use the child's weight in kilograms. The nurse would then multiply the child's weight in kilograms by 3 mg (32 kg x 3 mg = 96 mg) for the low end and then by 4 mg for the high end (32 pounds x 4 mg = 128 mg). pg 377
The nurse is preparing to administer a vaccine to a 6-month-old child. The medication is to be given intramuscularly. The nurse is correct in choosing which administration site?
Vastus lateralis site The preferred injection site for infants less than 7 months old is the vastus lateralis muscle. In infants and children greater than 7 months old the ventrogluteal site should be considered. The dorsogluteal site, often used in adults, is not recommended in children younger than 5 years of age. The deltoid muscle may be used in a child older than 3 years of age. pg 382
