RN Pediatric Nursing Online Practice A
A nurse in an emergency department is caring for a school-age child who is
experiencing an anaphylactic reaction. Which of the following is the priority action by the
nurse?
Administer epinephrine IM
Rationale: When using the urgent vs. non-urgent approach to client care, the nurse
should determine that the priority action is administering epinephrine IM to the child.
During an anaphylactic reaction, histamine release causes bronchoconstriction and
vasodilation. This is an emergency because ultimately it causes decreased blood return
to the heart.
A nurse in a pediatric emergency department is planning care for an adolescent. Based
on the information in the adolescent's medical record, which of the following actions
should the nurse plan to take?
Select all that apply.
Apply supplemental oxygen
Rationale: According to the medical record and chest x-ray report, the adolescent could
potentially have a pneumothorax. Also according to the medical record and chest x-ray
report, the adolescent's oxygen saturation level is decreasing, which indicates hypoxia.
Therefore, the nurse should plan to administer supplemental oxygen.
Prepare for chest tube insertion
Rationale: According to the medical record and chest x-ray report, the adolescent could
potentially have a pneumothorax. A pneumothorax is the presence of air in the pleural
cavity, which results in decreased lung expansion. The adolescent could experience
dyspnea, tachypnea, tachycardia, hypoxia, and pain. This requires prompt intervention
by the provider, such as the placement of a chest tube into the thoracic cavity to remove
air and fluid from the pleural space, if present, allowing the lung to re-expand.
A nurse in an emergency department is caring for a school-age child who has
epiglottitis. Which of the following actions should the nurse take?
Monitor the child's oxygen saturation
Rationale: The nurse should monitor the child's oxygen saturation level because the
child is experiencing acute respiratory distress and it is necessary to determine if the
child is responding to treatment.