A nurse is assessing patients in the pediatric intensive care ...

[MGLQZ]

A nurse is assessing patients in the pediatric intensive care unit for signs of hypoperfusion. Which assessment findings are indicative of this condition? (Select all that apply.)
 
  A.
  Capillary refill: 2 seconds
  B.
  Mean arterial pressure: 32 mm Hg
  C.
  Mental status: lethargic
  D.
  Pedal pulses: bounding
  E.
  Urinary output: 2 mL/kg/hour

Question 2

A 7-year-old child is in the pediatric intensive care unit on a ventilator. Sedation is maintained with a midazolam (Versed) drip. Which items should the nurse ensure are readily available at the child's bedside? (Select all that apply.)
 
  A.
  Back-up ventilator
  B.
  Bag-valve mask device
  C.
  Flumazinil (Romazicon)
  D.
  Narcan (Naloxone)
  E.
  Working suction setup

[emilymalinowski12]

Answer to Question 1

ANS: B, C
Signs of hypoperfusion include urinary output less than 1 mL/kg/hour, mean arterial pressure less than 45-50 mm Hg, decreased peripheral and pedal pulses, tachycardia, mental status changes, lethargy, delayed capillary refill, and pallor. A capillary refill of 2 seconds is normal. Mean arterial pressure of 32 mm Hg is too low and is indicative of hypoperfusion. Lethargy is a sign of hypoperfusion. Bounding pedal pulses may indicate fluid overload, and a urine output of 2 mL/kg/hour is normal.

Answer to Question 2

ANS: B, C, E
For the child on a ventilator, the nurse should have a bag-valve mask for manual ventilation and working suction. The antidote for Versed is Romazicon, which should also be available. A back-up ventilator for every ventilator in use is not only prohibitively expensive, but having the bag-valve mask allows for manual ventilation in case of ventilator failure. Narcan is not the antidote for Versed.

[MGLQZ]

Thank you

[emilymalinowski12]

No problemo