Which postoperative nursing care must be provided for the child who had a tonsillectomy Quizlet

4 Rationale:
COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All the problems listed are potentially appropriate for a client with COPD. For the nurse prioritizing this client's problems, it is important first to maintain circulation, airway, and breathing. At present, the client demonstrates problems with ventilation because of ineffective coughing, so the correct option would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The client's respiratory rate is only slightly elevated, so option 3, altered breathing pattern is not as important as airway. The client is cyanotic, but this probably is owing to the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support lo

A nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings?
1. pH, 7.40; Pao2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L
2. pH, 7.32; Pao2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L
3. pH, 7.47; Pao2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L
4. pH, 7.31; Pao2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L

4 Rationale:
Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. Options 1, 2, and 3 are not clinical manifestations of respiratory alkalosis.

A client is admitted to the hospital 24 hours following an aspirin (acetylsalicylic acid) overdose. The nurse assesses this client for which signs/symptoms, indicating the acid-base disturbance that could occur in the client?
1.Bradypnea, dizziness, and paresthesias
2.Bradycardia, listlessness, and hyperactivity
3.Headache, nausea, vomiting, and diarrhea
4.Restlessness, confusion, and a positive Trousseau's sign

3 Rationale:
The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours after the poisoning. If metabolic acidosis occurs, the client may exhibit hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity-smelling breath because of improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia. Shortly after aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours post-overdose, however, the compensatory mechanism fails and the client reverts to metabolic acidosis.

1 Rationale:
Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. The clinical picture does not include hypercalcemia, hypochloremia, or hypernatremia.

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The nurse is assessing a 5-month-old infant who presents with signs of respiratory infection. What signs are the nurse most likely to find?

Mild diarrhea

Blocked nasal passages

Watery nasal discharge

Coughing

The parent of a child with cystic fibrosis calls the clinic nurse to report that the child has developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent to bring the child to the clinic because these symptoms are suggestive of:

pneumothorax

The nurse is caring for a child who presents with a respiratory tract infection and is febrile. The child has also been vomiting frequently. What should be the most immediate nursing care action?

Administer an infalyte or pedialyte solution.

The nurse is caring for a child that has a persistent cough for two days and a fever of over 38.3° C. What should be included in the nursing Interventions if the primary health care provider suspects nasopharyngitis?

Obtain throat swab for culture or perform rapid antigen testing.

Instruct the parents to administer oral antibiotics as prescribed.

Obtain a prescription to administer antipyretics when needed.

The primary health care provider speculates that a child has sleep-disordered breathing and prescribes diagnostic tests. What are the most appropriate interventions by the nurse to aid in diagnosis?

Observe the child's nightlysleep patterns.

Insert the pH probe into the esophagus

Ensure accurate placement by radiography.

The parents ask the nurse about nursing care of a child with sleep-disordered breathing. What areas should the nurse include in the instructions about how to care for the child?

Dietary counseling and weight managementof the child

A child's tonsils and pharynx are inflamed and covered with exudate. The primary health care provider performs a throat culture. How should the nurse explain the diagnostic test to the concerned parent?

"It is a way to test for Group A Beta-hemolytic Streptococcal Infections or GABHS."

A child is diagnosed with pulmonary edema and suffering from acute tachydysrhythmia. What should the nurse include in the plan of care as the most important intervention?

Monitor pulse oximetry

A 4-year-old boy needs to use a metered-dose inhaler to treat asthma. He cannot coordinate the breathing to use it effectively. The nurse should suggest that he use a:

spacer.

The nurse is teaching a group of students about preventing respiratory infections. Which statement by a student suggests a need for additional teaching?

"Playing with ill children is safe."
"Reuse tissues to cover the mouth when sneezing."
"Keep away from children who are at risk."

A child with nasopharyngitis is prescribed rest, a humidified environment, and lots of fluids at home. However, the parents are concerned and ask the attending nurse for signs of crisis when they should bring the child to the primary health care provider. What signs should the nurse teach the parents to report?

If there are signs of an earache or poor sleep
Respirations faster than 50 to 60 breaths/min
Fever over 38.3° C or101° F and refusal to eat
Persistent cough that lasts for 2 days or more

The nurse is caring for a 13-month-old patient with dehydration and diarrhea. What beverages does the nurse use to rehydrate the infant?

Oral rehydration solutions
Water
Low-carbohydrate drink

The mother of a 20-month-old boy tells the nurse that he has a barking cough at night. His temperature is 37° C. The nurse suspects croup and should recommend:

trying a cool-mist vaporizer at night and watching for signs of difficulty breathing.

When obtaining the history of a 6-month-old with possible respiratory syncytial virus (RSV), the nurse asks the parents about the infant's health history. What information would the nurse anticipate hearing from the parents to help determine if RSV is the problem?

The infant was born in November to a 17-year-old mother who didn't finish high school.

The nurse is caring for a child with dyspnea, shortness of breath, and nasal flaring. What does the nurse do in order to promote chest expansion and maintain a patent airway?

Position the child to facilitate the drainage of secretions and ventilatory efficiency.Provide humidified oxygen, suction the airway, and give bronchodilator medications.Assist with coughing and administer anti-inflammatory and antipyretic medications

The nurse is educating new parents on how to prevent the occurrence of acute otitis media (AOM) in the child. What preventive measures does the nurse include in the teaching?

Breastfeed the infants for at least 6 months.
Discontinue use of the pacifier after 6 months.
Preventing exposure to second hand smoke

A child presents with hoarseness and laryngeal discomfort due to a respiratory tract infection. The parents ask the nurse about nursing care at home to make the child more comfortable. What is the most appropriate response by the nurse?

"Use warm or cool mist under parental supervision. It will soothe inflamed membranes."

A child presents with chest pain, labored respirations, and decreased oxygen saturation. After diagnosis, the primary health care provider diagnosis the child with a pneumothorax. How should the nurse explain this condition to the child's parents? "Your child:

"Has an accumulation of air in the pleural space that causes respiratory distress."

The mother of a 6-month-old with a second upper respiratory infection in two and a half months asks the pediatric nurse why these infections are happening so often at this time. Which response by the nurse is best?

"Your maternal antibodies have been decreasing during this time and your baby hasn't begun making his or her own yet."

A child presents with a persistent fever, cough, and mild tightness in the chest. What are the most appropriate questions that the nurse should ask to determine the risk of latent tuberculosis infection (LTBI) in the child?

Did any of your family members ever have tuberculosis disease?"

"Did your child recently travel to any of the high risk countries?"

"Did your child have a caretaker who has had tuberculosis recently?"

Cystic fibrosis may affect singular or multiple systems of the body. The primary factor responsible for possible multiple clinical manifestations is:

mechanical obstruction caused by increased viscosity of mucous gland secretions.

Because the absorption of fat-soluble vitamins is decreased in children with cystic fibrosis, supplementation of which vitamins is necessary?

A, D, E, K

When an infant chokes on a piece of food, an immediate intervention is to:

position the infant in a head-down, face-down position and administer five quick blows between the shoulder blades.

Parents of a child with nasal congestion ask the nurse about using saline nose drops in order to clear the nasal passages. What should be the nurse's response to explain the procedure of how to prepare the saline drops? "You can dissolve:

"1 teaspoon of salt in 1 pint of warm water."

The nurse is caring for a teenager with a respiratory infection. The patient's mother asks the nurse, "Can you tell me what germs are usually responsible for such respiratory infections?" What is an appropriate response by the nurse? .

Respiratory syncytial virus
Nonpolio enteroviruses
Parainfluenza viruses
Haemophilus influenza

The nurse is teaching a group of students about pertussis. The nurse says, "Pertussis and several other respiratory infections are common in young children." What represents the possible etiology for that statement?

Children have weaker immune systems.

Children have small airways.

Children are exposed to more germs.

A child in the school frequently puts foreign objects in their mouth. What should be the most appropriate action by the nurse?

Educate parents alone or in groups about hazards of aspiration.

The parents are taking a child home after having a tonsillectomy. What discharge instructions should the nurse provide to the parents?

Do not give the child highly seasoned foods."

"Do not let the child cough or clear the throat."

"Use analgesics or apply an ice collar for pain."

The nurse is caring for a child who has recently undergone a tonsillectomy. What steps should the nurse take to facilitate drainage of the secretions?

Place the child on the abdomen.

A 5-year-old child presents with common cold and infrequent coughing. The child's mother tells the nurse, "I'm using cough suppressants because they bring my child so much comfort." What is an appropriate response by the nurse?

"It is better to avoid cough suppressants."

The parents of a child who has infectious mononucleosis are concerned. Which symptoms does the nurse ask the parents to watch out for as a sign to bring the child in to be evaluated by the primary health care provider?

Difficulty in breathing

Pain in the abdomen

Inability to drink liquid

Respiratory stridor

The parents of a 4-year-old child are concerned after their child is diagnosed with an obstructive sleep-disordered breathing. How should the nurse explain the condition to the parents? "Your child has:

"An upper airway disorder of breathing that happens during sleep."

A humidified atmosphere is recommended for a young child with an upper respiratory tract infection because this environment facilitates:

soothing inflamed mucous membrane.

A 3-year-old has just returned from the postanesthesia care unit after a tonsillectomy and has been transferred into his or her bed. What nursing activities would be performed within the first hour after arrival?

Assess vital signs, including oxygenation saturation, check for bleeding and frequent swallowing, and position the patient on his or her side.

A child has bronchiolitis and the primary health care provider has prescribed the child to be treated by humidified oxygen and medications at home. The concerned parents ask the nurse whether their child needs hospitalization. What symptoms should the nurse teach the parents to report to the primary health care provider?

Acute respiratory distress and inadequate hydration
2
An underlying or debilitating lung or heart condition

A 3-year-old child is diagnosed with acute laryngotracheobronchitis (LTB). The graduate nurse asks for help from the senior nurse as the child is extremely restless. What should the senior nurse advise the graduate nurse about managing the care of this child?

Continuously observe and assess the child's respiratory status."

"Pulse oximetry should be assessed often to monitor oxygenation status

"Therapy should be adapted based on the child's response and tolerance."

The health care provider prescribes acetaminophen (Tylenol) to the child with a respiratory tract infection. What instructions should the nurse provide the parents about the administration of the medicine?

"Administer the drug at correct intervals."

"Read the label on the medicine before administering."

"Calculate the dose as prescribed."

The nurse is caring for a newly admitted 6-month-old with suspected respiratory syncytial virus (RSV) with these vital signs: temperature 101.2 (ax), pulse 130, respiration 56, and oxygen saturation of 89% on room air. What activities would the nurse anticipate doing within the first three hours of admission?

Obtain a culture of the nasal secretions and calculate the infant's fluid requirements.

The nurse is teaching a group of children and their parents about ways to prevent the spread of respiratory tract infections. What should the nurse ask the parents to do in order to prevent the spread of such infection?

"Perform frequent hand hygiene and avoid hand-to-mouth contact."

"Cover mouth when coughing and safely dispose of the secretions."

The nurse is caring for a 12-year-old patient with an acute febrile illness. What signs in the patient will the nurse observe to assess improvement?

increase activity

The nurse is teaching a group of students about respiratory infections in children. What statement by a student indicates a need for additional teaching?

"Respiratory infections become more frequent by 5 years of age."

The nurse is caring for a 10-year-old child with a severe cold and a runny nose. The patient's parent tells the nurse, "Steam really helps. I plan to use steam vaporizers for the cold." What is an appropriate response by the nurse?

"Steam baths can be helpful."

A 3-year-old toddler is being discharged post-tonsillectomy and the parents ask what he or she should be allowed to eat and drink. Teaching by the nurse has been effective if the parents choose which foods and fluids for the first few days at home?

scrambled eggs, banana popsicles, mashed potatoes, sweetened ice tea, and apple juice

Asthma is classified into four categories: mild intermittent, mild persistent, moderate persistent, and severe persistent. Clinical features used to determine these categories include:

lung function.
frequency of symptoms.
frequency and severity of exacerbations.

The nurse is caring for a child with acute laryngotracheobronchitis (LTB). What assessment findings noted by the nurse would warrant immediate notification of the primary health care provider?

Increased pulse and increased respiratory rate
Substernal, suprasternal, or intercostal retractions
Flaring of the nares and increased restlessness

The primary health care provider instructs the nurse not to administer antihistamines to a child. A graduate nurse asks the senior nurse about the reason. What should be the most appropriate response of the senior nurse?

It can cause drowsiness or stimulation

What should be included in a plan of care as Nursing Interventions for a child admitted with acute otitis media?

Relieve the pain and facilitate drainage of the ear.

Prevent complications or recurrence of infection.

Educate the family and provide emotional support.

What are the general clinical manifestations of nasopharyngitis in younger children?

Fever

Irritability

Sneezing

Vomiting

Diarrhea

A 4-year-old girl is brought to the emergency room. She has a "froglike" croaking sound on inspiration and is agitated and drooling. She insists on sitting upright. The nurse should:

Notify the physician immediately and be prepared to assist with a tracheostomy or intubation.

A child with bacterial pneumonia is prescribed antibiotics as well as supplemental oxygen. The child also requires sufficient fluids. In addition to this, the child has chest tube to remove air from the intrathoracic space. What should the nurse include in the plan of care of this child? Select all that apply.

Carefully assess the respiratory status.

Monitor functions of chest tube and drainage device.

Monitor chest tube insertion site to ensure patency.

A child with tonsillitis requires nursing care. The child has recently undergone a tonsillectomy. What should the nurse include in the plan of care in order to minimize the risk of bleeding during the post-operative period?

Give the child a soft or a liquid diet

Instruct the child how to use a cool-mist vaporizer.

Instruct on warm salt-water gargles.

Provide analgesic-antipyretic drugs.

A febrile 6-month-old with severe nasal congestion is unable to feed or sleep well. What suggestions should the nurse make to the parents to help relieve the infant's symptoms?

"Use the bulb suction to remove secretions from your baby's nose and have the cool mist vaporizer wherever the infant is."

The parents of a child with pertussis ask the nurse about the nursing care and management of their child at home. What should the nurse include in the teaching plan for the parents?

Encourage adequate hydration.
Administer antipyretics.
Provide adequate psychological support.

A child is diagnosed with infectious mononucleosis. The child has a fever, exudative pharyngitis, and lymphadenopathy. The parents are concerned and ask the nurse for further clarification. What should be the most appropriate response of the nurse to clarify the condition?

"It is an acute, self-limiting infectious disease caused by herpes-like virus."

The nurse is assessing a child who is undergoing treatment for tonsillitis. The nurse needs to assess for enlargement of the palatine tonsils. In which anatomic area should the nurse expect to locate the palatine tonsil?

3

A 9-year-old child complains of a runny nose and significant respiratory discomfort. What is an appropriate nursing action to bring symptomatic relief to the patient?

Use a cool or warm mist for comfort.

A 6-month-old infant with respiratory syncytial virus (RSV) has the following vital signs: temperature 100.4 (ax), pulse 140, respiration 68, oxygen saturation 92%, and has just had his or her nose bulb suctioned. What action should the nurse take to best determine the effectiveness of the suctioning?

Recount the respirations.

A child born before 32 weeks of gestation is prescribed to have palivizumab (Synagis) monthly to prevent hospitalization associated with respiratory syncytial virus (RSV). How should the nurse administer the medication to the child?

Administer within 6 hours of being reconstituted with sterile water.

The nurse recognizes signs of respiratory failure in the child admitted to the pediatric unit for cancer treatment. Soon the child undergoes respiratory arrest. What are the most appropriate resuscitative measures that the nurse should implement?

Insert an endotracheal tube.
Position the airway.
Administer oxygen via mask.

The parents of a 3-year-old with chronic tonsillitis ask when the tonsils can be removed. Which response by the nurse would reinforce what the health care provider would have told the parents?

"Surgery can be scheduled for several weeks from now as long as no tonsillitis recurs near the time of surgery."

A child who is at high risk for developing a respiratory emergency is left under the care of an experienced nurse. What assessment findings should the nurse observe for in order to initiate resuscitative measures for respiratory failure?

Hypo- or hypertensive changes

Change inlevel of consciousness

Tachypnea or rapid breathing

Tachycardia or rapid heart rate

The primary health care provider prescribes a nasal spray for an older child. What precautionary instructions should the nurse provide the parents and the child on the use of the nasal sprays? "Do not:"

Share your nasal spray with anyone else in the family.

""Use nasal sprays for more than three consecutive days.

When caring for a child after a tonsillectomy, the nurse should:

watch for continuous swallowing.

A 5-year-old child is brought to the Emergency Department with abrupt onset of sore throat, pain with swallowing, fever, and sitting upright and forward. Acute epiglottitis is suspected. What are the most appropriate nursing interventions?

Vital signs
C. Medical history
D. Assessment of breath sounds
E. Emergency airway equipment readily available

It is important that a child with Group A ß-hemolytic streptococci (GABHS) infection be treated with antibiotics to prevent:

acute rheumatic fever.

The graduate nurse asks the senior nurse about the typical symptoms that can occur in a child who has otitis media. What should the senior nurse instruct about this condition?

When otitis media happens the functioning of the eustachian tubes is impaired.""This condition exposes the middle ear to all of the nasopharyngeal secretions.""The air pressure within the middle ear and the atmosphere is compromised."

A child with bronchiolitis is kept under the care of a graduate nurse. The new nurse needs to be educated about precautionary measures of such condition. What precautionary instructions about nursing care management should the senior nurse provide? "You should not:

Routinely administer corticosteroids and antihistamines.""Administer large amount of fluids through the mouth.""Routinely perform chest percussion and postural drainage.

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