Chapter 35: Caring for the Critically Ill Child Nursing School Test Banks

Chapter 35: Caring for the Critically Ill Child

MULTIPLE CHOICE

1. A nurse is working with a student in the pediatric intensive care unit. The student reports that a 3-year-old patient looks very anxious, and the parents report that this behavior is not normal for her and she seems disoriented. Which action suggested by the registered nurse is the most appropriate?
A. Assess the child for sensory overload.
B. Encourage the child to take a short nap.
C. Have the parents leave for a short break.
D. Plan age-appropriate diversionary activities.
ANS: A
Sensory overload is a common finding in the pediatric intensive care unit. Manifestations of this finding include lethargy, behavioral changes, disorientation, panic, withdrawal, hallucinations, fear, and anxiety. The student (and nurse) should assess the child for sensory overload. Regular sleep-wake cycles can help diminish stress, but a short nap would not alleviate these symptoms. Having the parents leave is not consistent with family-centered care. Diversionary activities are always appropriate for hospitalized children, but, again, will not diminish the symptoms.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

2. 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
ANS: 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.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Basic Care and Comfort
Integrated Process: Nursing Process: Application
Difficulty: Easy

PTS: 1

3. A nursing student asks how excessive noise and sensory overload could cause feelings of panic in hospitalized children. Which response by the registered nurse is the most appropriate?
A. Children are frightened by all the activity in the intensive care unit.
B. Excessive noise irritates the inner ear, which leads to behavior changes.
C. Its just the bodys natural way of dealing with unfamiliar stimuli.
D. Stimulation of the adrenal glands leads to secretion of stress hormones.
ANS: D
Sensory overload and excessive noise stimulate the adrenal glands, which secrete the stress hormones epinephrine and norepinephrine, leading to activation of the fight-or-flight response. This response can lead to feelings of panic. Children may well be frightened by all the activity in the unit, but this is not the best explanation. Excessive noise may well irritate the childs ears, but this does not lead to behavior problems. Stating that this is just the bodys natural way of dealing with stress does not provide any specific information.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

4. A pediatric intensive care nurse wants to practice in a way that helps reduce parents stress while their child is in the unit. Which action by the nurse would be most helpful?
A. Explain procedures to the parents first, then to the child.
B. Include the parents in all decisions and care activities.
C. Provide comprehensive discharge teaching in advance.
D. Round with physicians to ensure parents understanding.
ANS: B
Incorporating a family-centered approach to care is the best way to reduce stress and anxiety in the critically ill childs family. Involving the family in all decisions and care activities (if appropriate) is one of the most powerful ways of providing family-centered care. Comprehensive discharge teaching is a good nursing intervention, but not as important as including the family. Discharge teaching also cannot be done too far in advance. Rounding with physicians to ensure understanding is a great intervention, but is not as important as inclusion. Explaining procedures to the parents first, then to the child, may or may not be appropriate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

5. A nursing student asks a pediatric intensive care nurse why being bed-bound for several weeks would affect a young childs growth and development. Which response by the nurse is the most appropriate?
A. A child on bedrest has depression, slowing development.
B. Bedrest causes muscle weakness that limits activity.
C. Growth and development are highly connected to activity.
D. Isolation from peers has a negative effect on growth.
ANS: C
In all children, but especially younger ones, growth and development are tightly bound to activity and movement. Children who have their movement restricted for medical purposes often regress in their developmental stage. The other options are all part of this reaction, but do not explain the phenomenon as comprehensively as the correct option.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

6. A child in the pediatric intensive care unit is alert and able to eat. The childs parent asks the nurse Why do you keep feeding my child so much? I dont 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 wont get fat.
ANS: 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 childs 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 wont get fat is playing into the parents concern about weight without giving any objective reason for the increased intake.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Basic Care and Comfort
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

7. A child is hospitalized with anemia and critically low hemoglobin. The health-care provider orders a blood transfusion. The parents wont sign the consent form even though they have been told that without it, their child will die. What does the pediatric intensive care nurse understand about this situation?
A. Legally permissible to give the transfusion against the parents objections
B. Legally permissible to give the transfusion after getting an emergency court order
C. Not legally permissible to give the transfusion if both parents are in agreement
D. Not legally permissible to give the transfusion if the parents wont sign the consent
ANS: A
Under Section 24 of the Human Tissue Act 1982, a medical practitioner who gives a child a transfusion against the express wishes of the parents is not committing a criminal offense. The transfusion must be for a condition the child actually has, and it must be the case that without the transfusion the child will likely die.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

8. A nurse is assessing a critically ill childs respiratory status. The child is grunting and has nasal flaring, but the pulse oximeter reads the childs 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 childs medical chart.
C. Notify the rapid response team immediately.
D. Turn up the oxygen and reassess the child in 30 minutes.
ANS: A
The oxygen saturation does not correlate with the childs work of breathing. 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, notifying the rapid response team may be appropriate if the child needs further attention and the primary provider is not available. This child is too ill to just turn up the oxygen and reassess later.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

9. A child in the pediatric intensive care unit has a pulse oximeter for continuous oxygen saturation readings. Which action by the nurse is important for this patients safety?
A. Calibrate and zero the oximeter once per shift.
B. Ensure the machine stays plugged in at all times.
C. Have maintenance inspect the machine before use.
D. Move the oximeter probe to a new site each day.
ANS: D
The probe of a pulse oximeter uses infrared light, which can damage skin. The nurse should move the probe and inspect the skin underneath it per facility policy or at least once a day. Biomedical equipment has an inspection and maintenance schedule, and the nurse should not have to ask to have the machine inspected before use. Oximeters are not zeroed. The machine should stay plugged in whenever possible, but batteries allow for portability.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

10. A child in the emergency department has just undergone emergent intubation. When listening to lungs, the nurse notes absent sounds on the left side. What action by the nurse is the most appropriate?
A. Ask a more experienced provider to assess the child.
B. Facilitate completion of a portable chest x-ray.
C. Hyperoxygenate the patient and suction the airway.
D. Reposition the endotracheal tube and reassess.
ANS: D
Anatomical differences between the right and left bronchus can cause intubation of only the right main stem bronchus, leading to decreased oxygenation. If the nurse does not hear lung sounds on the left, this possibility should be considered, and the tube must be repositioned. The other actions will delay the childs receiving adequate oxygenation.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

11. A nurse is supervising a student who is suctioning a 5-year-old patient in the pediatric intensive care unit. Which action by the student results in the nurse intervening?
A. Auscultates lung sounds beforehand
B. Cleanses catheter after suctioning
C. Hyperoxygenates prior to suctioning
D. Sets suction pressure to 150 mm Hg
ANS: D
Suction pressure for a child is 110130 mm Hg. The nurse should intervene and have the student reduce the pressure before suctioning. The other options are correct actions.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

12. The staff in the pediatric intensive care unit is preparing to intubate a 3-year-old child. To facilitate intubation by providing skeletal muscle paralysis, which drug does the nurse anticipate administering?
A. Fentanyl citrate (Sublimaze)
B. Lorazepam (Ativan)
C. Pentobarbital sodium (Nembutol)
D. Vecuronium bromide (Norcuron)
ANS: D
Vecuronium bromide is a neuromuscular blocking agent that paralyzes skeletal muscles. Fentanyl is an opiate analgesic. Lorazepam is a benzodiazepam for sedation. Pentobarbital is a barbiturate, which provides sedation.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

13. A child is mechanically ventilated. Which assessment finding indicates that a priority goal is being met?
A. Enteral feeding tube present
B. PaCO2: 40 mm Hg
C. Intact skin integrity
D. Ventilator on control mode
ANS: B
The PaCO2 reading is normal, indicating that goals for the diagnosis of impaired gas exchange are being met. The presence of an enteral feeding tube indicates that goals for nutrition are being met, but this is not the priority over gas exchange. Maintaining intact skin is also an important goal, but is not a priority over gas exchange. Having the ventilator on control mode shows that breathing patterns are being maintained, but this does not give any information about the clinical status of the child.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Evaluation
Difficulty: Difficult

PTS: 1

14. Family members are visiting a child who is mechanically ventilated and heavily sedated. The parents are visibly distressed. Which statement from the nurse is most appropriate?
A. Her latest arterial blood gases show compensated acidosis.
B. Im glad you are here; let me get you some chairs to sit in.
C. She is so heavily sedated that she will not know if you are here or not.
D. You can talk to and touch your child to let her know you are here.
ANS: D
The distraught parents need to feel as if they are providing some comfort to their child but may be afraid to touch or talk to her for fear of causing complications. The nurse should let them know that this is not only alright to do, it is desirable and will help the child. The nurse should certainly provide information about the childs condition, but this amount of jargon given to distressed parents is not likely to be helpful. The nurse needs to provide comfort to them and give them an active role in caring for their child by touching and talking to her. Information like this can come later (and with less jargon). Getting the parents chairs and acknowledging their importance is kind and caring, but this statement relegates them to a passive role. The nurse does not know if the child can hear or if she will or will not be comforted by her parents touch, so the nurse should not tell the parents the child is too sedated to know if they are here.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

15. A child is being mechanically ventilated and is very agitated and fighting the ventilator despite receiving fentanyl citrate (Sublimaze) and midazolam (Versed). Which action by the nurse is the most appropriate?
A. Restrain the hands so child does not pull out the endotracheal tube.
B. Request an order for vecuronium bromide (Norcuron).
C. Slow the frequency and depth of mandatory ventilations.
D. Tell the family that someone must stay at the bedside.
ANS: B
After ensuring the child has adequate pain control and sedation, the next step would be to administer a neuromuscular blocking agent such as for vecuronium bromide (Norcuron). This will paralyze the childs skeletal muscles and reduce the agitation and fighting of the ventilator. Restraints may be necessary but should be used as a last resort. Changing ventilator settings is not appropriate for agitation control. Putting the responsibility of maintaining the childs airway on the family is a huge burden that may cause distress, and family members may not be able to stay at the bedside at all times.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

16. A child on a ventilator suddenly desaturates. Which nursing action is the priority?
A. Assess for displacement of the tube.
B. Assess for obstruction of the tube.
C. Ensure the ventilator is functioning properly.
D. Listen to lung sounds for pneumothorax.
ANS: A
When a mechanically ventilated patient suddenly desaturates (oxygen saturation drops), the nurse responds using the DOPE mnemonic (displaced tube, obstructed tube, pneumothorax, equipment problem). The most common cause is a displaced tube, so the nurse should assess this first.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

17. A mechanically ventilated adolescent has a RASS score of 3. The child is receiving pain medication and sedation by intravenous infusion. Which action by the nurse is the most appropriate?
A. Assess the child for uncontrolled pain.
B. Document findings and continue to monitor.
C. Increase the fentanyl (Sublimaze) infusion.
D. Suction the patient in case of tube obstruction.
ANS: B
A RASS score of 3 indicates moderate sedation, which would be appropriate for a child being mechanically ventilated. The nurse should document the findings and continue to monitor. This score does not indicate agitation, so uncontrolled pain should not be an issue. The fentanyl infusion does not need adjustment. There is no indication that the child needs to be suctioned.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Communication and Documentation
Difficulty: Difficult

PTS: 1

18. A mechanically ventilated 2-year-old child has copious oral secretions. What action by the nurse takes priority?
A. Assess placement of the endotracheal tube.
B. Clean and dry the skin around the mouth.
C. Raise the head of the childs bed to 60.
D. Suction the oral cavity every 2 hours.
ANS: A
Moisture can interfere with securing the endotracheal (ET) tube, especially if tape is used. The nurse should assess the placement of the tube and then clean and dry the skin. The oral cavity should be suctioned as often as needed. Raising the head of the bed will not decrease secretions (and may cause pooling of secretions in the childs mouth) and may lead to skin problems if the child slides down in bed frequently.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

19. The nurse has just repositioned a child who is intubated and mechanically ventilated. Which action by the nurse takes priority?
A. Assess placement of the endotracheal tube.
B. Document the condition of the childs skin.
C. Ensure that the child cannot pull on tubing.
D. Turn the ventilator alarms back on.
ANS: A
Repositioning is a common cause of endotracheal tube displacement. After turning the child, the nurse should assess the tube placement as the priority. Other actions the nurse should take include documenting the condition of the childs skin and ensuring that the child cannot reach the tube or ventilator tubing and pull it out, but these do not take priority over assessing for correct tube placement. The ventilator alarms should not be turned off, even for a brief period of time.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

20. A critically ill child on a ventilator is mildly anemic. Which action by the nurse is the most appropriate?
A. Decrease the administration rate of the IV fluids.
B. Draw minimal amounts of blood for laboratory tests.
C. Have parents sign consent for blood transfusions.
D. Monitor the childs hemoglobin levels daily.
ANS: B
Critically ill children have frequent blood draws for laboratory tests. The nurse should ensure that the minimum amount of blood is collected each time. Decreasing fluid rates might concentrate the hemoglobin and raise the level, but at the risk of dehydration. A mildly anemic child would not need transfusions. Monitoring the hemoglobin daily is an essential nursing function but will not actively help the child with this condition.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

21. A child is being weaned from the ventilator. He is awake and alert but getting increasingly tired. Which action by the nurse is the most appropriate?
A. Cluster nursing care so the child is able to get uninterrupted periods of rest.
B. Collaborate with other health team members to slow or stop the weaning process.
C. Draw a blood sample for blood gas analysis, and compare the results to the last blood gas values.
D. Have all of the childs visitors leave to allow the child to take a short nap.
ANS: B
Weaning from the ventilator is an individualized process that takes into account several different parameters. A child who is becoming increasingly fatigued is not tolerating the weaning. The nurse should collaborate with other members of the health-care team to adjust the weaning process. Rest is important to the critically ill child, but is not the most important action at this time. Laboratory work should be reviewed, but the results may be normal despite the childs fatigue level at this point.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

22. A mechanically ventilated child is being assessed for extubation. Which assessment finding would cause extubation to be delayed?
A. Alert and oriented with occasional confusion
B. Evidence that prior pulmonary infection has resolved
C. Peak inspiratory ventilator pressure of 14 cm H2O
D. 3+ pitting pedal edema, 1-lb weight gain overnight
ANS: D
Fluid overload puts the child at risk for developing respiratory distress, so the child with edema and weight gain should not be weaned from the ventilator at this time. The other parameters are acceptable for weaning.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

23. The nursing manager is collaborating with health-care providers to determine appropriate candidates for ventilator weaning in the pediatric intensive care unit. Which child is the best candidate?
A. Oxygen requirement: 60%
B. Peak inspiratory pressure: 32 cm H2O
C. Spontaneous tidal volume: 2 mL/kg
D. Ventilator rate: 6 breaths/minute
ANS: D
Signs that a child is a good candidate for ventilator weaning include oxygen requirements of less than 40%, peak inspiratory pressure of 1625 cm H2O, spontaneously initiated breaths with tidal volume of 46 mL/kg, and a ventilator rate of 610 breaths/minute. The child whose ventilator rate is 6 breaths/minute is the best candidate of these children.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

24. A nurse receives report on patients in the pediatric intensive care unit who are at risk for hypoperfusion. Which child should the nurse see first?
A. Hypotensive
B. Oliguric
C. Tachycardic
D. Weak pedal pulses
ANS: A
All options are signs of hypoperfusion, but hypotension is a late and ominous sign in a child. The nurse should see this child first.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

25. A child has a radial arterial line in place. The nurse assesses the distal fingertips as cool and pale. Which action is most appropriate based on these assessment findings?
A. Apply warm, moist heat.
B. Disconnect the device.
C. Elevate the extremity.
D. Notify the provider.
ANS: D
An invasive device within an artery can disrupt arterial blood flow to the distal tissues. The nurse should notify the provider so the arterial line can be moved, or possibly discontinued. Warm, moist heat will not increase perfusion that is disrupted mechanically. Elevating the extremity will decrease perfusion further. The nurse should not disconnect the device.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

26. A child has just had an invasive hemodynamic monitor inserted. After connecting the monitoring device to the monitor, what action should the nurse take next?
A. Assess the childs postprocedural pain status.
B. Document hemodynamic assessments.
C. Have the parents return to the room to comfort the child.
D. Perform hand hygiene and dispose of equipment.
ANS: B
Immediately after connecting the monitoring device to the monitor, the nurse should begin hemodynamic assessments. If equipment needs to be zeroed or calibrated, this is done first. The other actions are important, but in the critically ill child, obtaining immediate and frequent readings is critical.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

27. A child in the intensive care unit had a pulmonary artery catheter inserted 2 hours ago. The child is increasingly restless. The childs vital sign trends show a slow increase in pulse rate. Which action by the nurse is the most appropriate based on the assessment findings?
A. Check to ensure the connections are secure.
B. Document the findings in the patients chart.
C. Increase the frequency of hemodynamic readings.
D. Notify the health-care provider immediately.
ANS: D
A potential complication of inserting an invasive line for hemodynamic monitoring is vessel laceration, which can cause internal bleeding. Internal bleeding is often insidious, and changes will be noted over time, some of which can be subtle. The presence of increased agitation and pulse could indicate internal bleeding, and the nurse should notify the provider at once. The other actions are also appropriate, but do not take priority and can be done after notifying the provider.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

28. The nurse has an order for isotonic crystalloid solution to treat a child with hypoperfusion. Which solution does the nurse choose?
A. Albumin
B. D5W (5% dextrose in water)
C. Normal saline
D. Whole blood
ANS: C
Crystalloids are fluids that are crystal clearyou can see through them. Colloids have more solvents in them. Crystalloids include most standard IV solutions. Colloids include blood products and albumen. Normal saline and lactated Ringers solution are isotonic. D5W is physiologically hypotonic. The nurse should choose normal saline.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

29. A new nurse is caring for a child who has an arterial catheter in the radial artery. Which action by the new nurse causes the experienced nurse to intervene?
A. Checks to see if arterial line connections are secure frequently
B. Cleans the hub before giving medication through the site
C. Documents arterial blood pressures and mean arterial pressure
D. Monitors for blood loss at the site each time rounding is done
ANS: B
Arterial lines should not be used to give medications and should be clearly labeled so that this does not happen. The other actions are appropriate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

30. A patient in the intensive care unit has a pulmonary artery catheter for hemodynamic monitoring. On assessment, the nurse finds the patient clinically unchanged from the last assessment, but the hemodynamic data are significantly changed. Which action by the nurse is the most appropriate?
A. Document the findings and continue to monitor.
B. Level and recalibrate the hemodynamic line.
C. Notify the health-care provider of the findings.
D. Review the last set of laboratory data for any changes.
ANS: B
When caring for a patient with hemodynamic monitoring, the nurse must be able to zero and level the catheter transducers, monitor the waveforms, and interpret the data. When the data do not match the clinical picture, the nurse should check the equipment. The findings should be documented, but further action is needed. The health-care provider may or may not need to be notified, but the nurse would first check the equipment to ensure the readings were accurate. Reviewing laboratory data is another nursing responsibility, but does not directly address the issue.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

31. A nurse is supervising a student working with hemodynamic monitors. Which action by the student requires the nurse to intervene?
A. Adjusts the transducer each time the patient is repositioned
B. Assesses all connections each time he or she is in the room
C. Positions the transducer at the fifth intercostal space
D. Positions the transducer in the mid-clavicular line
ANS: C
The transducer must be placed level with the phlebostatic axis, and so is placed in line with the fourth intercostal space, mid-clavicular line. When the students places it in line with the fifth intercostal space, the nurse should intervene. The transducer may need to be adjusted when the patient is repositioned. All the monitoring device connections should be firmly connected and should be assessed each time the student is in the room.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

32. A child is brought to the emergency department with moderate respiratory distress. She has an oxygen saturation of 89% but is awake, alert, and responsive, and is clinging to the mother. The nurse is consulting about appropriate oxygen delivery devices and expresses concern about the patient retaining CO2. Which oxygen delivery device is the most appropriate for this child?
A. Facial CPAP
B. Nasal cannula
C. Oxygen tent
D. Venturi mask
ANS: D
A Venturi mask can deliver oxygen concentrations up to 40% and is especially beneficial for the patient who potentially will retain CO2. Facial CPAP is invasive and is not warranted for a child in this degree of distress. Nasal cannulae do not have a benefit in CO2 retainers. An oxygen tent will require the child to be taken from the mother, which potentially will increase her agitation and oxygen needs.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

33. A nurse receives report on a patient in the pediatric intensive care unit and is told the patient is on a ventilator in SIMV mode. Which information is inconsistent with the nurses knowledge of this type of ventilation?
A. Breaths delivered with preset pressure
B. Can be used in cases of respiratory failure
C. Invasive form of ventilation that requires intubation
D. Will override any spontaneous breathing
ANS: D
SIMV, or synchronized intermittent mandatory ventilation, is an invasive form of ventilation requiring the patient to be intubated. SIMV delivers mandatory breaths at a preset pressure. It can augment spontaneous tidal volume or inspiratory efforts. It will synchronize with the patients respiratory efforts, not override them.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

34. A child in the pediatric intensive care unit is started on cortisone. When the nurse enters the room to check his blood glucose, the parents are concerned that he is now a diabetic. Which response by the nurse is the most appropriate?
A. Being critically ill can raise a patients blood glucose.
B. Im sorry; we should have been checking this all along.
C. Increased blood glucose can be a side effect of steroids.
D. The doctor is curious about how his glucose levels are.
ANS: C
Corticosteroids have many side effects, including elevated blood glucose levels. When the child is started on them, he should have his glucose levels monitored per facility policy. Being ill can raise blood glucose levels, but this is not the specific reason this child is having them checked. The physician does want to know about the readings, but, again, this reason is not specific to this child. To apologize for not checking the glucose all along is not being truthful.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

35. A patient in the pediatric intensive care unit has hemodynamic monitoring. Her cardiac output is 3 L/minute. Which assessment finding is consistent with this reading?
A. Capillary refill: 2 seconds
B. Temperature: 103F (39.4C)
C. Urine output: 3 mL/kg/hour
D. Weak, thready pulse
ANS: D
A cardiac output of 3 L/minute is low, indicating such conditions as heart failure, hypovolemia, or increased systemic vascular resistance. A weak, thready pulse would be consistent with this reading. Capillary refill of 2 seconds is normal. An increased temperature would not be related. A urine output of 3 mL/kg/hour is more than sufficient and does not indicate low cardiac output.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

36. A 36-lb (16.4-kg) patient in the pediatric intensive care unit is started on a propofol (Diprovan) infusion. The health-care provider orders the infusion started at 410 g/minute. Which action by the nurse is the most appropriate?
A. Administer the infusion using an infusion pump.
B. Consult the pharmacist about giving this drug as an infusion.
C. Ensure the appropriate antidote is available bedside.
D. Notify the provider that the dose is above the safe range.
ANS: A
The safe dose range for propofol is 2550 g/kg/minute, so this dose is acceptable. The nurse should administer the drug using an infusion pump. It is not necessary to check whether the drug is given as an infusion, nor is it necessary to notify the provider that the dose is out of range. Propofol is a short-acting drug with a limited half-life and has no antidote.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

37. A 62-lb (28.1-kg) child has symptomatic bradycardia. Which medication does the nurse anticipate administering?
A. Atropine, 0.28 mg IV push
B. Atropine, 28 mg IV push
C. Norepinephrine, 0.28 mg IV push
D. Norepinephrine, 28 mg IV push
ANS: A
Atropine is used for symptomatic bradycardia in a dose of 0.010.05 mg/kg, IV. This is the correct drug and dose. Norepinephrine is used to produce vasoconstriction at a dose of 0.11 g/kg/minute, by IV infusion.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

MULTIPLE RESPONSE

1. The pediatric intensive care nurse understands the effects of stress on the critically ill child. Which factors increase stress in this population? (Select all that apply.)
A. Communication barriers
B. Consistent sleep hours
C. Lighting
D. Noise
E. Pain
ANS: A, C, D, E
Many things can cause stress in the child admitted to the pediatric intensive care unit, including sensory overload from light, noise, and pain. Communication barriers also cause stress in these patients. Consistent sleep hours help decrease stress.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

2. A toddler is critically injured and admitted to the pediatric intensive care unit. The child is on a ventilator and is sedated. The parents explain that the child is normally very active, wants to do everything himself, and is very chatty. Which aspects of this situation would cause the greatest psychosocial impact on this child? (Select all that apply.)
A. Activity restrictions
B. Body image disturbances
C. Communication barriers
D. Loss of control
E. Separation from peers
ANS: A, C, D
Toddlers are in Eriksons stage of autonomy versus shame and doubt, and need to feel a sense of control over their physical abilities and increasing autonomy. Activity restrictions, not being able to talk while intubated, and a loss of control will all have a major impact on this child. Body image disturbances and separation from peers would have a bigger impact on an older child.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

3. The nursing faculty informs a clinical group of nursing students about the detrimental effects of excessive noise exposure to patients in the pediatric intensive care unit. Which effects does the faculty member include in the discussion with the clinical group? (Select all that apply.)
A. Decreased immune function
B. Depressed pituitary function
C. Increased gastric secretions
D. Slower wound healing
E. Weight loss
ANS: A, C, D
Exposure to excessive noise has several detrimental physiological effects, including slower healing and recovery process, sleep disturbances, cardiovascular stimulation, increased gastric secretions, pituitary and adrenal gland stimulation, and suppression of the immune response to infection.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

4. A student nurse assesses a child for nonverbal signs of pain to report to the registered nurse. Which information should the student include? (Select all that apply.)
A. Complaints of nausea
B. Diaphoresis
C. Facial grimacing
D. Sleepiness
E. Tachypnea
ANS: A, B, C, E
Objective manifestations of pain include tachycardia, tachypnea, diaphoresis, sleep disturbances, hypertension, and nausea.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Easy

PTS: 1

5. A child is admitted to the pediatric intensive care unit with respiratory distress and respiratory acidosis. The childs pulse oximeter reads 98%. Which actions by the nurse are the most appropriate at this time? (Select all that apply.)
A. Assess the childs most recent hemoglobin and hematocrit levels.
B. Prepare for immediate intubation and mechanical ventilation.
C. Request an order to use a transcutaneous carbon dioxide monitor.
D. Titrate the oxygen flow rate down to prevent oxygen toxicity.
E. Wait 30 minutes, then draw another sample for arterial blood gasses.
ANS: A, C
This childs oxygen saturation does not correlate with respiratory distress and acidosis. Appropriate actions include assessing the childs hemoglobin and hematocrit and requesting the use of a carbon dioxide monitor. If the child is anemic, even with a saturation of 98%, the child will not have enough oxygen for tissue needs. The child may also have high levels of carbon dioxide causing or caused by the respiratory distress and acidosis, so this value should be monitored. The oximeter may not be working properly or reading accurately. Without further information, it is unknown if the child needs immediate intubation and mechanical ventilation. Titrating oxygen down in the face of respiratory distress is not warranted. Waiting 30 minutes is also not warranted, as this child is quite ill.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

6. A 7-year-old child is in the pediatric intensive care unit on a ventilator. Sedation is maintained with a midazolam (Versed) drip. Which items should the nurse ensure are readily available at the childs bedside? (Select all that apply.)
A. Back-up ventilator
B. Bag-valve mask device
C. Flumazinil (Romazicon)
D. Narcan (Naloxone)
E. Working suction setup
ANS: B, C, E
For the child on a ventilator, the nurse should have a bag-valve mask for manual ventilation and working suction. The antidote for Versed is Romazicon, which should also be available. A back-up ventilator for every ventilator in use is not only prohibitively expensive, but having the bag-valve mask allows for manual ventilation in case of ventilator failure. Narcan is not the antidote for Versed.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

7. A registered nurse working with a student nurse explains problems that can cause ventilator alarms. Which patient problems does the nurse include? (Select all that apply.)
A. Asynchronous breathing
B. Biting the endotracheal tube
C. Copious secretions obstructing the tube
D. Coughing and gagging
E. Kinking of the ventilator tubes
ANS: A, B, C, D
Asynchronous breathing, biting the tube, secretions, and coughing and gagging are all patient-related problems that lead to ventilator alarms. Kinked tubing is a ventilator problem.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

8. A nurse is assessing patients in the pediatric intensive care unit for signs of hypoperfusion. Which assessment findings are indicative of this condition? (Select all that apply.)
A. Capillary refill: 2 seconds
B. Mean arterial pressure: 32 mm Hg
C. Mental status: lethargic
D. Pedal pulses: bounding
E. Urinary output: 2 mL/kg/hour
ANS: B, C
Signs of hypoperfusion include urinary output less than 1 mL/kg/hour, mean arterial pressure less than 4550 mm Hg, decreased peripheral and pedal pulses, tachycardia, mental status changes, lethargy, delayed capillary refill, and pallor. A capillary refill of 2 seconds is normal. Mean arterial pressure of 32 mm Hg is too low and is indicative of hypoperfusion. Lethargy is a sign of hypoperfusion. Bounding pedal pulses may indicate fluid overload, and a urine output of 2 mL/kg/hour is normal.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

9. A nurse is removing an arterial line from a patients radial artery. What actions by the nurse are most appropriate after the line is removed? (Select all that apply.)
A. Apply pressure for at least 5 minutes.
B. Assess perfusion distal to the site.
C. Monitor the patient for bleeding.
D. Place a clean dressing over the site.
E. Secure the insertion site with Steri-Strips.
ANS: A, B, C
After removing the invasive device, pressure is held for at least 5 minutes, and up to 20 minutes, at the femoral site. Perfusion distal to the insertion site must be assessed, including for warmth, sensation, movement, color, pulse, and capillary refill time. The patient should be monitored for bleeding. The dressing should be sterile, and Steri-Strips are not routinely needed.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

10. A nurse is preparing to transfer a child from the intensive care unit to progressive care. The parents seem very anxious and do not want the child to transfer. Which responses by the nurse are most appropriate? (Select all that apply.)
A. I am interested in what is most stressful about moving your child.
B. Parents are always involved with their childs care in any unit.
C. The nurses will monitor your child closely as often as needed.
D. We can keep her here if you really insist on it.
E. You should be happy because your child is getting better.
ANS: A, B, C
Parents are often anxious about moving their child out of the intensive care unit for many reasons. The caring nurse will ask what is most stressful so that this topic can be addressed. Assuring them that they will remain involved in their childs care is reassuring. Letting the parents know that the new staff will continue to monitor and care for the child based on his or her needs is also important. The nurse should not offer to keep a child in the intensive care unit to placate the parents, as this may not be possible in the facility. It is also not desirable to maintain a higher level of care than needed. Telling the parents how they should feel is dismissive of their concerns.

Cognitive Level: Applying/Application
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

COMPLETION

1. A child weighs 32 lb. The health-care provider orders a loading dose of midazolam (Versed) prior to intubation. The safe dose range for this drug is ____________________.

ANS:
0.732.9 mg
32 lb = 14.54 kg. The safe dose range for this drug is 0.050.2 mg/kg. This calculates to 0.732.9 mg.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

2. A childs blood pressure is 92/64 mm Hg. Therefore, the mean arterial pressure is ____________________.

ANS:
73.3 mm Hg
Mean arterial pressure = systolic blood pressure + 2 (diastolic blood pressure)
3
92 + 2(64) = 73.3
3

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

3. A child who weighs 28 lb needs fluid resuscitation. The nurse plans to administer ____________________.

ANS:
127254 mL
The child weighs 12.72 kg. The rate for fluid resuscitation is 1020 mL/kg, which is 127254 mL total.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

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