NCLEX Practice Exam for Pharmacology: Pediatric Medications

EXPLANATION

✔ Correct answer:

A normal saline IV infusion. In the initial management of diabetic ketoacidosis (DKA), the primary goal is to correct dehydration and electrolyte imbalances. Normal saline (0.9% sodium chloride) is the recommended initial fluid for rehydration. This helps to restore circulatory volume and improve perfusion to vital organs.

DKA is characterized by hyperglycemia, ketosis, and metabolic acidosis. The resulting osmotic diuresis leads to significant fluid loss and dehydration. Administering normal saline helps to correct hypovolemia and prevent shock. After initial rehydration, other fluids and electrolytes may be adjusted based on laboratory results and clinical response.

Imagine a plant that has dried out due to lack of water. The first step is to give it water to restore its hydration and health. Similarly, the first step in treating DKA is to rehydrate the body with normal saline to restore fluid balance and improve organ function.

Nurse Jamie should follow these steps in the initial management of a child with DKA:

• Administer a normal saline IV infusion to rehydrate the child and correct hypovolemia.
• Monitor vital signs, including blood pressure, heart rate, and respiratory rate, to assess the child's response to fluid resuscitation.
• Check blood glucose levels frequently to monitor for changes and guide further treatment.
• Monitor serum electrolytes, particularly potassium, as levels can fluctuate during treatment.
• Prepare for the administration of insulin to correct hyperglycemia and halt ketosis once initial rehydration is underway.

✘ Incorrect answer options:

A dextrose 5% IV infusion. Dextrose 5% is not appropriate as the initial fluid for rehydration in DKA. It is typically added later in treatment once blood glucose levels decrease to prevent hypoglycemia.

A Ringer’s Lactate solution. While Ringer's Lactate can be used for fluid resuscitation, it contains lactate, which may be metabolized to bicarbonate. This can complicate the management of acid-base balance in DKA, making normal saline the preferred initial fluid.

An IV infusion of potassium chloride. Potassium chloride may be needed during DKA treatment due to shifts in potassium levels. However, it is not the initial treatment. Potassium is usually added to the IV fluids after initial rehydration and once urine output is adequate to avoid hyperkalemia or hypokalemia.

EXPLANATION

✔ Correct answer:

Vastus lateralis. For intramuscular injections in infants, the vastus lateralis muscle is the preferred site. This muscle is located on the outer part of the thigh and is well-developed even in infants, making it a suitable and safe site for injections. The vastus lateralis can accommodate the required volume of medication and has fewer nerves and blood vessels compared to other sites, reducing the risk of complications.

The vastus lateralis muscle is a large and thick muscle, providing an ideal site for intramuscular injections in infants. It allows for proper absorption of the medication into the bloodstream. Additionally, this muscle is easily accessible and can be stabilized during the injection, which is important for ensuring accurate and safe administration in a young child.

Think of the vastus lateralis muscle as a large, open field where it's easy to safely land a small helicopter (the injection). This field has plenty of space and is free from obstacles (nerves and blood vessels), making it the best place to land.

Nurse Anna should follow these steps when administering an intramuscular injection to an infant:

• Position the infant securely, either on their back or held by a caregiver, to ensure the leg remains still during the injection.
• Locate the vastus lateralis muscle on the outer part of the infant’s thigh.
• Cleanse the injection site with an alcohol swab and allow it to dry.
• Insert the needle at a 90-degree angle to the skin, ensuring proper depth for intramuscular administration.
• Administer the medication slowly and steadily, then withdraw the needle and apply gentle pressure to the site with a clean gauze pad.
• Comfort and soothe the infant after the injection to minimize distress.

✘ Incorrect answer options:

Rectus femoris. The rectus femoris muscle is located in the front of the thigh. While it can be used for injections, it is not the preferred site for infants because it is more painful and has a higher risk of hitting nerves and blood vessels.

Ventrogluteal. The ventrogluteal site, located on the hip, is a good option for older children and adults. However, it is not recommended for infants because the muscle is not well-developed in this age group, making it difficult to ensure accurate and safe administration.

Dorsal gluteal. The dorsal gluteal site, located on the buttocks, is not recommended for infants due to the risk of injury to the sciatic nerve and inadequate muscle development in this area.

EXPLANATION

✔Correct answer:

Weighing the infant's diaper. Weighing the infant's diaper is the most appropriate method for measuring urine output in an infant receiving furosemide (Lasix) via IV. This method allows for precise measurement of the urine volume. By weighing the diaper before and after use and subtracting the dry weight from the wet weight, healthcare providers can accurately determine the amount of urine the infant has produced. This is crucial for monitoring the effectiveness of the diuretic therapy and ensuring the infant maintains proper fluid balance.

Furosemide is a potent diuretic that promotes the excretion of sodium, chloride, and water by inhibiting the reabsorption of these ions in the kidney's loop of Henle. Accurate monitoring of urine output is essential to prevent complications such as dehydration, electrolyte imbalances, and to assess the drug's effectiveness.

Think of the diaper as a sponge that absorbs liquid. By weighing the sponge before and after it absorbs water, you can determine exactly how much water was absorbed. Similarly, weighing the diaper before and after use provides a precise measurement of the infant's urine output.

Nurses should ensure they have an accurate scale specifically designed for weighing diapers. They should follow strict hygiene practices when handling diapers and maintain accurate records of the weights to ensure precise fluid balance calculations.

• Use a scale to weigh each diaper before and after use.
• Record the weights accurately and subtract the dry weight from the wet weight to determine urine output.
• Monitor the infant for signs of dehydration or electrolyte imbalances.
• Educate parents on the importance of monitoring urine output and how it relates to the infant's health.

✘Incorrect answer options:

Comparing the intake with the output. While comparing intake and output is important, it is not a direct method of measuring urine output. It provides an overall assessment of fluid balance but lacks the precision needed for infants on diuretic therapy.

Asking the mother about the number of diaper changes. This method is too subjective and imprecise for accurately measuring urine output. The volume of urine in each diaper can vary significantly, and this approach does not provide exact measurements necessary for medical management.

Inserting a Foley catheter. Although this method provides accurate urine measurements, it is invasive and generally not recommended for infants unless absolutely necessary due to the risk of infection and other complications. Weighing diapers is a less invasive and safer alternative.

EXPLANATION

✔Correct answer:

Use a thin layer of cream and gently rub it into the affected areas. When applying 1% hydrocortisone cream for eczema, the nurse should advise the mother to use a thin layer and gently rub it into the affected areas. This ensures that the medication is absorbed properly and reduces the risk of potential side effects such as skin thinning or irritation. Hydrocortisone is a corticosteroid that reduces inflammation, itching, and redness associated with eczema.

Eczema, or atopic dermatitis, is a chronic inflammatory skin condition characterized by itchy, red, and dry patches of skin. The application of topical corticosteroids like hydrocortisone helps to reduce the inflammatory response and alleviate symptoms.

Think of applying the cream like spreading a small amount of butter on toast. You only need a thin layer to cover the surface evenly without overloading it.

Nurses should educate parents on the correct application technique, including the importance of using a thin layer, the frequency of application, and potential side effects. They should also advise on maintaining proper skin hygiene and avoiding triggers that may exacerbate eczema.

• Instruct the mother to clean the affected area with mild soap and water before application.
• Advise using a thin layer of hydrocortisone cream and gently rubbing it into the skin until it is absorbed.
• Inform the mother to apply the cream only to the affected areas as prescribed.
• Discuss the importance of following the prescribed frequency and duration of application to prevent overuse.
• Encourage the use of moisturizers to keep the skin hydrated and to apply them after the hydrocortisone cream has been absorbed.
• Educate on avoiding known triggers and maintaining a cool, humid environment to reduce flare-ups.

✘Incorrect answer options:

Apply a thick layer of the cream to the affected areas only. Applying a thick layer is not recommended as it does not increase efficacy and may increase the risk of side effects such as skin thinning and irritation.

Spread the cream to unaffected areas to prevent further issues. Hydrocortisone cream should not be applied to unaffected areas as a preventive measure. It is intended to treat inflammation and should be used only on affected areas to avoid unnecessary exposure to steroids.

Skip cleansing the area before applying the cream. Cleansing the area before application is important to remove any dirt, oils, or bacteria that could interfere with the absorption of the medication or exacerbate the condition.

EXPLANATION

✔ Correct answer:

“I should mix the medication in the baby food and give it during feeding.” Mixing medication in baby food is not recommended because it can alter the taste and texture of the food, making it unappealing to the child. Additionally, there is no guarantee that the child will consume the entire portion of food, leading to an incomplete dosage of the medication. This practice can result in inconsistent dosing, which is critical to avoid, especially with medications that require precise dosing for effectiveness and safety.

Proper medication administration ensures that the child receives the correct dose needed for therapeutic effectiveness. When medication is mixed with food, the child might not consume the entire mixture, leading to an underdose. Moreover, certain medications can interact with food, affecting their absorption and efficacy.

Imagine needing to take a full cup of medicine but mixing it into a bowl of soup. If you don’t finish the soup, you won’t get all the medicine you need, which can make it less effective. It's the same with mixing medication into baby food; there's no way to ensure the full dose is consumed.

Nurse Mia should provide the following guidance to ensure safe and effective medication administration:

• Explain the importance of giving medication directly to ensure the child receives the full dose. Use a calibrated medicine spoon, dropper, or oral syringe for accuracy.
• Advise against mixing medication with food to avoid altering the taste and ensuring complete consumption.
• Offer positive reinforcement like giving the child a toy or a favorite activity after taking the medication to create a positive association.
• Suggest offering a favorite drink, like juice, after medication to help wash down the taste and encourage cooperation.
• Emphasize the importance of positioning the child upright with their head elevated during medication administration to prevent choking and ensure safe swallowing.

✘ Incorrect answer options:

“I will give my child a toy after administering the medication.” This statement indicates positive reinforcement, which is an effective strategy to encourage medication compliance.

“I will offer my child a juice drink after swallowing the medication.” Offering a juice drink can help mask the taste of the medication and make the experience more pleasant for the child.

“I should give the oral medication with my child sitting upright and with the head elevated.” This statement demonstrates correct technique to prevent choking and ensure the medication is swallowed properly.

EXPLANATION

✔Correct answer:

Oral Warfarin. Oral Warfarin is the medication least likely to be included in the treatment regimen for Kawasaki disease. Kawasaki disease is an acute febrile illness primarily affecting children, characterized by inflammation of blood vessels throughout the body, which can lead to coronary artery aneurysms if untreated. The standard treatment includes Intravenous Gamma Globulin (IVIG) and high-dose aspirin to reduce inflammation and prevent coronary artery complications. Regular acetaminophen may be used for fever and discomfort.

Warfarin is an anticoagulant that is typically used to prevent blood clots in conditions such as atrial fibrillation, deep vein thrombosis, or after certain types of surgeries. It is not part of the standard treatment for Kawasaki disease unless there is a specific indication for anticoagulation, which is uncommon in the general treatment of this condition.

Kawasaki disease involves inflammation of the medium-sized arteries, including the coronary arteries, which can lead to aneurysms. The goal of treatment is to reduce inflammation and prevent thrombosis in the coronary arteries.

Think of Kawasaki disease as a fire (inflammation) spreading through a field of grass (blood vessels). The primary treatment (IVIG and high-dose aspirin) acts like water to put out the fire and prevent further damage. Warfarin, on the other hand, is like a snowplow—effective for specific tasks (preventing clots) but not appropriate for extinguishing fires (reducing inflammation).

Nurses should monitor the child for response to the treatment, including reduction in fever and inflammation, and watch for potential side effects of the medications used. They should educate parents about the disease, treatment plan, and signs of complications that require immediate medical attention.

• Administer Intravenous Gamma Globulin (IVIG) as prescribed to reduce inflammation and the risk of coronary artery aneurysms.
• Give high-dose aspirin during the acute phase to reduce inflammation and fever, and lower-dose aspirin during the subacute phase to prevent thrombosis.
• Use acetaminophen for fever management as needed, avoiding additional NSAIDs that may increase bleeding risk when the child is on aspirin.
• Educate parents on the importance of follow-up appointments for echocardiograms to monitor the child’s heart.

✘Incorrect answer options:

Intravenous Gamma Globulin. IVIG is a crucial part of Kawasaki disease treatment as it significantly reduces the incidence of coronary artery aneurysms.

Regular Acetaminophen. Acetaminophen is commonly used to manage fever and discomfort in children with Kawasaki disease, making it an appropriate part of the treatment regimen.

High-dose Aspirin. High-dose aspirin is used during the acute phase of Kawasaki disease to reduce inflammation and fever. It is then typically continued at a lower dose to prevent platelet aggregation and thrombosis.

EXPLANATION

✔Correct answer:

Ibuprofen. The medication most likely to be administered to an infant with patent ductus arteriosus (PDA) is ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help close a PDA by inhibiting the synthesis of prostaglandins, which are compounds that help keep the ductus arteriosus open. By reducing prostaglandin levels, ibuprofen promotes the closure of the ductus arteriosus, a normal fetal blood vessel that should close shortly after birth.

The ductus arteriosus is a vessel connecting the pulmonary artery to the descending aorta in a fetus, allowing blood to bypass the lungs, which are not yet functional. After birth, this vessel usually closes as the newborn's circulatory system adjusts to breathing air. When the ductus arteriosus remains open (patent), it can lead to abnormal blood flow between the aorta and pulmonary artery, causing complications such as heart failure and inadequate oxygenation of blood.

Think of the ductus arteriosus as a temporary shortcut in a road system that should be closed off after a new main road is built. NSAIDs like ibuprofen act as construction workers closing off the shortcut so that traffic (blood flow) can follow the new, proper route.

Nurses should monitor the infant for signs of adverse effects from ibuprofen, such as gastrointestinal bleeding or renal impairment, and ensure the correct dosing schedule is followed. They should also monitor the infant's cardiovascular status, including heart rate, respiratory rate, and oxygen saturation, to assess the effectiveness of the treatment.

• Administer ibuprofen according to the prescribed dosage and schedule.
• Monitor for potential side effects, such as gastrointestinal issues or changes in renal function.
• Assess the infant's cardiovascular and respiratory status regularly.
• Educate the parents about the condition, the purpose of the medication, and what to watch for at home.

✘Incorrect answer options:

Penicillin. Penicillin is an antibiotic used to treat bacterial infections. It is not indicated for the closure of PDA, which is not caused by an infection.

Prednisone. Prednisone is a corticosteroid used to reduce inflammation and suppress the immune system. It is not effective for closing a PDA and is not typically used in this context.

Albuterol. Albuterol is a bronchodilator used to treat conditions like asthma by relaxing the muscles in the airways and increasing airflow to the lungs. It has no role in the management of PDA.

EXPLANATION

✔ Correct answer:

“If my child vomits after taking the medicine, I will administer the dose again.” This statement suggests the mother needs additional instruction because administering another dose of Digoxin (Lanoxin) after the child vomits can be dangerous. Digoxin has a narrow therapeutic index, meaning the difference between a therapeutic dose and a toxic dose is small. Giving an additional dose after vomiting could result in digoxin toxicity, which can be life-threatening.

Digoxin is a cardiac glycoside used to improve heart contractility and manage symptoms of congestive heart failure. Because of its narrow therapeutic window, even small deviations in dosage can lead to toxicity, manifesting as symptoms like nausea, vomiting, dizziness, confusion, and serious cardiac arrhythmias. Therefore, it is crucial to avoid administering extra doses without consulting a healthcare provider.

Imagine giving a child a very specific amount of medicine that must be precise, like giving them the exact right amount of an ingredient for a delicate recipe. If the child spits out the medicine, adding more without knowing how much they retained could spoil the recipe and be harmful. Similarly, giving another dose of Digoxin without knowing how much was absorbed can be dangerous.

Nurse Kelly should provide the mother with clear guidelines on what to do if the child vomits after taking Digoxin. Key points include:

• Do not administer another dose if the child vomits after taking Digoxin. Wait until the next scheduled dose.
• Contact the healthcare provider for further instructions if the child vomits or if multiple doses are missed.
• Monitor the child for signs of digoxin toxicity, such as nausea, vomiting, loss of appetite, bradycardia, and arrhythmias, and report these symptoms to the healthcare provider immediately.
• Ensure that the mother knows how to use the special measuring spoon or cup for accurate dosing.
• Advise administering Digoxin either 1 hour before or 2 hours after meals to enhance absorption.

✘ Correct answer options:

“I will give the medication either 1 hour before or 2 hours after meals.” This statement is correct. Giving Digoxin on an empty stomach helps with its absorption.

“If I miss more than one dose, I will contact the doctor.” This statement is also correct. Missing multiple doses of Digoxin can lead to subtherapeutic levels and should be discussed with a healthcare provider.

“I will use a special measuring spoon or cup for the liquid form, not a regular tablespoon.” This statement is correct. Accurate measurement of Digoxin is crucial due to its narrow therapeutic index.

EXPLANATION

✔Correct answer:

Deferasirox. For a child with β-thalassemia undergoing blood transfusions, Deferasirox should be added to the chelation therapy regimen to manage excess iron. β-thalassemia is a genetic blood disorder characterized by reduced hemoglobin production, necessitating regular blood transfusions. These transfusions can lead to iron overload, as the body has no natural way to excrete the excess iron from transfused red blood cells. Iron chelation therapy is essential to prevent iron-induced damage to organs.

Deferasirox is an oral iron chelator that binds excess iron and facilitates its excretion through the urine and feces. It is particularly useful in long-term management of iron overload in patients receiving regular transfusions.

In patients with β-thalassemia, frequent blood transfusions lead to accumulation of iron in the body. Excess iron is toxic and can deposit in organs like the heart, liver, and endocrine glands, causing serious complications such as heart failure, liver cirrhosis, and endocrine disorders. Chelation therapy with Deferasirox helps to reduce iron levels and prevent these complications.

Imagine the body's iron stores as a cup. Regular transfusions keep pouring more iron (liquid) into the cup, risking overflow (iron toxicity). Deferasirox acts like a sponge, soaking up the excess iron and safely removing it from the cup, preventing overflow and damage.

Nurses should ensure that Deferasirox is administered as prescribed and monitor the child for any side effects. They should also educate the family about the importance of adherence to the chelation therapy and regular monitoring of iron levels.

• Administer Deferasirox according to the prescribed dosage and schedule.
• Monitor the child for potential side effects, such as gastrointestinal disturbances, kidney and liver function abnormalities.
• Educate the parents about the importance of regular blood tests to monitor iron levels and organ function.
• Encourage adherence to the chelation therapy regimen to prevent complications associated with iron overload.

✘Incorrect answer options:

Desirudin. Desirudin is an anticoagulant used to prevent deep vein thrombosis (DVT) following hip replacement surgery. It is not used for iron chelation.

Desipramine. Desipramine is a tricyclic antidepressant used to treat depression and certain types of chronic pain. It has no role in iron chelation therapy.

Dextromethorphan. Dextromethorphan is a cough suppressant found in many over-the-counter cold and cough medications. It is not effective for chelation of excess iron.

EXPLANATION

✔ Correct answer:

Permethrin. Permethrin is the medication of choice for treating scabies, especially in young children. It is a topical cream that is safe and effective in eradicating the scabies mite. Permethrin 5% cream is applied to the entire body from the neck down and left on for a specified period, usually 8-14 hours, before being washed off.

Scabies is caused by the infestation of the skin by the mite Sarcoptes scabiei. The mites burrow into the skin, causing intense itching and a rash. Permethrin works by disrupting the function of the nerve cell membrane of the mites, resulting in their paralysis and death.

Think of scabies mites as intruders in a house. Permethrin is like a strong pesticide that is safe to use around children and effectively eliminates the intruders, making the house safe again.

Nurse Alex should provide the following instructions and care:

• Instruct the caregiver on the correct application of Permethrin 5% cream, ensuring it covers all areas of the body from the neck down, including fingers, toes, and under the nails.
• Ensure the cream remains on the skin for the recommended duration before washing it off.
• Advise washing all clothing, bedding, and towels used by the child in hot water and drying on high heat to eliminate any mites and prevent reinfestation.
• Monitor the child for any signs of skin irritation or allergic reaction to the medication and report any adverse effects to the healthcare provider.
• Educate the caregiver on the importance of treating all household members and close contacts, even if they are asymptomatic, to prevent the spread of scabies.

✘ Incorrect answer options:

Lindane. Lindane is another medication that can be used to treat scabies, but it is not recommended for use in young children due to its potential neurotoxicity and risk of serious side effects, including seizures. It is generally reserved for cases where other treatments have failed and is contraindicated in children under 2 years of age.

Both medications. Using both Permethrin and Lindane together is not recommended. Permethrin alone is effective and safe for treating scabies in young children.

Neither medication. This is incorrect as Permethrin is the recommended and safe treatment for scabies in young children.

EXPLANATION

✔Correct answer:

Apply a cold compress to the injection area. Nurse Rivera should instruct the mother to apply a cold compress to the injection area. Redness and swelling at the site of a recent DTaP (Diphtheria, Tetanus, and acellular Pertussis) vaccination are common localized reactions. Applying a cold compress can help reduce inflammation and provide relief from discomfort by constricting blood vessels and numbing the area.

Local reactions to vaccinations, such as redness and swelling, occur due to the body's immune response to the vaccine components. The cold compress helps manage these symptoms by reducing blood flow to the area and decreasing inflammatory processes.

Think of the injection site like a small bruise or bump. Applying something cold, like an ice pack, helps reduce swelling and soothes the area, much like how you would treat a minor injury.

Nurses should provide parents with clear instructions on how to manage common vaccine-related side effects at home, including the proper use of cold compresses, signs to monitor for potential complications, and when to seek further medical advice.

• Instruct the mother to apply a cold compress to the injection area for 15-20 minutes at a time, several times a day, to reduce swelling and discomfort.
• Advise monitoring the site for signs of infection, such as increased redness, warmth, or pus, and to seek medical attention if these symptoms occur.
• Reassure the mother that mild redness and swelling are common and typically resolve on their own.
• Encourage the mother to give the infant an age-appropriate dose of acetaminophen if the child appears uncomfortable or has a low-grade fever.
• Educate the mother on other common side effects of vaccinations and the importance of completing the vaccination schedule.

✘Incorrect answer options:

Schedule a clinic visit for a repeat injection at a different site. This is unnecessary for a minor local reaction. Repeating the injection could cause further discomfort and is not indicated for managing localized redness and swelling.

Use a hot compress on the affected area. A hot compress can increase blood flow and potentially worsen the swelling and inflammation at the injection site. Cold compresses are more appropriate for reducing these symptoms.

Monitor the child for potential signs of fever. While it is important to monitor for fever, this option does not provide immediate relief for the local reaction. Additionally, fever is a common, mild reaction to vaccination, and specific measures like a cold compress or acetaminophen are more appropriate for addressing discomfort.

EXPLANATION

✔Correct answer:

Administer the supplement using a straw. Nurse Roberts should instruct the mother to administer the liquid oral iron supplement using a straw. This method helps prevent the iron from coming into direct contact with the child's teeth, which can cause staining. Iron supplements are crucial for treating and preventing iron deficiency anemia, but proper administration is essential to minimize side effects and ensure effectiveness.

Iron is a critical component of hemoglobin, which is necessary for oxygen transport in the blood. Iron deficiency can lead to anemia, characterized by fatigue, weakness, and pallor. Liquid iron supplements can be effective in increasing iron levels, but they can also stain teeth if not administered properly.

Think of the straw as a direct pipeline that delivers the supplement straight to the stomach, bypassing the teeth and preventing any staining.

Nurses should provide comprehensive instructions on the correct administration of iron supplements, including the use of a straw, proper dosing, and timing relative to meals and other substances that may interfere with absorption.

• Instruct the mother to use a straw to administer the iron supplement to prevent tooth staining.
• Advise giving the supplement on an empty stomach or between meals to enhance absorption, as certain foods and drinks can interfere with iron absorption.
• Recommend avoiding the administration of iron supplements with milk, dairy products, tea, or coffee, as these can inhibit iron absorption.
• Encourage the child to drink a small amount of water or juice (such as orange juice, which contains vitamin C) after taking the supplement to help wash it down and enhance absorption.
• Educate the mother about potential side effects, such as gastrointestinal upset or dark stools, and provide strategies to manage these if they occur.

✘Incorrect answer options:

Mix the supplement with food. Mixing the iron supplement with food can decrease its absorption. While some children may need to take it with a small amount of food to avoid stomach upset, it's generally better absorbed on an empty stomach.

Give the supplement with meals. Administering the supplement with meals can reduce the absorption of iron due to the presence of certain compounds in food that inhibit iron absorption, such as calcium and tannins.

Combine the supplement with milk. Milk and dairy products contain calcium, which can significantly inhibit the absorption of iron. It's important to avoid giving iron supplements with dairy products to ensure maximum efficacy.

EXPLANATION

✔ Correct answer:

Ventrogluteal. For a 5-year-old child receiving a 3ml intramuscular injection, the ventrogluteal site is the most appropriate choice. The ventrogluteal site is located on the hip, specifically in the gluteus medius muscle, and is suitable for larger volumes of medication. It is well-developed in children over 3 years old, making it a safe and effective site for administering intramuscular injections.

The ventrogluteal site is preferred because it is free from major blood vessels and nerves, reducing the risk of injury. This site provides a large, well-developed muscle mass that can safely accommodate a 3ml injection. Additionally, the ventrogluteal site is less likely to cause discomfort or complications compared to other sites.

Imagine the ventrogluteal site as a spacious parking lot where you can easily and safely park a large vehicle (the injection). It has plenty of space and is free from obstacles, making it an ideal location for the task.

Nurse Sam should follow these steps when administering an intramuscular injection to a child:

• Position the child comfortably, either lying on their side or standing with the weight off the injection site.
• Locate the ventrogluteal site by placing the heel of your hand on the child's greater trochanter (hip bone) with the thumb pointing towards the groin and the fingers pointing towards the head. The injection site is in the V-shaped area between the index and middle fingers.
• Cleanse the injection site with an alcohol swab and allow it to dry.
• Insert the needle at a 90-degree angle to the skin, ensuring proper depth for intramuscular administration.
• Administer the medication slowly and steadily, then withdraw the needle and apply gentle pressure to the site with a clean gauze pad.
• Provide comfort and reassurance to the child after the injection to minimize distress.

✘ Incorrect answer options:

Vastus lateralis. The vastus lateralis muscle on the outer part of the thigh is a good site for intramuscular injections in infants and young children. However, for a 5-year-old child receiving a 3ml injection, the ventrogluteal site is preferred due to its larger muscle mass and lower risk of complications.

Deltoid. The deltoid muscle in the upper arm is suitable for smaller volume injections (up to 1ml) in children and adults. A 3ml injection is too large for this site and could cause significant discomfort and muscle damage.

Rectus femoris. The rectus femoris muscle on the front of the thigh is another possible site for intramuscular injections, but it is more painful and has a higher risk of hitting nerves and blood vessels compared to the ventrogluteal site.

EXPLANATION

✔Correct answer:

Apricot and baked potato skin. Furosemide (Lasix) is a potent loop diuretic that increases the excretion of water, sodium, and potassium. This can lead to hypokalemia, a condition characterized by low potassium levels in the blood. To prevent or correct hypokalemia, it is important for the child to consume foods rich in potassium. Apricots and baked potato skins are high in potassium, making them excellent choices to help maintain adequate potassium levels while the child is receiving Furosemide.

Furosemide works by inhibiting the reabsorption of sodium and chloride in the loop of Henle in the kidneys, which increases the excretion of these ions along with water. This can also cause increased excretion of potassium, leading to potential hypokalemia. Adequate potassium intake is essential for normal cellular function, nerve transmission, and muscle contraction.

Think of potassium in the body like fuel for a car's engine. If the fuel level gets too low, the engine (muscles and nerves) can't run properly. Eating potassium-rich foods helps to refuel the body's potassium levels, ensuring everything runs smoothly.

Nurses should educate parents about the importance of monitoring potassium levels and encourage the inclusion of potassium-rich foods in the child's diet. They should also be aware of the signs and symptoms of hypokalemia and ensure the child is monitored regularly.

• Encourage the mother to include potassium-rich foods such as apricots, bananas, oranges, spinach, and baked potato skins in the child's diet.
• Monitor the child's potassium levels through regular blood tests as ordered by the healthcare provider.
• Educate the mother on the signs and symptoms of hypokalemia, such as muscle weakness, cramps, and irregular heartbeats, and to seek medical advice if these occur.
• Ensure the child stays well-hydrated and follows any additional dietary recommendations provided by the healthcare provider.

✘Incorrect answer options:

Gelatin and cauliflower. While cauliflower contains some potassium, gelatin has negligible potassium content. This combination does not provide sufficient potassium to counteract the losses from Furosemide.

Bread and butter. Bread and butter are low in potassium and would not be effective in preventing or correcting hypokalemia.

Ginger ale and cereal. Most cereals and ginger ale contain very little potassium, making them inadequate choices for maintaining potassium levels.

EXPLANATION

✔ Correct answer:

The child's urine output levels. Before administering an IV solution containing potassium chloride, it is crucial for Nurse Ellie to check the child's urine output levels. Adequate urine output is essential to ensure that the kidneys are functioning properly and can excrete the potassium safely. Administering potassium chloride to a patient with inadequate urine output can lead to hyperkalemia, a dangerous condition characterized by elevated potassium levels in the blood, which can cause serious cardiac and neuromuscular complications.

Potassium is primarily excreted by the kidneys. If a patient has decreased urine output (oliguria) or no urine output (anuria), potassium can accumulate in the blood, leading to hyperkalemia. Symptoms of hyperkalemia include muscle weakness, cardiac arrhythmias, and even cardiac arrest. Therefore, it is critical to assess urine output to ensure the safe administration of potassium-containing IV solutions.

Think of the kidneys as a filtration system. If the system is clogged and not working properly, adding more material to filter (potassium) can cause an overflow, leading to problems. Ensuring the filtration system (kidneys) is working well is like making sure the drain is clear before pouring more water into the sink.

Nurse Ellie should take the following steps before administering the IV solution:

• Check the child's urine output levels to ensure they are adequate (typically at least 1-2 ml/kg/hr in children).
• Monitor the child's electrolyte levels, including serum potassium, to ensure they are within normal limits before administration.
• Assess renal function through laboratory tests such as blood urea nitrogen (BUN) and creatinine levels.
• Observe for signs of dehydration and adequate hydration status, which can affect renal perfusion and urine output.
• Communicate with the healthcare provider if urine output is inadequate or if there are any concerns about renal function or electrolyte imbalances.

✘ Incorrect answer options:

The child's current height. While height is important for determining appropriate medication dosages and fluid volumes, it is not specifically relevant to assessing the safety of potassium chloride administration.

The child's blood pressure readings. Blood pressure is important for assessing overall cardiovascular status and hydration, but it does not directly determine the safety of potassium administration. However, it can provide indirect information about hydration status and renal perfusion.

The child's weight measurement. Weight is important for calculating fluid requirements and medication dosages. However, before administering potassium chloride, the immediate priority is ensuring adequate urine output to prevent hyperkalemia.

EXPLANATION

✔Correct answer:

Administer activated charcoal. The most appropriate initial nursing action for managing an unconscious child with Tylenol (acetaminophen) poisoning is to administer activated charcoal, if it is within the timeframe of ingestion (usually within 1-2 hours). Activated charcoal binds to the acetaminophen in the gastrointestinal tract, preventing its absorption into the bloodstream, and is an important step in the initial management of acute acetaminophen overdose.

Acetaminophen overdose can lead to severe liver damage due to the accumulation of a toxic metabolite, N-acetyl-p-benzoquinone imine (NAPQI). Activated charcoal helps to reduce the amount of acetaminophen that gets absorbed, thereby decreasing the amount that gets converted to NAPQI.

Think of activated charcoal as a sponge that soaks up the poison (acetaminophen) in the stomach before it can be absorbed into the body and cause harm.

Nurses should be prepared to administer activated charcoal and monitor for its effectiveness and potential side effects. They should also be ready to provide supportive care and collaborate with the healthcare team for further treatment, such as the administration of N-acetylcysteine (NAC), which is the antidote for acetaminophen poisoning.

• Administer activated charcoal as soon as possible if the child is within the appropriate timeframe for it to be effective and if there are no contraindications (e.g., unconsciousness without a protected airway).
• Ensure that the child's airway is protected, particularly if they are unconscious, to prevent aspiration.
• Monitor for potential side effects of activated charcoal, such as vomiting or aspiration.
• Be prepared to start an intravenous line for fluid administration and potential antidote (NAC) administration as part of ongoing care.
• Regularly monitor the child's vital signs and overall condition, and be prepared for further interventions as needed.

✘Incorrect answer options:

Monitor the child's vital signs every hour. While monitoring vital signs is important, it is not the initial priority in managing acetaminophen poisoning. Immediate actions to prevent further absorption of the toxin should take precedence.

Start an intravenous line and administer fluids. Starting an IV line and administering fluids is important for overall supportive care but is not the most immediate action to prevent further acetaminophen absorption.

Check the child's blood glucose level. Checking blood glucose is relevant, especially if the child is unconscious and there is a concern for hypoglycemia. However, it is not the priority action in the context of acetaminophen poisoning. The primary focus should be on preventing further absorption of the toxin.

EXPLANATION

✔Correct answer:

Subcutaneously in the outer aspect of the upper arm.  The measles, mumps, and rubella (MMR) vaccine should be administered subcutaneously in the outer aspect of the upper arm. The subcutaneous route is preferred for the MMR vaccine because it ensures proper absorption and effectiveness of the vaccine. The outer aspect of the upper arm (the triceps area) is a recommended site for subcutaneous injections in children and adults due to its accessibility and low risk of complications.

The MMR vaccine contains live attenuated viruses that stimulate the immune system to produce an immune response without causing the disease. Subcutaneous administration allows the vaccine to be absorbed slowly, providing adequate time for the immune system to recognize and respond to the antigens.

Think of the subcutaneous tissue as a sponge that absorbs the vaccine and slowly releases it into the body, allowing the immune system to gradually build up its defense against the viruses.

Nurses should follow proper injection techniques to ensure the vaccine is administered correctly. They should also educate parents about the importance of the MMR vaccine and what to expect after vaccination, including potential side effects and the normal immune response.

• Prepare the injection site by cleaning it with an alcohol swab and allowing it to dry.
• Pinch the skin to create a small fold and insert the needle at a 45-degree angle into the subcutaneous tissue.
• Inject the vaccine slowly and withdraw the needle, applying gentle pressure to the site with a gauze pad.
• Observe the child for a few minutes after the injection for any immediate adverse reactions.
• Educate the parents about common side effects, such as mild fever or a rash, and when to seek medical advice.

✘Incorrect answer options:

Intramuscularly in the deltoid muscle. While the deltoid muscle is a common site for intramuscular injections, the MMR vaccine is recommended to be given subcutaneously to ensure proper absorption and effectiveness.

Subcutaneously in the gluteal area. The gluteal area is not recommended for subcutaneous injections due to the presence of a thicker layer of fat, which can affect the absorption of the vaccine.

Intramuscularly in the vastus lateralis muscle. The vastus lateralis muscle is commonly used for intramuscular injections in infants and young children, but it is not the recommended route for the MMR vaccine, which should be administered subcutaneously.

EXPLANATION

✔Correct answer:

Aspirin should be given for any pain related to the injection. This statement is inaccurate and potentially harmful. Aspirin should not be given to children, especially those who have received the varicella vaccine, due to the risk of Reye's syndrome. Reye's syndrome is a rare but serious condition that causes swelling in the liver and brain and has been associated with aspirin use in children recovering from viral infections, including varicella (chickenpox).

Reye's syndrome can develop after a viral infection such as chickenpox or the flu, particularly if the child is given aspirin. The exact mechanism is not fully understood, but it involves mitochondrial damage leading to liver dysfunction and encephalopathy. Therefore, it's crucial to avoid giving aspirin to children who have recently received the varicella vaccine.

Imagine your car's engine has a warning not to use a specific type of oil because it can cause severe damage. Similarly, giving aspirin to children who have had the varicella vaccine is like using that harmful oil in your engine; it can lead to serious problems like Reye's syndrome.

Nurses should educate parents and caregivers about safe pain management options for children post-vaccination. Instead of aspirin, recommend using acetaminophen (Tylenol) or ibuprofen (Advil) for pain or fever after vaccinations.

• Educate parents to avoid aspirin and instead use acetaminophen or ibuprofen for pain relief.
• Monitor the vaccination site for any signs of adverse reactions and provide appropriate care.
• Inform parents about the symptoms of Reye's syndrome and advise them to seek medical attention if they suspect their child has it.

✘Incorrect answer options:

The vaccine is administered subcutaneously. This statement is correct. The varicella vaccine is administered subcutaneously, typically into the fatty tissue over the triceps muscle.

Children aged 13 years and older who have no history of chickenpox or prior vaccination need two doses, spaced at least 28 days apart. This statement is correct. The CDC recommends that children aged 13 years and older who have not had chickenpox or received the vaccine previously should receive two doses of the varicella vaccine, spaced at least 28 days apart.

The most common mild side effects include pain, redness, or swelling at the injection site. This statement is correct. Common mild side effects of the varicella vaccine include pain, redness, or swelling at the injection site, as well as a mild rash or fever.

EXPLANATION

✔Correct answer:

History of an anaphylactic reaction to streptomycin. The nurse should consider withholding the inactivated polio vaccine (IPV) if the child has a history of an anaphylactic reaction to streptomycin. IPV is contraindicated in individuals who have had a severe allergic reaction to any component of the vaccine, including antibiotics such as streptomycin, polymyxin B, and neomycin. Anaphylactic reactions are severe and potentially life-threatening, and administering a vaccine containing an allergen to which the patient is hypersensitive could result in a serious adverse reaction.

Anaphylaxis is a rapid and severe allergic reaction that can affect multiple organ systems. It is mediated by the release of histamine and other inflammatory mediators from mast cells and basophils. In the context of vaccination, if a component of the vaccine triggers anaphylaxis, it can cause symptoms such as swelling, difficulty breathing, low blood pressure, and even shock.

Administering a vaccine containing an allergen to which a child is highly allergic is like knowingly exposing someone with a severe peanut allergy to peanuts; it can trigger a dangerous and immediate reaction.

Nurses should carefully review the child’s medical history for any known allergies to vaccine components. They should also be prepared to manage anaphylactic reactions by having emergency medications and equipment readily available.

• Review the child’s medical history for any known allergies to vaccine components, specifically streptomycin, polymyxin B, and neomycin.
• Consult with the healthcare provider if there is any uncertainty about the safety of administering the vaccine.
• Ensure that emergency medications and equipment are available to manage anaphylactic reactions.
• Educate parents about the importance of disclosing any known allergies and the potential risks associated with vaccine components.

✘Incorrect answer options:

Recent history of diarrheal episodes. A recent history of diarrhea is generally not a contraindication for receiving IPV. Mild to moderate illnesses, including diarrhea, are not reasons to delay vaccination.

Recent history of upper respiratory infections. Mild upper respiratory infections without fever are not contraindications for IPV administration. Vaccination can usually proceed if the child is otherwise healthy.

Previous redness at the injection site. Redness or minor reactions at the injection site are common and not a contraindication for future vaccinations. These reactions are typically mild and self-limiting.

EXPLANATION

✔Correct answer:

Factor VIII. In a child with hemophilia A presenting with nosebleeds and joint bruises, the nurse should anticipate the administration of Factor VIII. Hemophilia A is a genetic bleeding disorder caused by a deficiency in Factor VIII, a crucial blood-clotting protein. This deficiency leads to prolonged bleeding and frequent bleeding episodes, especially into joints and muscles.

Administration of Factor VIII concentrates is the mainstay treatment for hemophilia A. It helps to replace the missing clotting factor, thereby allowing the blood to clot properly and preventing or controlling bleeding episodes.

Hemophilia A is caused by mutations in the F8 gene that encodes Factor VIII. The deficiency or dysfunction of Factor VIII impairs the blood clotting cascade, leading to an increased risk of bleeding. Treatment with Factor VIII concentrate corrects the clotting defect, allowing for effective hemostasis.

Imagine Factor VIII as a crucial ingredient in a recipe for making a strong glue (blood clot). Without this ingredient, the glue cannot set properly, and things (bleeds) won't stick together. Adding Factor VIII to the mixture allows the glue to set correctly, stopping the leaks (bleeds).

Nurses should be prepared to administer Factor VIII concentrates as prescribed and monitor the child for any adverse reactions. They should also educate the family about recognizing early signs of bleeding and the importance of regular follow-up and prophylactic treatments if necessary.

• Prepare and administer Factor VIII concentrate according to the prescribed dosage.
• Monitor the child for any signs of allergic reactions or other adverse effects during and after the infusion.
• Educate the parents and child on how to recognize early signs of bleeding and the importance of prompt treatment.
• Discuss the importance of adhering to prophylactic regimens if prescribed to prevent spontaneous bleeding episodes.
• Provide guidance on safe activities and precautions to minimize the risk of injury and bleeding.

✘Incorrect answer options:

Factor X. Factor X deficiency is a rare bleeding disorder and is not related to hemophilia A. Administering Factor X would not be appropriate for managing hemophilia A.

Oral iron supplement. Oral iron supplements are used to treat iron deficiency anemia and would not address the underlying issue of Factor VIII deficiency in hemophilia A.

Cyclosporine. Cyclosporine is an immunosuppressant used in organ transplantation and certain autoimmune conditions. It has no role in the treatment of hemophilia A.