A child is admitted to the pediatric intensive care unit with ...

[go.lag]

A child is admitted to the pediatric intensive care unit with respiratory distress and respiratory acidosis. The child's pulse oximeter reads 98. Which actions by the nurse are the most appropriate at this time? (Select all that apply.)
 
  A.
  Assess the child's most recent hemoglobin and hematocrit levels.
  B.
  Prepare for immediate intubation and mechanical ventilation.
  C.
  Request an order to use a transcutaneous carbon dioxide monitor.
  D.
  Titrate the oxygen flow rate down to prevent oxygen toxicity.
  E.
  Wait 30 minutes, then draw another sample for arterial blood gasses.

Question 2

A student nurse assesses a child for nonverbal signs of pain to report to the registered nurse. Which information should the student include? (Select all that apply.)
 
  A.
  Complaints of nausea
  B.
  Diaphoresis
  C.
  Facial grimacing
  D.
  Sleepiness
  E.
  Tachypnea

[carojassy25]

Answer to Question 1

ANS: A, C
This child's oxygen saturation does not correlate with respiratory distress and acidosis. Appropriate actions include assessing the child's hemoglobin and hematocrit and requesting the use of a carbon dioxide monitor. If the child is anemic, even with a saturation of 98, the child will not have enough oxygen for tissue needs. The child may also have high levels of carbon dioxide causing or caused by the respiratory distress and acidosis, so this value should be monitored. The oximeter may not be working properly or reading accurately. Without further information, it is unknown if the child needs immediate intubation and mechanical ventilation. Titrating oxygen down in the face of respiratory distress is not warranted. Waiting 30 minutes is also not warranted, as this child is quite ill.

Answer to Question 2

ANS: A, B, C, E
Objective manifestations of pain include tachycardia, tachypnea, diaphoresis, sleep disturbances, hypertension, and nausea.