Peds CCRN Review Questions with answers 2023 (from AACN), Exams of Nursing

Download Peds CCRN Review Questions with answers 2023 (from AACN) and more Exams Nursing in PDF only on Docsity! Peds CCRN Review Questions with answers 2023(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 ✔C. Pneumothorax These patients typically have thick secretions, mucosal edema, and bronchoconstriction, all of which put them at risk for increased airway resistance and air trapping. This, in turn, places them at higher risk for the development of pneumothoraces associated with positive pressure ventilation. A patient with status asthmatics is increasingly somnolent and only able to speak one word between breaths. The priority intervention is: A. Increasing the beta-agonist B. Chest tube placement C. Inhaled nitric oxide D. Intubation ✔D. Intubation This patient is exhibiting changes in level of consciousness and worsening respiratory distress. The priority intervention at this point is intubation and airway protection. A chest tube may be needed if a pneumothorax develops. The primary objective in the treatment of an infant with pulmonary hypertension is to: A. Maintain the pH level <7.40 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 In prerenal AKI, oliguria is the body's compensatory mechanism to: A. Conserve bicarbonate to alter the acid-base balance B. Increase the glomerular filtration rate C. Restore the intravascular volume to increase tissue perfusion D. Excrete potassium to maintain electrolyte balance ✔C. Restore the intravascular volume to increase tissue perfusion. -Oliguria (a significant decrease in urine output) is the body's compensatory mechanism to retain more fluid, increase intravascular volume, and thereby improve tissue perfusion. Common laboratory findings associated with AKI include an increase in the BUN level, as well as which of the following changes in the concentrations of potassium and creatinine? A. Increased potassium and increased creatinine B. Decreased potassium and increased creatinine C. Increased potassium and decreased creatinine D. Decreased potassium and decreased creatinine ✔A. Increased potassium and increased creatinine -In AKI, there is an accumulation of nitrogenous waste products (BUN and creatinine). Additionally, many patients develop hyperkalemia as the result of injury to the distal tubules. -Hypokalemia and/or a decreased serum creatinine are not commonly seen in AKI. Which is a potential result of a significant, sudden occurrence of hyponatremia? A. Respiratory failure B. Cerebral edema C. Hypotension D. Hyperkalemia ✔B. Cerebral edema -A significant, sudden decrease in serum Na+ levels will result in a sudden decrease in serum osmolality. This, in turn, will lead to a shift of fluid into the intracellular space. -When there is a significant decrease in serum Na over a short period of time, this can result in cerebral edema and increased ICP. Classic signs of hemolytic uremic syndrome (HUS) include: A. Chronic kidney disease, oliguria, and pernicious anemia B. Chronic kidney disease, leukopenia, and hemolytic anemia C. Thrombocytopenia, hemolytic anemia, and acute kidney injury D. Acute kidney injury, positive Coombs test, and anemia ✔C. Thrombocytopenia, hemolytic anemia, and acute kidney injury. The priority intervention for symptomatic hyperkalemia is: A. Initiation of CVVH B. Administration of 20 mL/kg fluid bolus C. Administration of sodium polystyrene D. Administration of insulin and glucose ✔D. Administration of insulin and glucose -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. receiving multiple, large-volume blood transfusions? A. Hypernatremia and hyperphosphatemia B. Hypocalcemia and hypophosphatemia C. Hyperkalemia and hyponatremia D. Hypocalcemia and hyperkalemia ✔D. Hypocalcemia and hyperkalemia -Patients who receive large-volume blood transfusions must be monitored for the development of hypocalcemia and hyperkalemia. -The hypocalcemia is the result of calcium binding to the citrate used as a preservative in the blood -The hyperkalemia is typically associated with the breakdown of cells in "older" blood. Which should be avoided in the patient with sickle cell disease? A. Opioids B. Oxygen C. Dehydration D. Normothermia ✔C. Dehydration Management strategies for the patient with sickle cell disease include providing hydration, oxygenation, pain control, and antibiotics if infection is a suspected cause The triad of metabolic disturbances most frequently seen with tumor lysis syndrome is: A. Hypophosphatemia, hyperkalemia, hypercalcemia B. Hyperphosphatemia, hyperkalemia, hyperuricemia C. Hyperphosphatemia, hyperuricemia, hypocalcemia D. Hypophosphatemia, hypokalemia, hypocalcemia ✔B. Hyperphosphatemia, hyperkalemia, hyperuricemia -Tumor cells have a higher concentration of potassium and phosphorous than normal cells do. -The hyperuricemia is from the breakdown of nucleic acids in tumor cells. -The hypocalcemia that occurs is secondary to the hyperphosphatemia. Strategies for managing tumor lysis syndrome include increasing: A. Oral potassium intake B. Hydration C. Intravenous phosphate intake D. Uric acid production ✔B. Hydration -The purpose of hydration is to maximize renal excretion of potassium, phosphate, and uric acid. -It would be contraindicated to administer potassium or phosphate to this patient. -An additional goal is to decrease the uric acid level, not increase production. A toddler was extubated 2 days ago after 10 days of mechanical ventilation for viral bronchiolitis. With your initial assessment, you note bleeding from the patient's nares and two large bruises on the chest, with petechiae on all extremities. Lab results demonstrate a normal PT/PTT and D-dimer, but the platelet count is significantly decreased. What do you suspect? A. Disseminated intravascular coagulopathy B. Thrombotic thrombocytopenic purpura C. Idiopathic thrombocytopenic purpura D. Hemolytic uremic syndrome ✔C. Idiopathic thrombocytopenic purpura -ITP is an immune-mediated decrease in platelet count. -It often occurs following a viral infection. -Diagnostic studies will reveal a low platelet count, but normal PT/PTT and D-dimer. A child having a seizure has a serum sodium level of 125 mEq/L and a decreased urine output. What disease process is most likely? A. Diabetes mellitus (DM) B. Syndrome of inappropriate antidiuretic hormone (SIADH) C. Diabetes insipidus (DI) D. Diabetic ketoacidosis (DKA) ✔B. Syndrome of inappropriate antidiuretic hormone (SIADH) -The symptoms of SIADH include hyponatremia and decreased urine output. -The child is likely having a seizure because of the low serum sodium. -A child with DI would have an increased serum sodium level and a significantly increased urine output. -Diabetes mellitus and DKA are disorders of glucose control. Which parameters signal the development of SIADH? A. Decreased serum sodium, decreased serum osmolality B. Increased serum sodium, increased serum osmolality C. Decreased serum sodium, increased serum osmolality D. Increased serum sodium, decreased serum osmolality ✔A. Decreased serum sodium; decreased serum osmolality -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. 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 C. Immobility D. Dry skin ✔C. Immobility -Immobility puts a patient at risk for the development of a pressure injury. -Other risk factors include poor nutrition, moisture problems, and shearing forces. A critically ill patient is hypotensive with pale, mottled, and cool extremities. The nurse should be concerned for: A. Skin failure B. Bacterial colonization C. Over hydration D. Dehydration ✔A. Skin failure -Skin failure can occur when blood is shunted away from the skin to other vital organs in a critically ill patient. -It is also associated with impaired temperature control and metabolic conditions. -Skin failure and the injuries it causes may not be preventable. Pressure injuries may be prevented by ensuring the patient has: A. Appropriate antibiotics B. Adequate hemoglobin C. Frequent repositioning D. A wound care consult ✔C. Frequent repositioning -Frequent repositioning of the patient helps relieve pressure to bony prominences. -Other strategies to prevent pressure injuries include performing a thorough skin assessment on admission and every shift, ensuring adequate nutrition, and keeping the skin clean and dry. You are caring for a patient in hypovolemic shock. You would expect which of the following hemodynamic findings? A. Decreased HR B. Increased pulmonary occlusion pressure C. Decreased mean arterial pressure D. Increased systemic vascular resistance ✔D. Increased systemic vascular resistance -Children in hypovolemic shock will initially respond with an increase in systemic vascular resistance (eg, cool extremities, vasoconstriction, etc.). -A decreased HR and decreased mean arterial pressure would be seen as no longer being able to compensate You are caring for a patient with septic shock. The patient is intubated and mechanically ventilated with normal ABG results. The patient has received a total of 20 mL/kg of isotonic fluids for persistent hypotension without improvement and remains febrile, with a temperature of 40.3°C rectally. You anticipate the next intervention will be: A. Consult with the team about adjusting the ventilator settings B. Place a rectal probe and begin external cooling C. Start an epinephrine infusion D. Repeat a fluid bolus of 20 mL/kg ✔D. Repeat a fluid bolus of 20 mL/kg -Children with septic shock typically have very large fluid deficits. -Most children require at least 40-60 mL/kg, but some may require as much as 200 mL/kg. -There is no indication that ventilator settings need to be adjusted. -The other two interventions (epinephrine and cooling) may be indicated, as well, but fluid resuscitation is the first priority. Lactic acid production occurs when there is: A. Improved cellular function B. Anaerobic metabolism C. Alteration in body temperature D. Aerobic metabolism ✔B. Anaerobic metabolism -As shock progresses to an uncompensated state, metabolism shifts from aerobic to anaerobic, resulting in increased production of lactic acid. The following blood gas results are consistent with which condition? pH 7.25 PaC02 61 mmHg Pa02 58 mmHg HCO3 24 mmHg A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis ✔A. Respiratory acidosis This blood gas result reveals a low pH, elevated CO2, low 02, and normal HCO3. We would expect to see a child with this blood gas in respiratory distress. A 4-month-old arrives with a 24-hour history of vomiting and diarrhea. The patient is lethargic, pale, cool, and clammy. Weak peripheral pulses can be palpated and her capillary refill time is >4 seconds. The child is in: A. Hypovolemic shock B. Septic shock C. Anaphylactic shock D. Cardiogenic shock ✔A. Hypovolemic shock -This patient's history and clinical exam are consistent with hypovolemic shock. -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 -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 -These clinical manifestations are an indication of poor cardiac output. -Decreased (not increased) urinary output would also be an indicator. -Cyanosis is an indication of oxygenation rather than cardiac output and perfusion. Stimulation of the sympathetic nervous system has which effect on the cardiovascular system? A. Decreases stroke volume and increases blood pressure B. Increases stroke volume and decreases blood pressure C. Slows conduction through the AV node D. Increases stroke volume and HR ✔D. Increases stroke volume and HR -As you review the choices, A and B don't make sense physiologically; decreasing stroke volume will decrease, not increase blood pressure so you should be able to eliminate those quickly. -Now consider the role of the sympathetic nervous system ("fight or flight"). -Increasing stroke volume and HR would happen when the sympathetic nervous system is activated. A slowing down of the conduction system would not. Which of these will likely decrease myocardial oxygen demand? A. Pain control B. Arrhythmias C. Exercise D. Fever ✔A. Pain control Of the items listed, only improving pain control will decrease a patient's myocardial oxygen demand. Things like arrhythmias, exercise, and fever all increase oxygen demand. A patient with congestive heart failure would most likely exhibit all of the following clinical manifestations except: A. Increased urine output B. Decreased cardiac output C. Hepatomegaly D. Cardiomegaly ✔A. Increased urine output -Patients with congestive heart failure typically exhibit increased heart size, fluid volume overload with decreased urine output, and hepatomegaly-not increased urine output. A child is admitted in a hypertensive crisis and vasodilators are ordered. The nurse understands that the intention is to improve cardiac function through: A. Increasing SVR B. Inotropic and chronotropic actions C. Decreasing afterload D. Improving renal function ✔C. Decreasing afterload -Introducing vasodilators into this child's medical management will allow for reduction of systemic vascular pressures, thereby reducing afterload. -Medications that increase SVR or have inotropic and chronotropic actions would worsen this situation. A 16-year-old crashes her car into a wooden fence and is impaled through the chest by a fence post. She presents with significant shortness of breath. You are unable to auscultate breath sounds on the right side and you palpate crepitus throughout the right side of the chest. Her HR is 146 and you are unable to obtain a blood pressure. She is most likely experiencing: A. Cardiomyopathy B. Cardiogenic shock C. Hypertensive crisis D. Cardiogenic/obstructive shock ✔D. Cardiogenic/obstructive shock -Cardiogenic/obstructive shock occurs when cardiac output is obstructed and there is an inability to provide adequate tissue perfusion despite normal intravascular volume and myocardial function. -Causes include trauma to the great vessels, tamponade, pulmonary embolism, valvular stenosis, and coarctation of the aorta A child experiences sudden cardiac death after playing soccer. The most likely etiology is: A. Restrictive cardiomyopathy B. Hypertrophic cardiomyopathy C. Dilated cardiomyopathy D. Kawasaki disease ✔B. Hypertrophic cardiomyopathy 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. -It is ethically acceptable in this situation to use higher than normal dosages of pain and anxiety relieving medications. A nurse manager feels that the number of blood culture samples reported by the laboratory as "contaminated" is excessive. The most appropriate action for the nurse manager would be to: A. Observe the staff as they obtain blood culture samples B. Track the actual blood culture contamination rate C. Convene a staff meeting to discuss the problem D. Develop a poster demonstrating the correct procedure ✔B. Track the actual blood culture contamination rate -The first step of analyzing a potential problem is to collect actual data to determine whether or not the problem truly exists. -In this scenario, the blood culture contamination rate would be determined by evaluating the number of blood cultures drawn as compared to the number that are reported as contaminated. -Once that assessment is done, appropriate next steps such as direct observations or education can be determined. The parents of a toddler who is transferring out of the ICU state, "We want to stay one more day and then be discharged from the ICU." Which is the most appropriate response? A. "Aren't you glad there are sicker patients who needs this bed?" B. "You sound concerned about leaving the ICU" C. "They have great nurses in his new unit" D." We have to move him once he doesn't meet ICU criteria" ✔B. "You sound concerned about leaving the ICU" -Transfer from the ICU environment can be stressful for both the patient and family. This is particularly true after a long ICU stay, or when the child has been very ill. -Providing the parents with an opportunity to voice their concerns will allow the nurse to understand their questions and anxiety. With this knowledge, the nurse can better address the situation. The mother of a recently admitted, technology-dependent child tells the nurse that she has missed several clinic appointments. How can the nurse best help in this situation? A. Inform the social worker about the medical neglect B. Assess the mother's access to tangible resources C. Notify the clinic physician that the child is admitted D. Reassure the mother that she is doing her best ✔B. Assess the mother's access to tangible resources -The nurse's first response should be to further assess the mother's situation and determine why she has missed appointments. -Assessing tangible resources, like transportation, may better elicit the mother's needs and the nurse can then best respond from a systems thinking perspective. Parents need education and training to care for their child's new gastrostomy tube. When developing a teaching plan, the nurse must first: A. Obtain written information about the procedure B. Determine a schedule for demonstrating the technique 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.