Question 1

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 patient's 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.

Accepted Answer

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.

Question 2

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 child's hemoglobin levels daily.

Accepted Answer

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.

Question 3

A child is hospitalized with anemia and critically low hemoglobin.The health-care provider orders a blood transfusion.The parents won't 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 won't sign the consent

Accepted Answer

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.

Question 4

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)

Accepted Answer

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.

Question 5

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.

Accepted Answer

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.

Question 6

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) "It's just the body's natural way of dealing with unfamiliar stimuli."
D) "Stimulation of the adrenal glands leads to secretion of stress hormones."

Accepted Answer

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 child's ears,but this does not lead to behavior problems.Stating that this is just the body's natural way of dealing with stress does not provide any specific information.

Question 7

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

Accepted Answer

Suction pressure for a child is 110-130 mm Hg.The nurse should intervene and have the student reduce the pressure before suctioning.The other options are correct actions.

Question 8

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) Notify the rapid response team immediately.
D) Turn up the oxygen and reassess the child in 30 minutes.

Accepted Answer

The oxygen saturation does not correlate with the child's 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.

Question 9

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.

Accepted Answer

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 child's receiving adequate oxygenation.

Question 10

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 child's bed to 60°.
D) Suction the oral cavity every 2 hours.

Accepted Answer

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 child's mouth)and may lead to skin problems if the child slides down in bed frequently.

Question 11

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."

Accepted Answer

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.

Question 12

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.

Accepted Answer

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.

Question 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

Accepted Answer

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.

Question 14

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.

Accepted Answer

Incorporating a family-centered approach to care is the best way to reduce stress and anxiety in the critically ill child's 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.

Question 15

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) "I'm 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."

Accepted Answer

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 child's 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.

Question 16

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.

Accepted Answer

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.

Question 17

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

Accepted Answer

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.

Question 18

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 child's skin.
C) Ensure that the child cannot pull on tubing.
D) Turn the ventilator alarms back on.

Accepted Answer

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 child's 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.

Question 19

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.

Accepted Answer

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 child's 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 child's 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.

Question 20

A nursing student asks a pediatric intensive care nurse why being bed-bound for several weeks would affect a young child's 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."

Accepted Answer

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.

Quiz 35: Caring for the Critically Ill Child

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 patient's safety?

A critically ill child on a ventilator is mildly anemic.Which action by the nurse is the most appropriate?

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 child on a ventilator suddenly desaturates.Which nursing action is the priority?

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 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 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 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 mechanically ventilated 2-year-old child has copious oral secretions.What action by the nurse takes priority?

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 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 child is mechanically ventilated.Which assessment finding indicates that a priority goal is being met?

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?

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 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?

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?

The nurse has just repositioned a child who is intubated and mechanically ventilated.Which action by the nurse takes priority?

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 nursing student asks a pediatric intensive care nurse why being bed-bound for several weeks would affect a young child's growth and development.Which response by the nurse is the most appropriate?