Peds CCRN Review Questions (from AACN), Exams of Nursing

Download Peds CCRN Review Questions (from AACN) and more Exams Nursing in PDF only on Docsity! Peds CCRN Review Questions and Answers (from AACN) PEEP is intended to do which of the following? A. Improve ventilation/perfusion matching B. Decrease functional residual capacity C. Increased venous return to the heart D. Increased cardiac output - ✔A. Improve ventilation/perfusion matching - PEEP increases alveolar volume, thereby improving ventilation/perfusion matching and increasing functional residual capacity. - A detrimental effect of PEEP (especially at high levels) is a decrease in venous return to the heart and a subsequent decrease in cardiac output. In an infant with sepsis, factors that impair the release of oxygen by negatively affecting oxyhemoglobin dissociation include: A. Hyperthermia B. Metabolic acidosis C. Respiratory acidosis D. Hypothermia - ✔D. Hypothermia - To answer this question, you must consider the factors that would cause a left shift of the oxyhemoglobin curve. - Hypothermia, decreased CO2, and increased pH (alkalosis) would all cause a left shift. - Hyperthermia and acidosis would cause a right shift of the curve In which condition might you observe a decreased V/Q ratio (<0.8)? A. Status asthmaticus B. Sepsis C. Pulmonary emboli D. Tricuspid atresia - ✔A. Status asthmaticus - A V/Q ratio of <0.8 is indicative of perfusion exceeding ventilation. Air trapping from diseases such as asthma is a common cause of this scenario Factors such as small nostrils, larger tongue, and narrower airways in an infant.... A. Decrease airway resistance B. Make intubation easier C. Increase airway resistance D. Improve airway obstruction - ✔C. Increase airway resistance - There are a number of factors that increase airway resistance and obstruction in young infants, including their larger heads and tongues, smaller nostrils, decreased muscle tone, and narrower airways. - Intubation is more difficult because of an anterior larynx and narrow cricoid ring. Indications that a patient is ready to wean from mechanical ventilation include: A. Hemodynamic instability B. Adequate cough and gag reflexes C. Persistent coma D. PEEP > 8 - ✔B. Adequate cough and gag reflexes - Before being extubated, a child needs to have an adequate level of consciousness to protect his or her airway. This includes having an adequate cough and gag; hemodynamic stability (not instability); and a PEEP <5, with an oxygen requirement generally less than an FiO2 of 0.4. A toddler who was found unresponsive in a swimming pool is in respiratory distress. On chest x-ray you see bilateral infiltrates and the PaO2/FiO2 ratio is 190. These findings suggest: A. Aspiration pneumonia B. Viral pneumonia C. Acute respiratory distress syndrome D. Pneumothorax - ✔C. Acute respiratory distress syndrome - This child has signs of acute respiratory distress syndrome (ARDS), which include bilateral infiltrates on chest x-ray, PaO2/FiO2 ratio <200, and pulmonary edema, among other things. - Both aspiration and viral pneumonia may lead to ARDS, but that's not the correct answer for this question. - The symptoms described are not consistent with a pneumothorax. An infant with bronchiolitis is intubated due to an acute respiratory failure. Post- intubation ABG results demonstrate: pH 7.22 PaCO2 62 PaO2 75 HCO3 22 O2 sat 90% This blood gas reflects: A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis - B. Dilate the pulmonary vascular bed C. Dilate the systemic vascular bed D. Constrict the pulmonary vascular bed - ✔B. Dilate the pulmonary vascular bed Infants with pulmonary hypertension have significantly increased pulmonary vascular resistance. The goal of therapy is to lower the pulmonary vascular resistance through dilation of the pulmonary bed. Patients at risk for pulmonary embolus include those with an inherited hypercoagulable state and: A. Sickle cell disease B. Diabetes C. Asthma D. Pneumonia - ✔A. Sickle cell disease Patients with sickle cell disease are at risk for developing a pulmonary embolus. Sickling of the RBCs within the small blood vessels of the lung and other organs leads to small vessel occlusion and, ultimately, infarction of areas of the pulmonary parenchyma. A baby with BPD will have: A. Left-sided heart failure B. Increased fluid requirements C. Decreased pulmonary vascular resistance D. Increased caloric needs - ✔D. Increased caloric needs -Infants with BPD have increased caloric needs because of the chronic increased work of breathing distress. -They require diuretics and generally do not tolerate fluid overload. -And, they experience increased pulmonary vascular resistance and resultant right-sided heart failure. Cerebrospinal fluid is produced by the: A. Choroid plexus B. Cerebral ventricles C. Arachnoid villi D. Pia mater - ✔A. Choroid plexus Cerebrospinal fluid is formed in the choroid plexus and reabsorbed in the arachnoid villi. Problems with CSF production or absorption can result in hydrocephalus. A child is admitted after falling off a golf cart. The child was initially awake and alert, but now is unresponsive. The nurse should suspect which condition? A. Hydrocephalus B. Epidural hematoma C. Subdural hematoma D. Diffuse axonal injury - ✔B. Epidural hematoma Epidural hematomas result from hemorrhage into the extradural space, usually from a tear in the middle meningeal artery. With the classic presentation, the child is initially awake and alert, but as the bleeding continues, the hematoma gets larger and the child can become unresponsive. An infant with a ventriculoperitoneal shunt is irritable with a high-pitched cry and setting-sun sign. The nurse should be concerned this child may have: A. Diabetes insipidus B. Stroke C. New-onset seizures D. Shunt malfunction - ✔D. Shunt malfunction This child is demonstrating symptoms of hydrocephalus and increased ICP. The most common cause of this in a child with a VP shunt is shunt malfunction. This needs further investigation with medical imaging and the child may require surgery to correct the problem. A traumatically injured 8-year-old is being cared for in the ICU. The nurse notes the child has an ICP of 18 mmHg, arterial blood pressure of 112/72 mmHg, with MAP of 86 mmHg and central venous pressure of 7 mmHg. The nurse calculates the cerebral perfusion pressure and anticipates which intervention? A. MRI evaluation B. Ongoing monitoring C. Emergent surgery D. Fluid bolus - ✔B. Ongoing monitoring -This child has age-appropriate values for blood pressure, MAP, and CVP. The calculated CPP is 68 mmHg (MAP minus ICP). -Based on the information given in this scenario, there is no indication for additional brain imaging, surgical intervention, or fluid bolus. -The nurse should continue monitoring the patient and supporting vital functions. The priority management strategy for an epidural hematoma is: A. Surgery B. ICP monitoring C. Steroids D. Pain control - ✔A. Surgery - Large epidural hematomas are treated with surgery. - Depending on the child's condition, ICP monitoring may be indicated, but surgical removal is the priority. - Steroids are not indicated in this scenario. - The child will need pain assessed and treated in the postoperative period. Which is the initial independent nursing intervention to maintain cerebral perfusion? A. Hypertonic saline administration B. Maintain head midline C. Initiate blood transfusion D. Administer sedation - ✔B. Maintain head midline -This question asks about the initial independent nursing intervention. -Of the choices offered, maintaining the head midline is the only independent nursing action. This will help to promote venous drainage, which can improve cerebral perfusion. A patient presents with agitation, nuchal rigidity, and a positive Brudzinski sign. The priority intervention is: A. ICP monitoring B. Medical restraints C. Antibiotic administration D. Intraventricular catheter - ✔C. Antibiotic administration -This patient is demonstrating signs of meningitis. Initial treatment includes antibiotic administration. -ICP monitoring and placement of an intraventricular catheter are not indicated in this scenario. -Restraints may be needed, but they could further agitation. A child is admitted to the ICU following a motor vehicle collision in which he was an unrestrained passenger. He is complaining of numbness and tingling in his legs and feet, and has decreased sensation. Preliminary imaging studies are normal. The nurse anticipates: A. Removal of the cervical collar B. Discontinuation of log rolling C. Administration of anti-anxiety medications D. Ongoing spinal cord protective measures - ✔D. Ongoing spinal cord protective measures. -This patient's clinical picture is consistent with spinal cord injury, even though there were no findings on imaging studies. He may have Spinal Cord Injury Without Radiograph Abnormality (SCIWORA). -The patient should have spinal cord protective measures in place (eg, log rolling, cervical collar) at this point. Which is a required element of the exam for brain death determination? A. Apnea test B. EEG C. MRI D. Spinal cord reflexes - ✔A. Apnea test -While each of the interventions listed may be utilized, the intervention choice that will have the most immediate effect is the administration of insulin and glucose. This will help to shift potassium back into the cells and decrease the serum potassium levels. -Additionally, calcium chloride or calcium gluconate should be administered first in order to protect the heart A young child is admitted with hemolytic uremic syndrome. The preferred mode of dialysis in this patient is: A.Peritoneal dialysis B. Hemodialysis C. CVVH D. Dialysis is not indicated - ✔A. Peritoneal dialysis Peritoneal dialysis (PD) is the preferred mode for the patient with HUS. These patients are usually of a younger age, which makes PD a good choice. A recently admitted child has muscle weakness and a tall, peaked T. wave was observed on electrocardiogram. Which intervention do you anticipate? A. Administration of hypertonic saline B. Administration of potassium replacement C. Emergent cardioversion D. Removal of potassium from all IV fluids - ✔D. Removal of potassium from all IV fluids -This patient is demonstrating signs of hyperkalemia. The only option listed that would begin to address this is the removal of potassium from all IV fluids. -Depending on the serum potassium level, the nurse should anticipate administering calcium, insulin/glucose, sodium bicarbonate, and kayexalate. -Hypertonic saline and cardioversion are not indicated and administering potassium in this situation is contraindicated. The nurse is caring for a child with liver failure and who is experiencing profound abdominal distention. What is the primary concern? A. Renal insufficiency B. Biliary atresia C. Intestinal perforation D. Respiratory failure - ✔D. Respiratory failure -Children with liver failure can experience profound abdominal ascites and distention. This process pushes up on the diaphragm and can result in respiratory distress, which can lead to respiratory failure. -Increased pressure in the abdomen can compromise perfusion to other abdominal organs, like the kidney. But in this scenario, respiratory distress is the primary concern. The nurse caring for a child who was injured in a motor vehicle crash notes positive Cullen's sign in the right abdomen around the umbilicus. This is indicative of: A. Impending disseminated intravascular coagulopathy B. Necrotic bowel process C. Sepsis D. Intra-abdominal bleeding - ✔D. Intra-abdominal bleeding In cases of severe intra-abdominal bleeding, Cullen's sign (bluish discoloration around the periumbilical area) may be seen. The nurse should be concerned that the child has severe injuries and may need surgical exploration or repair. The primary concern for a child diagnosed with intussusception is: A. Dehydration B. Bowel infarction C. Infection D. Pain - ✔B. Bowel infarction -When intussusception occurs, part of the bowel telescopes inside itself. This can result in decreased arterial blood flow to the area and resultant bowel infarction. -Intervention to correct the telescoping bowel needs to be initiated immediately. -The child may experience severe paroxysmal pain, is at risk for dehydration, and can develop an infection if perforation occurs. You are caring for an adolescent with multiple traumatic injuries sustained in a motor vehicle collision. Upon assessment, you notice that the patient has developed shallow, rapid respirations and abdominal distention; is now complaining of pain in the area of the right shoulder; and whose BP has also dropped to 80/50 mmHg. You suspect that this patient has sustained a traumatic injury to the: A. Spleen B. Liver C. Kidneys D. Clavicle - ✔B. Liver Abdominal distention and rapid, shallow respirations may be seen with many abdominal injuries. -Pain that radiates to the right shoulder is consistent with hepatic injury. -Additionally, the patient is showing signs of shock, which can be associated with bleeding from a lacerated liver. Which would be an indication for urgent surgical intervention in the child with a gastrointestinal hemorrhage? A. Presence of free air on abdominal radiograph B. Weakness and faintness C. Age <3 months D. Unknown etiology of the gastrointestinal hemorrhage - ✔A. Presence of free air on abdominal radiograph -Indications for urgent surgical intervention include the presence of free air on abdominal radiograph (sign of possible intestinal perforation) or severe hemorrhage that is unresponsive to blood component therapy. -Less invasive measures can be used to determine the cause of the Gl bleed. Which finding is most concerning for necrotizing enterocolitis (NEC)? A. Sausage-shaped mass in the RUQ B. Apnea and bradycardia C. Pneumatosis intestinalis D. Hyperbilirubinemia - ✔C. Pneumatosis intestinalis -Pneumatosis intestinalis is a specific finding on abdominal x-ray that is indicative of NEC in a patient at risk for this condition. -Apnea and bradycardia are nonspecific symptoms associated with many neonatal conditions. -A sausage-shaped mass in the RUQ is associated with intussusception. Potential complications of blood component administration include: A. Anaphylaxis B. Thrombocytopenia C. Anemia D. Vaso-occlusive crisis - ✔A. Anaphylaxis -Symptomatic anemia is an indication for blood component therapy, not a complication. -Anaphylaxis is a potential complication of blood component therapy caused by antigen antibody complexes. -The patient may experience bronchospasm, cough, respiratory distress, and hypotension. -Thrombocytopenia is a low platelet count, and vaso-occlusive crisis is a risk for patients with sickle cell disease Twenty minutes after initiation of a PRBC transfusion, your patient develops a fever; becomes hypotensive, anxious, and dyspneic; and begins to shake uncontrollably. You suspect which of the following is occurring? A. Citrate toxicity B. Acute hemolytic transfusion reaction C. Acute nonhemolytic transfusion reaction D. Transfusion-related acute lung injury (TRALI) - ✔B. Acute hemolytic transfusion reaction -These symptoms are consistent with an acute hemolytic reaction. -These reactions occur with transfusions of -In SIADH, an increase in the production of ADH results in retention of fluid, hyponatremia, and hypo-osmolality. -Hypernatremia and hyperosmolality would be clinical manifestations of DI, not SIADH. -Under most circumstances, sodium levels are the primary determinant of osmolality. In a patient being treated for SIADH, which one of the following sodium levels would indicate reversal of this syndrome? A. 119 mEg/L B. 128 mEq/L C. 135 mEq/L D. 152 mEq/L - ✔C. 135 mEq/L -A sodium level of 135 mEq/L would indicate that Na+ levels are returning to normal and SIADH is reversed. -Answers A and B would relate to a patient who is having ongoing issues with hyponatremia, an indication that SIADH has not been reversed. -Answer D indicates hypernatremia, which also is not an indication of reversal of SIADH. Which of the following findings is indicative of Diabetes Insipidus? A.Serum sodium 150 mEq/L B. Urine-specific gravity 1.012 C. CVP 15 mmHg D. Serum osmolality 280 mOsm/L - ✔A. Serum sodium 150 mEq/L -DI is associated with hypovolemia, hypernatremia, and hyper-osmolality. -Among the possible answers to this question, a sodium level of 150 mEq/L (hypernatremia) would be your best choice. A child with a closed head injury has developed SIADH. Which of the following laboratory results would this patient exhibit? A. Serum Na+ 122 mEg/L; serum Osm 262 mOsm/L B. Serum Na+ 134 mEq/L; serum Osm 280 mOsm/L C. Serum Na+ 144 mEq/L; serum Osm 282 mOsm/L D. Serum Na+ 158 mEq/L; serum Osm 295 mOsm/L - ✔A. Serum Na+ 122 mEq/L; serum Osm 262 mOsm/L -You know that patients with SIADH have hyponatremia and hypo-osmolality, you know that answer "A" is the best response. A child experiencing Diabetes Insipidus (DI) has a urine output >4 mL/kg/hr and a serum sodium of 158 mEq/L. The nurse should expect the patient will need: A. Hypotonic intravenous fluids and urine output replacement B. Vasopressin administration and urine output replacement C. Hypertonic saline administration and 75% maintenance intravenous fluid D. Vasopressin and hypertonic saline administration - ✔B. Vasopressin and urine output replacement -Immediate treatment for a patient with symptomatic DI is ADH replacement and urine output replacement to keep the patient from progressing to profound hypovolemic shock. -Hypotonic fluids and hypertonic saline administration are contraindicated in this situation. -Fluid restriction to 75% of maintenance needs is a treatment for SIADH. Which of the following actions would be appropriate after the administration of Desmopressin (DDAVP) to a patient with DI? A. Decreasing fluids B. Increasing fluids C. Increasing sodium intake D. Decreasing sodium intake - ✔A. Decreasing fluids -Administration of DDAVP should result in renal retention of water and a subsequent increase in intravascular volume. -If those things occur, the nurse could anticipate that intravenous fluids would be decreased. A child being treated for DKA becomes more lethargic, is difficult to arouse, and has vomited twice in the past hour. These symptoms could be interpreted as indications of: A. Exhaustion due to lack of sleep B. The development of hypoglycemia C. Decreased intestinal motility D. Cerebral edema and increased ICP - ✔D. Cerebral edema and increased ICP -These symptoms are indications that the child may be developing cerebral edema and an increased ICP. -Nurses must recognize that children with DKA are at a higher risk for the development of cerebral edema and must monitor closely for any changes in neurological status. A child in DKA has a glucose of 350 mg/dL. One hour later the glucose is 250 mg/dL. The nurse would anticipate the administration of: A. Potassium chloride B. Sodium bicarbonate C. Dextrose solution D. Subcutaneous insulin - ✔C. Dextrose solution -As the glucose decreases to 250 mg/dL, it will become necessary to administer glucose in addition to the insulin infusion that this patient is likely already receiving. -The child in DKA will not receive SQ insulin, as she will not be able to utilize that as effectively as IV insulin. -You have no information to suggest that this patient requires electrolyte supplementation. -Sodium bicarbonate is not appropriate An adolescent is admitted with an unstable pelvic fracture. The nurse should anticipate the patient may need which intervention because of this injury? A. Frequent pupillary assessment B. Incentive spirometry C. Long-bone casting D. Leg-length monitoring - ✔B. Incentive spirometry -Patients with unstable pelvic fractures are likely to need prolonged bedrest and are at risk for atelectasis; thus, meticulous pulmonary toilet is important, which includes incentive spirometry. -Other nursing interventions include neurovascular monitoring of the distal extremities and measures to prevent skin breakdown. What is the priority intervention for compartment syndrome? A. Neurovascular monitoring B. Elevating the extremity C. Fasciotomy D. Pain management - ✔C. Fasciotomy -The priority intervention to relieve the effects of compartment syndrome and prevent further damage is a fasciotomy. -It is important to continue neurovascular monitoring and ensure the child receives adequate pain management. The nurse should be concerned for which electrolyte imbalance after a fasciotomy is performed to manage compartment syndrome? A. Hyperkalemia B. Hypernatremia C. Hypophosphatemia D. Hypercalcemia - ✔A. Hyperkalemia -The child who requires a fasciotomy for compartment syndrome is at risk for rhabdomyolysis after the damaged skeletal muscle cells release myoglobin, potassium, phosphate, and lactate into the circulation. -The result is hyperkalemia, hypocalcemia, hyperphosphatemia, and acidosis. Which is a risk factor for the development of a pressure injury? A. Adequate nutrition B. Hyperperfusion -Gastroenteritis is a common cause of fluid loss in an infant, which can result in significant hypovolemia. The child is placed on high-flow oxygen and an IV is inserted. An initial fluid bolus is ordered. The child weighs 7 kg. Which of the following is the most appropriate fluid to administer to this infant? A. D1OW B. 0.9% normal saline C. Packed red blood cells D. Hypertonic saline - ✔B. 0.9% normal saline -The initial fluid bolus for a child in hypovolemic shock from gastroenteritis should be an isotonic crystalloid solution, usually 0.9% normal saline. -D10W contains glucose and is not isotonic; therefore, it should not be used as a fluid bolus. -Packed red blood cells and hypertonic saline are not indicated in this patient scenario. The parents of a 15-month-old state that she has a high fever and vomiting and is now extremely irritable. The mother states there are "bruises" and a spotty rash on the child's legs, but she has no history of recent trauma. The child's vital signs are HR 160, RR 38, BP 74/52, and rectal temperature of 41°C. This child is most likely experiencing: A. Hypovolemic shock B. Cardiogenic shock C. Septic shock D. Anaphylactic shock. - ✔C. Septic shock -The child's history and clinical presentation are suggestive of sepsis and septic shock. She quickly needs an IV fluid bolus and antibiotics An adolescent intentionally ingested acetaminophen and has a toxic level. In addition to fluid hydration, the patient should receive: A. Hemodialysis B. N-acetylcysteine C. Sodium bicarbonate D. Ipecac syrup - ✔B. N-acetylcysteine -The antidote for acetaminophen ingestion is N-acetylcysteine, given as an intravenous infusion. -Hemodialysis and sodium bicarbonate are not indicated in this scenario, but might be appropriate for salicylate overdose. -Ipecac syrup is not recommended. -This child may also benefit from psychosocial support and mental health care A toddler is hospitalized after ingesting her older sister's clonidine. Which is an essential intervention to prevent future occurrences? A. Tell the parents the child protective team will be notified next time B. Ensure parents store the medication in their bedroom C. Ask the pediatrician to discontinue the sister's medication D. Ensure parents use a lock box to store medication - ✔D. Ensure parents use a lock box to store medication -Medication should be kept in a lockbox so young children are unable to access it accidentally. -Part of the process of investigating a child's accidental ingestion includes a psychosocial and safety assessment, which may involve the social worker or the child protective team. Which of the following is likely to be most successful in reducing an ICU's CLABSI rate? A. Using clean technique during catheter insertion B. Exclusively using central catheters in all patients C. Implementing a bundle of effective strategies D. Reinforcing loose catheter dressings - ✔C. Implementing a bundle of effective strategies -Our goal is to prevent CLABSI from occurring by bundling care practices as they pertain to insertion of the catheter, maintenance of the catheter, and early removal. -Sterile technique and maximum barrier precautions should be used during insertion, not clean technique. -Catheters should be placed only when truly indicated and removed as soon as possible. -Loose dressing should be changed, not reinforced. Complications of organ transplant include rejection and: A. Infection B. Malignant hyperthermia C. Osteopenia D. Developmental delay - ✔A. Infection -A patient who receives a transplant will receive immunotherapy and thus will have a lifelong risk of infection. -Other potential post-transplant complications include bleeding, delayed graft functioning postoperatively, and potential challenges with medical compliance. The risk for drowning increases with: A. Swimming lessons B. Adequate adult supervision C. The winter season D. Overestimating swimming ability - ✔D. Overestimating swimming ability -There is an increased risk for drowning when the swimmer overestimates his or her swimming skills and abilities. -The risk is decreased with adequate adult supervision. -Swimming lessons may improve skills, but do not replace supervision. A 5-month-old arrives unconscious with a history of falling from a changing table. Head CT reveals a subdural hematoma. Which additional assessment finding is concerning for abusive head trauma? A. Forehead bruising B. Poorly reactive pupils C. Retinal hemorrhage D. Linear skull fracture - ✔C. Retinal hemorrhage -You would not anticipate seeing retinal hemorrhage with the history provided. -You could see a bruise on the head where the baby fell, poorly reactive pupils, or a linear skull fracture. -A history that does not match the patient's injuries is concerning for inflicted trauma. A 9-month-old arrives with a burn injury. Which of these is most concerning for inflicted injury? A. The burn injury is consistent with the history B. The parent sought out medical care immediately C. The burns have a splash pattern across the thighs D. The parent reports the child pulled a hot pot off the stove - ✔D. The parent reports the child pulled a hot pot off the stove -A child this age would not have the developmental skills to pull a pot off a stove, so that statement is concerning. -Other red flags that a burn may be inflicted include linear demarcations without splash marks, and a pattern that resembles a hot object. -It is also concerning when the parent or caregiver delay seeking medical care Which statement from an adolescent hospitalized for a second suicide attempt is most concerning? A. "Things will never get any better" B. "I know where my dad keeps his gun" C. "I have friends I can talk to" D. "Sometimes I forget to take my medication" - ✔B. "I know where my dad keeps his gun" -Having ready access to a lethal weapon and a previous suicide attempt puts this patient at higher risk for future, successful suicide attempts. -Hopelessness and psychiatric illness also put a patient at risk, but it's the access to a firearm that is most concerning in this scenario. Poor cardiac output is often manifested by: A. Cyanotic extremities B. Increased urinary output C. Cold, pale, and mottled extremities D. Cyanotic lips, gums, and nailbeds - ✔C. Cold, pale, and mottled extremities -Symptoms occur due to back-up of blood and include facial swelling, dyspnea, cough, arm edema, and headache, full jugular veins, and engorgement of collateral veins. Twelve hours after cardiac surgery, a patient develops hypotension, tachycardia, and increased central venous and left atrial pressures. There are clots in the chest tube. What is the next likely intervention? A. Chest x-ray B. Pericardiocentesis C. Fluid administration D. Increase in inotropic infusions - ✔B. Pericardiocentesis -This patient is showing signs of cardiac tamponade, a complication that can develop after cardiac surgery, especially if the chest tubes stop draining due to clotting. -The appropriate intervention to relieve the building pressure and improve cardiac output is a pericardiocentesis. -A chest x-ray, fluid administration, and/or increasing the inotropes would not alleviate this emergency. Which intervention would not be appropriate for an infant with Tetralogy of Fallot who is experiencing a "tet" spell? A. Placing the baby in knee-to-chest position B. Morphine administration C. Decreasing the concentration of oxygen administration D. Fluid administration - ✔C. Decreasing the concentration of oxygen administration -In a "tet" spell, the infant experiences obstruction to the outflow tract, which increases right-to-left shunting and decreases pulmonary blood flow. -Interventions such as placing the baby in a knee-to-chest position and administering morphine and fluids will help relieve this shunting. -Oxygen concentration should actually be increased, not decreased, during a "tet" spell because it is a potent pulmonary vasodilator, which can improve pulmonary blood flow. The nurse should anticipate which patient will need a balloon septostomy? A. Baby with small ventricular septal defect B. Toddler with infectious pericarditis C. Infant with a large atrial septal defect D. Newborn with transposition of the great arteries - ✔D. Newborn with transposition of the great arteries -A baby born with transposition of the great arteries has parallel pulmonary and systemic circulations and is dependent on some type of shunt to survive. -A balloon septostomy may be used to create an atrial septal defect until surgical repair is made. -This procedure is not indicated for a VSD or ASD, or for pericarditis. A child recently underwent a diagnostic cardiac catheterization. The nurse notes the patient's distal foot is cool, with poor perfusion and an absent pulse, and should suspect what? A. Post-procedure bleeding B. This is a normal finding C. Hematoma D. Heart failure - ✔C. Hematoma -Post-procedure monitoring after cardiac catheterization includes observing for bleeding and perfusion. -A hematoma can form, which may require intervention if distal perfusion is significantly compromised, and this is not a normal finding. -The assessment findings described in this question do not indicate there is bleeding or heart failure. When is there a particular risk for arrhythmias? A. Post atrial balloon septostomy B. After large ventricular septal defect (VSD) repair C. With indomethacin therapy for patent ductus closure D. Whenever there is right to left shunting of blood - ✔B. After large ventricular septal defect (VSD) repair -Surgical repair for a large VSD occurs around the AV conduction system, placing the patient at risk for arrhythmias. -The risk is not as high for atrial repairs or during indomethacin therapy for closing a patent ductus arteriosus. The nurse should be concerned for postoperative bleeding when the chest tube drainage: A. Increases to 8 mL/kg in 1 hour B. Decreases and develops clots C. Becomes lighter in color on day 2 D. Is 2 mL/kg in 1 hour - ✔A. Increases to 8 mL/kg in 1 hour -Postoperative bleeding can be significant, especially in small babies. -Chest tube drainage that exceeds 3 mL/kg/hr for >3 hours OR 5-10 mL/kg/hr in any 1 hour is a red flag for bleeding. -It is normal for drainage to become lighter in color over time, but be concerned that pericardial tamponade is developing if the drainage suddenly decreases or you see significant clots. A neonate is receiving an infusion of prostaglandin to keep the patent ductus arteriosus from closing. Which is a potential complication of this medication? A. Seizures B. Apnea C. Rash D. Fever - ✔B. Apnea -Babies receiving prostaglandin are at risk for developing apnea. -Seizures, rash and fever are not significant concerns with this medication. Members of the nursing staff are developing written patient/family education materials. Who would be most important to consult for feedback? A. Nurses in another intensive care unit B. Publication services/communication department C. Respiratory therapy department supervisor D. Hospital risk management - ✔B. Publication services/communication department -Educational materials designed for patients and families should be written at an appropriate reading level. -The hospital's publication services/communication department should have experts that can assist with developing content that is both informative and written at the health literacy level of the intended audience. The nursing staff are resistant to being assigned a chronically disruptive patient. An appropriate first step would be to: A. Give the patient an ultimatum to stop the behavior B. Convene a team meeting to discuss possible options C. Rotate the patient assignment among staff D. Request the physician transfer the patient - ✔B. Convene a team meeting to discuss possible options. -Collaboration is a key component in this scenario. Bringing the team together will allow the nurses to articulate their concerns. They can then brainstorm strategies and collectively make the best choices to resolve this situation. -Possible solutions may include rotation of staff assignments and a conversation with the patient/family. -It may be valuable to include the physician in the team meeting, but requesting to transfer the patient does not move the situation toward an appropriate resolution. A nurse expresses concern about the high dosage of opioids ordered for the comfort care of a terminally ill and unconscious adolescent. The family's plan is to allow a natural death after extubation, and the nurse is concerned the medications will hasten that. What is the best resource to utilize in this situation? A. Ethics committee B. Hospital chaplain C. Risk manager D. Patient safety advocate - ✔A. Ethics committee -The nurse may be experiencing moral distress in this situation. Of the options listed, the ethics committee is the best resource to clarify the concept of double effect, where a legitimate act, such as relieving pain at the end of life, causes an undesired effect, such as oversedation or a slightly shortened life. -Before making a change in care practices or using new products, the first step is to review available scientific literature related to the product and the condition it is designed to impact. -After synthesizing the literature, the unit team can consider appropriate next steps, such as a product demonstration or the development of a protocol. -Key stakeholders should be identified and may include the unit's medical director and others. An adolescent with a terminal condition tells the nurse that she no longer wants aggressive treatment. Her father agrees, but her mother is adamantly opposed. The parents are divorced, but share custody. The most appropriate nursing response is to: A. Tell the parents to respect their child's wishes B. Ask the parents to speak privately and seek resolution C. Explain that the mother's wishes take priority D. Contact the social worker to begin conflict resolution - ✔D. Contact the social worker to begin conflict resolution -This sensitive situation calls for expertise on the part of the healthcare providers. The unit's social worker (or equivalent) is in the best position to begin the process of exploring the family's emotional needs and desires. -The next step may be a family meeting or care conference with the team. -The other options listed do not adequately move the process toward resolution. During a cardiopulmonary resuscitation event, the nurse notices the child's parents standing together in the corner of the room crying. What's the nurse's best response? A. Gently escort them to the family waiting area B. Stand near them and explain what is happening C. Notify them that family cannot be present during CPR D. Ask the nurse manager to intervene - ✔B. Stand near them and explain what is happening -The nurse's best option in this scenario is to be a supportive presence. -After explaining what is happening, the nurse can offer the parents the option of staying in the room, or close by if they choose. -Parents may need "permission" that it's okay to stay or step away if they are overwhelmed. -Family support should be an assigned role during any resuscitation, just like compressions or airway management. An adolescent is admitted after an intentional medication overdose. Although assigned female gender at birth, the patient identifies as male. How should the nurse respond? A. Refer to the patient as "her" or "she" B. Refer to the patient as "him" or "he" C. Assess the genitalia and notify the provider D. Assess the genitalia and notify the social worker - ✔B. Refer to the patient as "him" or "he" -Gender assignment at birth and gender identity are two different things. The nurse's best response in this scenario is to respect the patient's identity preference and use the pronouns "him" or "he." -While the provider and social worker will need information regarding the patient's preference, it is not appropriate to assess the genitalia specifically to determine gender identity in this scenario. A patient with a newly diagnosed condition is being discharged. The mother goes to the pharmacy to pick up the child's medications and returns to the unit without them after being told the insurance provider doesn't cover them. What is the nurse's best response? A. Tell the mother to follow up with the primary care provider B. Obtain today's doses of the medication and give to the mother C. Notify the social worker or case manager of the situation D. Suggest the mother return to the pharmacy and pay in cash - ✔C. Notify the social worker or case manager of the situation -The unit's social worker or case manager should have the expertise to ensure the patient has what is needed to manage care at home, including prescription medications. -In this scenario, the nurse's best response is to seek assistance from those who can help the family navigate the system. A child has just died. What's the nurse's best response to the parents? A." You can always have other children" B. "She's in a better place now" C. "I'm so sorry for your loss" D. "It's God's will when children die". - ✔C. "I'm so sorry for your loss" -The loss of a child is unimaginable for parents. -Being a quiet, supportive presence and offering a simple condolence, such as "I'm sorry," is a good initial response in this scenario. -The other options minimize the parents' emotions and do not give them a space to grieve A large pediatric/adult hospital is implementing a new continuous renal replacement therapy. Crucial considerations in the process include identifying equipment, financial resources and: A. Key stakeholders B. Staff educators C. Appropriate patients D. Attending physicians - ✔A. Key stakeholders -From a systems thinking perspective, key stakeholder identification is vital in the early stages of a major planned change. -Stakeholders from both pediatric and adult areas may include nurses, physicians, educators, and others who will be impacted by the change. Decision- making and planning should include everyone's input. The mother of a child experiencing delirium is worried about her child's condition. How can the nurse best support the mother? A. Give the mother written information about delirium B. Have the physician talk with the mother about delirium C. Assess the mother's understanding of delirium D. Have the mother of another delirious child speak with her - ✔C. Assess the mother's understanding of delirium -Parents of a delirious child may be fearful that the condition is permanent. -In this scenario, the nurse should first explore the mother's understanding of her child's condition and the expected course. -With this knowledge, the nurse can then plan appropriate interventions to support the mother. -These may include giving the mother written information or having a provider answer her additional questions.