Pediatrics Chp 50-51

An unresponsive toddler is brought to the emergency department. Assessment reveals mottled skin color, respiratory rate of 10 breaths per minute, and a brachial pulse of 52 bpm. What is the priority nursing action?

• Prepare the defibrillator and draw up code medications.

• Provide 100% oxygen with a bag-valve-mask and start chest compressions.

• Start chest compressions and provide 100% oxygen via a nonrebreather mask.

• Begin an IV fluid infusion and administer epinephrine IV.

A 10-year-old child in respiratory distress requires intubation. Which sizes of endotracheal tubes will the nurse prepare?

• 9.5 mm and 10.0 mm

• 8.5 mm and 9.0 mm

• 6.0 mm and 6.5 mm

• 6.5 mm and 7.0 mm

A preschooler presents to the emergency department with a history of vomiting, diarrhea, and fever over the past few days. She is receiving 100% oxygen via a nonrebreather mask. Vital signs are temperature 104.5°F, pulse 144 bpm, respiratory rate 22 breaths per minute, and BP 70/50 mm Hg. She is listless and difficult to arouse and has weak peripheral pulses and prolonged capillary refill. What nursing intervention takes priority?

• Administering acetaminophen rectally for the high fever

• Administering IV antibiotics for the infection

• Preparing the child for endotracheal intubation

• Giving an IV bolus of normal saline 20 mL/kg

Assessment of a 12-year-old who crashed his bicycle without a helmet reveals the following: temperature 99.2°F, pulse 100 bpm, respiratory rate 24 breaths per minute with easy work of breathing, and BP 102/70 mm Hg. What is the priority action by the nurse?

• Assess neurologic status while observing for obvious injuries.

• Administer IV fluid bolus of normal saline at 20 mL/kg.

• Remove the cervical collar if he complains that it bothers him.

• Listen for bowel sounds while assessing for pain.

An 18-month-old child is brought to the emergency department via ambulance after an accidental ingestion. What is the priority nursing action?

• Take the child’s vital signs.

• Give oral syrup of ipecac.

• Insert a nasogastric tube.

• Start an IV line.

The nurse is caring for an infant with SVT who is symptomatic and has an IV line in place. The infant weighs 16½ lb. The medication order reads: adenosine 0.01 mg/kg IV STAT followed by rapid flush. Adenosine is supplied as 6 mg/2 mL. How many milliliters will the nurse administer? Round to the nearest hundredth.

The nurse is caring for a child with ADHD. Which behavior would the nurse not expect the child to display?

• Moody, morose behavior with pouting

• Interruption and inability to take turns

• Forgetfulness and easy distractibility

• Excessive motor activities and fidgeting

An adolescent girl who has been receiving treatment for anorexia nervosa has failed to gain weight over the past week despite eating all of her meals and snacks. What is the priority nursing intervention?

• Increase the teen’s daily caloric intake by at least 500 calories.

• Ensure that the teen’s entire fluid intake includes calories.

• Supervise the teen for 2 hours after all meals and snacks.

• Assess the teen’s anxiety level to determine need for medication.

A 15-year-old girl has been making demands all day, exaggerating her every need. She is now crying, saying she has nothing to live for and threatening to kill herself. What is the priority nursing action?

• Ignore her continued exaggerated and melodramatic behavior.

• Consult with the physician or nurse practitioner to increase her antidepressant dose.

• Leave the girl alone for a little while until she composes herself.

• Take the girl’s suicidal threat seriously and provide close supervision.

When trying to manage aggressive or impulsive behaviors in children or adolescents, what is the best nursing intervention?

• Train the child to be assertive.

• Provide consistency and limit setting.

• Allow the child to negotiate the rules.

• Encourage the child to express feelings.