Solutions
A preschooler has a small laceration that required 2 stitches. The nurse
covers the wound with a bandage knowing that it will comfort the child to
have it covered. What is the developmental reason for this intervention.
ANS - Preschoolers are magical thinkers and imagine bandages keep their
insides from coming out.
A 7-month old presents to the ED with a complaint of fever. Assessment
reveals a patent airway and a slight cyanosis around his lips and nail beds.
He is alert and interactive. His vital signs are 38.5 (101.3), HR 134, RR 32, BP
78/54 mm Hg, and SPO2 of 84%. The nurse notes a healed surgical scar on
his chest.Based on this assessment, what is the nurse's priority? ANS - As
if the SPO2 is normal for him.
An 11-year-old presents to the ED with a complaint of hitting his head while
playing soccer. The nurse enters the room and performs an across the room
assessment. He is starting at the wall. He has no increased work of breathing
and his color is pink. Using the PAT what classification will the nurse assign?
ANS - Sicker
The pediatric prioritization process components include the focused
assessment, focused history, acuity rating decision and: ANS - The
pediatric assessment triangle (PAT)
A 2-year-old is brought to the ED by her father when he found her face down
in the pool. She remains unresponsive and is breathing shallowly and slowly.
Her color is pale. What is the priority? ANS - Immobilize the cervical spine
A 2-year-old has a suspected cervical spinal injury. In order to ensure neutral
spinal alignment, padding should be placed under which area? ANS - The
shoulders.
Test the Ph of the gastric contents. ANS - The nurse is preparing to
administer a feeding through an NG tube. The tube position was verified by
radiograph after insertion 2 hours ago. What is the best way to verify
placement before feeding?
A 20-ml syringe with a stopcock ANS - What is the best method to rapidly
administer a 20 ml/kg bolus of 0.9% normal saline to a pediatric patient
weighing 8 kg.