Chapter 13 Key: Pediatric Nursing
Interventions Study Exam and
Answers
An infant is to receive a hepatitis B vaccine within a few hours after birth. What is the best
approach for the nurse to take when giving this medication? - correct answer: Administer the
medication in the infant's vastus lateralis with a 25-gauge needle.
The vastus lateralis site is a safe choice for IM injections in an infant. A 25-gauge needle is
recommended for infants. The Dorso gluteal site should not be used until the child has been
walking for one year. The deltoid muscle is not a recommended IM site for infants. pg. 384
The nurse is preparing to administer an IV antibiotic to a child. After calculating the
recommended dose with the child's weight, she discovers the ordered dose exceeds the safe
dose range in a pediatric drug book. The medication has been given to the child at this dose for
three days. What should the nurse's next action be? - correct answer: Verify the dose with the
prescribing practitioner.
Medication calculations should always be checked before giving the dose. When a medication
dose is found to be outside of the safe dose range, the dose should be verified with the
prescribing practitioner. Doses that exceed the recommended range should always be verified,
even if they have been given before. The parents did not prescribe this medication. Even if the
medication had been given for three days, it does not make the dose correct. Calling the
pharmacy can only verify if the dose is out of the safe range. The pharmacy did not prescribe
the medication, nor do they know the child's medical background. pg. 375
The nurse is preparing to give a diphtheria, pertussis, and tetanus (DPT) immunization to a child
in an acute care setting before discharge. The label on the DPT bottle indicates the
immunization expired yesterday. What is the correct nursing action to take? - correct answer:
Return the bottle to the pharmacy and request a replacement.
,The expired immunization bottle should be returned to the pharmacy and a replacement should
be requested. Never give expired medications. Simply discarding the bottle does not solve the
problem and it is not necessary to inform the prescribing practitioner. pg. 388
The nurse is caring for a 12-year-old post-appendectomy client who weighs 86 pounds. The child
has a temperature of 38.5 ºC (101.3 ºF). The nurse prepares to give the client a dose of oral
Tylenol. The order reads "Tylenol 15mg/kg/dose every 4 to 6 hours PO PRN for fever or pain."
How many milligrams of Tylenol should the nurse give the client? - correct answer: 587
milligrams
The child's weight must first be converted to kilograms by dividing 86 by 2.2. The result is 39.1
kilograms. Next, the 39.1 kilograms must be multiplied by 15 milligrams. This answer is 587
milligrams. pg. 377
An infant is to have a scalp-vein intravenous infusion begun. What is an advantage of this
insertion site? - correct answer: The scalp veins are easily visualized.
The scalp veins are easily visualized, being covered only by a thin layer of subcutaneous tissue.
These veins do not have valves, so the device may be inserted in either direction, although the
preference would be in the direction of blood flow. pg. 388
The nurse is caring for a 7-year-old with a low-profile gastrostomy tube placed 6 months ago.
Which is the priority intervention to prevent irritation of the skin at the insertion site? - correct
answer: Cleaning the surrounding skin with soap and water daily plus keeping the area dry
Daily cleansing with soap and water and keeping the area dry are essential. Moisture can create
irritation and encourage the growth of organisms in the warm, moist climate created. Alcohol
can sting if used on the area plus remove protective skin oils, promoting excess drying, which
can lead to skin breakdown. Cleaning under the bumper or disc with hydrogen peroxide is not
recommended because it is irritating and damaging to skin cells. Rotating the gastrostomy tube
or button daily is important to prevent adherence in the tract, but keeping the skin clean and
dry is the priority. pg. 399
, Immediately following administering a medication by enteral tube, the nurse will: - correct
answer: flush the tube with water.
It is important to flush the tube to ensure all of the medication reaches the child's digestive
tract and to prevent occlusion of the tube. Right (not left) side-lying position will aid in stomach
emptying, although it was not specified that the enteral tube was located in the stomach.
Elevating the head of the bed is done prior to placing material in the gastrointestinal tract.
Checking for signs of nausea and vomiting is always important but not the immediately
following nursing action in this situation. pg. 398
Apply adhesive bandages generously after venipuncture or finger punctures as young children
find bandages comforting. - correct answer: true
Apply pressure to the site with a dry gauze dressing and then cover with a small adhesive
bandage. If possible, allow the child to choose the bandage. pg 394
The nurse is preparing to administer a vaccine to a 6-month-old child. The medication is to be
given intramuscularly. The nurse is correct in choosing which administration site? - correct
answer: Vastus lateralis site
The preferred injection site for infants less than 7 months old is the vastus lateralis muscle. In
infants and children greater than 7 months old the ventrogluteal site should be considered. The
Dorso gluteal site, often used in adults, is not recommended in children younger than 5 years of
age. The deltoid muscle may be used in a child older than 3 years of age. pg. 382
The nurse is assessing a child who is receiving TPN. The nurse determines the TPN bag was hung
24 hours ago. What initial action by the nurse is indicated? - correct answer: Hang a new bag of
TPN.
Interventions Study Exam and
Answers
An infant is to receive a hepatitis B vaccine within a few hours after birth. What is the best
approach for the nurse to take when giving this medication? - correct answer: Administer the
medication in the infant's vastus lateralis with a 25-gauge needle.
The vastus lateralis site is a safe choice for IM injections in an infant. A 25-gauge needle is
recommended for infants. The Dorso gluteal site should not be used until the child has been
walking for one year. The deltoid muscle is not a recommended IM site for infants. pg. 384
The nurse is preparing to administer an IV antibiotic to a child. After calculating the
recommended dose with the child's weight, she discovers the ordered dose exceeds the safe
dose range in a pediatric drug book. The medication has been given to the child at this dose for
three days. What should the nurse's next action be? - correct answer: Verify the dose with the
prescribing practitioner.
Medication calculations should always be checked before giving the dose. When a medication
dose is found to be outside of the safe dose range, the dose should be verified with the
prescribing practitioner. Doses that exceed the recommended range should always be verified,
even if they have been given before. The parents did not prescribe this medication. Even if the
medication had been given for three days, it does not make the dose correct. Calling the
pharmacy can only verify if the dose is out of the safe range. The pharmacy did not prescribe
the medication, nor do they know the child's medical background. pg. 375
The nurse is preparing to give a diphtheria, pertussis, and tetanus (DPT) immunization to a child
in an acute care setting before discharge. The label on the DPT bottle indicates the
immunization expired yesterday. What is the correct nursing action to take? - correct answer:
Return the bottle to the pharmacy and request a replacement.
,The expired immunization bottle should be returned to the pharmacy and a replacement should
be requested. Never give expired medications. Simply discarding the bottle does not solve the
problem and it is not necessary to inform the prescribing practitioner. pg. 388
The nurse is caring for a 12-year-old post-appendectomy client who weighs 86 pounds. The child
has a temperature of 38.5 ºC (101.3 ºF). The nurse prepares to give the client a dose of oral
Tylenol. The order reads "Tylenol 15mg/kg/dose every 4 to 6 hours PO PRN for fever or pain."
How many milligrams of Tylenol should the nurse give the client? - correct answer: 587
milligrams
The child's weight must first be converted to kilograms by dividing 86 by 2.2. The result is 39.1
kilograms. Next, the 39.1 kilograms must be multiplied by 15 milligrams. This answer is 587
milligrams. pg. 377
An infant is to have a scalp-vein intravenous infusion begun. What is an advantage of this
insertion site? - correct answer: The scalp veins are easily visualized.
The scalp veins are easily visualized, being covered only by a thin layer of subcutaneous tissue.
These veins do not have valves, so the device may be inserted in either direction, although the
preference would be in the direction of blood flow. pg. 388
The nurse is caring for a 7-year-old with a low-profile gastrostomy tube placed 6 months ago.
Which is the priority intervention to prevent irritation of the skin at the insertion site? - correct
answer: Cleaning the surrounding skin with soap and water daily plus keeping the area dry
Daily cleansing with soap and water and keeping the area dry are essential. Moisture can create
irritation and encourage the growth of organisms in the warm, moist climate created. Alcohol
can sting if used on the area plus remove protective skin oils, promoting excess drying, which
can lead to skin breakdown. Cleaning under the bumper or disc with hydrogen peroxide is not
recommended because it is irritating and damaging to skin cells. Rotating the gastrostomy tube
or button daily is important to prevent adherence in the tract, but keeping the skin clean and
dry is the priority. pg. 399
, Immediately following administering a medication by enteral tube, the nurse will: - correct
answer: flush the tube with water.
It is important to flush the tube to ensure all of the medication reaches the child's digestive
tract and to prevent occlusion of the tube. Right (not left) side-lying position will aid in stomach
emptying, although it was not specified that the enteral tube was located in the stomach.
Elevating the head of the bed is done prior to placing material in the gastrointestinal tract.
Checking for signs of nausea and vomiting is always important but not the immediately
following nursing action in this situation. pg. 398
Apply adhesive bandages generously after venipuncture or finger punctures as young children
find bandages comforting. - correct answer: true
Apply pressure to the site with a dry gauze dressing and then cover with a small adhesive
bandage. If possible, allow the child to choose the bandage. pg 394
The nurse is preparing to administer a vaccine to a 6-month-old child. The medication is to be
given intramuscularly. The nurse is correct in choosing which administration site? - correct
answer: Vastus lateralis site
The preferred injection site for infants less than 7 months old is the vastus lateralis muscle. In
infants and children greater than 7 months old the ventrogluteal site should be considered. The
Dorso gluteal site, often used in adults, is not recommended in children younger than 5 years of
age. The deltoid muscle may be used in a child older than 3 years of age. pg. 382
The nurse is assessing a child who is receiving TPN. The nurse determines the TPN bag was hung
24 hours ago. What initial action by the nurse is indicated? - correct answer: Hang a new bag of
TPN.
