July APE Quizz

Which nursing interventions for a 16-year-old patient in the hospital for severe malnutrition and depression is the HIGHEST priority?

• Encourage patient to select nutrient-rich foods she likes

• Enlist the patient’s mother to sit with the patient to remind the patient not to get out of bed without assistance

• 
  Remind the patient to sit on the side of the bed for 3 minutes to allow blood pressure normalization prior to standing

• Make sure patient's cell phone is close by and fully charged

Answer explanation

ABC's come first!!!

Airway- no answer

Breathing- no answer

Circulation- Due to the patient’s nutrition and hydration status, the patient has orthostatic hypotension. To maintain adequate circulation to the brain, the nurse reminds the patient to sit on the side of the bed to allow for blood pressure normalization

Answer A and B are important but not the highest priority

A patient is intubated due to a sudden deterioration in respiratory status.

Arterial blood gases (ABG) post intubation are as follows:  
pH: 7.31  
pCO2: 50  
pO2: 80  
HCO3: 22  
O2 Sat: 95%  

This ABG reflects which of the following?

• 1. Respiratory acidosis 

• 2. Respiratory alkalosis 

• 3. Metabolic alkalosis 

• 4. Metabolic acidosis

Answer explanation

Rationale: The patient in this scenario demonstrates a pH2 less than 7.35 and CO2 greater than 45 mmHg, which reflects respiratory acidosis.

The nursing manager of the pediatric intensive care unit wants to provide patients with improved sleep and rest. Which intervention would have the greatest impact on promoting rest in this environment?

• A. Clustering care so nursing interruptions are limited
  

• B. Decreasing the noise in the unit, especially at night
  

• 
  C. Enforcing a 2-hour "quiet time" on each shift
  

• D. Turning off equipment alarms when children are sleeping

Answer explanation

B
Research shows that over half of all awakenings and arousals in intensive care unit patients are due to noise. To have the greatest impact on sleep and rest, the manager should work with staff to reduce the noise level on the unit, especially at night, so that normal sleep-wake cycles can be maintained as much as possible. Clustering care is a good idea to allow for some periods of uninterrupted rest and to decrease sensory overload from all sources, but may not always be practical and, even when done, will not have the same impact as overall noise reduction. A 2-hour "quiet time" may not provide all children with adequate rest and may be impossible to enforce. Turning off alarms is a dangerous practice and should not be done.

 

A 14-year-old male with osteosarcoma of the L femur is admitted for Cycle 2, day 22 of HD Methotrexate. The Methotrexate was hung at 1630 on Tuesday and came down at 2030. When should you retime his leucovorin rescue for? 

• 1. Wednesday 0000 

• 2.  Wednesday 2030 

• 3. Wednesday 1630 

• 4. Thursday 1030 

Answer explanation

To give the methotrexate time to act on cancer cells, but not long enough to damage healthy cells- leucovorin is typically administered 24 hours after the start of the methotrexate infusion for those getting HD-MTX for osteosarcoma

A child in the pediatric intensive care unit is alert and able to eat. The child's parent asks the nurse "Why do you keep feeding my child so much? I don't want her to become fat." Which response by the nurse is the most appropriate?

• A. "I understand your concerns and would be worried too."
  

• B. "She is undernourished and needs to gain some weight."
  

• C. "Very sick children need more nutrition for healing."
  

• D. "We are monitoring her intake and she won't get fat."

Answer explanation

C
The parent needs an objective, factual rationale for feeding the child what to the parent seems to be too much food. Critically ill children have higher metabolic rates and need more high-quality calories for healing. The nurse should not convey worry about the child's weight, nor should the nurse state that the child is malnourished unless that is the case. There is no information in the stem of the question that suggests this. Stating that the child won't get fat is playing into the parent's concern about weight without giving any objective reason for the increased intake.

What is the acronym for fire safety should you happen to come across a fire in the hospital?

Answer explanation

R- rescue

A- alarm

C- contain

E- extinguish or evacuate

A nurse is assessing a critically ill child's respiratory status. The child is grunting and has nasal flaring, but the pulse oximeter reads the child's oxygen saturation at 96%. Which nursing action is the priority in this situation?

• A. Conduct a thorough assessment and call the provider.
  

• B. Document the findings in the child's medical chart.
  

• C. Call a code
  

• 
  D. Turn up the oxygen and reassess the child in 30 minutes.

Answer explanation

A

Even though oxygen saturation is WNL, the WOB is severe enough to cause concern. The nurse should do a more complete assessment, including vital signs, and notify the provider. Documentation should be thorough, but the nurse needs to take further action. Depending on institutional policies, calling a code may not be necessary at this point. This child is too ill to just turn up the oxygen and reassess later.

A 17-year-old with a history of Ewing Sarcoma is admitted for Cycle 5 VCR. The patient’s Cyclophosphamide was administered at 1830 on Tuesday and ended at 1930 on Tuesday. When would you retime the patient’s mesna for? 

• 1. Tuesday 2330 & Wednesday 2330 

• 2. Tuesday 2230 & Wednesday 0230 

• 3. Tuesday 2330 & Wednesday 0330 

• 4. Tuesday 2230 & Wednesday 2330 

Answer explanation

Mesna is administered 4 hour and 8 hours post the COMPLETION of cyclophosphamide

Which of the following interventions can help alleviate symptoms of radiation recall? 

• 1. Liberal application of scented lotions 

• 2. Apply a cool, wet compress to affected area 

• 3. Wear tight fitting clothing 

• 4. Use of sunscreen with SPF 8 

Answer explanation

A cool compress can be a helpful way to manage pain associated with radiation recall. 

• Soothes inflammation: The cool temperature helps to calm down the inflammation in the skin caused by radiation recall.

• Reduces pain: It can provide a soothing effect and alleviate the discomfort associated with the reaction

With use of an opioid analgesic, when is it MOST important to monitor for the adverse effect of respiratory depression?

• A) when monitoring system detects signs of distress 
  

• 
  B) immediately following administration 
  

• 
  C) within 1 to 2 hours of administration 
  

• 
  D) while the child is sleeping

Answer explanation

While opioid induced respiratory depression can occur at any time, it is most likely to occur when the child is sleeping due to the decreased level of consciousness and the potential for the tongue to obstruct the airway.