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Flashcards in Chapter 22 Deck (16):

The nurse needs to give an injection to a 4-year-old in the deltoid muscle. Based on the nurse’s knowledge of preschool development, the most appropriate approach by the nurse is to
a. smile while giving the injection to help the child relax.
b. the child that you will be so quick, the injection won't even hurt.
c. explain that child will experience "a little stick in the arm."
d. explain with concrete terms such as "putting medicine under the skin."

Ans: D
By using concrete terms, the nurse helps the child understand what the nurse is going to do.
Facial expressions are too abstract. The young child will not correlate a smile with relaxation. Distraction techniques are more appropriate.
The nurse does not know that the injection will not hurt the child. Lying or distorting the truth is never appropriate. This response will block trust, especially if the injection does hurt the child.
The child may visualize an actual stick being placed in the arm. Children at this age are very literal.


The nurse needs to take the blood pressure of a preschooler for the first time. What action would be best for gaining the child’s cooperation?
a. Take the blood pressure when a parent is there to comfort the child.
b. Tell the child that this procedure will help the child to get well faster.
c. Explain to the child how blood flows through the arm and why taking the blood pressure is important.
d. Permit the child to handle equipment and see the dial move before putting the cuff in place.

Ans: D
The best approach for a preschooler is to allow the child to play out the experience ahead of time, thereby decreasing the child’s anxiety.
The parent's presence will be helpful, but it will not alleviate fear of the unknown.
Telling a child that the procedure will help the child to get well faster is not a true statement, and the child will not be able to understand the relationship between the blood pressure and feeling better.
The explanation of how blood pressure is determined physiologically is too complex an explanation for this age group.


It is time to give a 3-year-old medication. What approach is most likely to receive a positive response from the child?
a. "It's time for your medication now. Would you like water or apple juice afterward?"
b. "Wouldn't you like to take your medicine now?"
c. "You must take your medicine because the doctor says it will make you better."
d. "See how nicely your roommate took medicine? Now take yours."

Ans: A
This statement provides the child with a structured choice with two acceptable options, which is important for preschoolers.
As a question, it allows the child the option of saying no and therefore should be avoided.
The statement "you must" can elicit negative behavior from the child. The nurse is also abdicating responsibility to the physician by telling the child, "The doctor said…."
Competition is not appropriate for this age group. What one child does or how one child acts should not be used to entice another child to do something, such as taking a medication.


When should clear liquids be stopped before scheduled surgery?
a. 2 hours before surgery
b. 6 hours before surgery
c. Varies according to the surgical procedure to be done
d. The night before surgery, at midnight

Ans: C
Each surgical procedure may have a different requirement for when nothing by mouth (NPO) status should be initiated. The nurse should follow the surgeon’s or anesthesiologist's order as to when clear liquids should be stopped.
Although 2 hours before surgery is a common time for stopping clear liquids to reduce the risk of pulmonary aspiration in healthy patients, the timing may vary. Therefore, it should be clarified with the surgeon or anesthesiologist.
Although a 6-hour time frame is often used for stopping milk and milk products before surgery, the timing may vary. Therefore, it should be clarified with the surgeon or anesthesiologist.
Stopping clear liquids by midnight may be too long a period before surgery. Therefore, the timing should be clarified with the surgeon or anesthesiologist.


The nurse is doing preoperative teaching with a child and the parents. The parents say the child “is dreading the shot for before surgery.” On which of the following facts should the nurse's response be based?
a. Preanesthetic medication can only be given intramuscularly.
b. In children, the intramuscular (IM) route is safer than the intravenous (IV) route.
c. The child will have no memory of the injection because of amnesia.
d. Preanesthetic medication should be "atraumatic," using oral, existing IV, or rectal routes.

Ans: D
The necessity of premedication is being investigated. If necessary, numerous drug regimens and routes exist; the route is not limited to the IM route.
Preanesthetic medicines can be given in a variety of routes other than intramuscularly.
The IV route is preferable to the IM route for premedication.
The muscle may be sore after the injection. Therefore, the child may have a memory, and telling the child otherwise will create distrust between the nurse and the child or family.


A 10-year-old child requires daily medications for a chronic illness. The mother tells the nurse that she is always nagging the child to take the medicine before school. The most appropriate nursing intervention to promote the child’s compliance is to
a. establish a contract with the child, including rewards.
b. suggest time-outs when the child forgets her medicine.
c. discuss with the child's mother the damaging effects of nagging.
d. ask the child to bring her medicine containers to each appointment so that the pills can be counted.

Ans: A
For school-age children, behavior contracting with desirable rewards is an effective method of encouraging compliance.
Any forms of negative consequences, such as time-outs, should only be used if the behavioral contracting is not successful.
Although nagging is not an effective strategy, the nurse needs to assist the mother in problem solving.
The technique of counting pills may be tried if the contracting is not successful, but it sends a punitive signal to the child that may make the situation worse.


A child, age 7 years, is being treated at home and has a fever associated with a viral illness. The principal reason for treating the child’s fever is
a. relief of discomfort.
b. reassurance that illness is temporary.
c. prevention of secondary bacterial infection.
d. prevention of life-threatening complications.

Ans: A
The primary reason for treating a fever with pharmacologic (acetaminophen and ibuprofen) or environmental interventions is to relieve discomfort in a child with a viral illness.
Fever management does not provide reassurance that the illness is temporary.
Fever-reducing medications do not have antibacterial actions and may inhibit the fever-enhancing effects on the immune system.
Fever-reducing medications do not prevent life-threatening complications of viral illnesses.


Standard precautions for infection control include
a. gloves are worn anytime a patient is touched.
b. needles are capped immediately after use and disposed of in a special container.
c. gloves are worn to change diapers when there are loose or explosive stools.
d. masks are needed only when caring for patients with airborne infections.

Ans: C
Handling diapers with loose or explosive stools has the greatest risk for exposure to body substances.
Gloves are not indicated, unless there is potential for contact with body substances.
Needles should never be recapped. They should be immediately disposed of in a rigid, puncture-proof container.
Masks are a component of transmission-based precautions, not standard precautions.


The nurse is preparing a plan to teach a mother how to administer 11/2 teaspoons of medicine to her 6-month-old child. Based on the nurse’s knowledge of administering pediatric medications, the nurse teaches the parent to use a
a. household measuring spoon.
b. regular silverware teaspoon.
c. paper cup measure in 5-ml increments.
d. plastic syringe (without needle) calibrated in milliliters.

Ans: D
Plastic calibrated syringes, without a needle, offer the most accurate measurement for medication administration in the infant. The nurse should teach the mother to give the child 7.5 mL of the medication.
Household measuring spoons can be used if other, more precise devices are not available, but they are not the preferred method of medication administration for an infant.
Regular silverware teaspoons are not acceptable for medication administration, because household teaspoons vary greatly in size.
A paper cup marked with 5-mL increments does not contain calibration for the additional 2.5 mL that is needed for this infant's required dosage, and its use would therefore limit the accuracy of the dosage.


Several types of long-term central venous access devices are used in practice. The benefit of using a long-term central venous access device such as a Port-a-Cath is that
a. implanted devices are easy to use for self-administered infusions.
b. implanted devices do not require piercing the skin for access.
c. implanted devices do not require limiting regular physical activity, including swimming.
d. implanted devices cannot dislodge, even if child "plays" with the port site.

Ans: C
Because this device is totally implanted under the skin, there are no activity limitations for the child.
The implantable port has to be accessed with a special needle, making it difficult to self-administer infusions.
Because the implantable port is totally under the skin, a needle must be used to access the port; therefore, the skin must be pierced for access.
The implantable port site is under the skin, so the child cannot play with it.


The nurse observes erythema, pain, and edema at a child's intravenous (IV) infusion site with streaking along the vein. The nurse’s priority action is to
a. immediately stop the infusion.
b. check for a good blood return.
c. ask another nurse to check the IV site.
d. increase IV drip with normal saline for 1 minute and recheck.

Ans: A
Erythema, pain, and edema at an IV site describe an extravasation or infiltration. The IV must be stopped to prevent further damage to the child.
Blood return suggests that the IV catheter is still in the vein, but this does not address the immediacy of the assessment findings.
Reassessment of the IV site by another nurse can be done once the IV has been stopped, which is the priority based on the assessment findings.
The IV infusion should not be increased. It will add additional fluid to the child's tissue and could cause further damage.


The best explanation for using pulse oximetry on young children is that it
a. is noninvasive.
b. is better than capnography.
c. is more accurate than arterial blood gas measurements.
d. provides intermittent measurements of oxygen.

Ans: A
Pulse oximetry is a noninvasive method for determining oxygen saturation.
Capnography measures carbon dioxide exhalation. It does not reflect oxygen perfusion.
Pulse oximetry is less invasive and easier to test than arterial blood gases.
Pulse oximetry provides continuous or intermittent measurements of oxygen saturation.


The nurse is caring for an infant with a tracheostomy when accidental decannulation occurs. The nurse is unable to reinsert the tube. What action should the nurse take next?
a. Notify the surgeon.
b. Perform oral intubation.
c. Try inserting a larger tracheostomy tube.
d. Try inserting a smaller tracheostomy tube.

Ans: D
A smaller tracheostomy tube should be available at the bedside at all times. Insertion of the smaller tube will keep the stoma open until further action can be taken.
Notification of the surgeon should be done after the emergent situation is handled.
Oral intubation is done if a tracheostomy tube cannot be inserted.
A larger tracheostomy tube would cause trauma to the trachea and, therefore, is not used.


A neonate had corrective surgery 3 days ago for esophageal atresia. The nurse notices that after gastrostomy feedings, there is often a backup of feeding into the tube. The most appropriate intervention by the nurse is to
a. position the child in a supine position after feedings.
b. position the child on the left side after feedings.
c. leave the gastrostomy tube open and suspended after feedings.
d. leave the gastrostomy tube clamped after feedings.

Ans: C
The formula is backing up into the tube because of delayed emptying. By keeping the tube open to air, it will prevent the buildup of pressure on the operative site and the subsequent backup of feeding into the tube.
The child should be positioned on the right side with the head elevated approximately 30 degrees after feeding.
The child should be positioned on the right side with the head elevated approximately 30 degrees after feeding.
Leaving the gastrostomy tube clamped after feedings will create pressure on the operative site and increase the risk of backup of the feedings.


Informed consent is valid when (Select all that apply)
a. universal consent is used
b. it is completed only for major surgery
c. a person is over the age of majority and competent
d. information is provided to make an intelligent decision
e. the choice exercised is free of force, fraud, duress, or coercion

Ans: C, D, E


When caring for a child with an intravenous (IV) infusion, the most appropriate nursing interventions are to (Select all that apply.)
a. use an infusion pump with a microdropper to ensure the prescribed infusion rate.
b. check IV fluids and infusion rate with another licensed professional.
c. avoid restraining the child to prevent undue emotional stress.
d. observe the insertion site frequently for signs of infiltration.
e. change the insertion site every 24 hours.

Ans: A, B, D