A nurse is supervising a student who is suctioning a 5-year-old ...

[burchfield96]

A nurse is supervising a student who is suctioning a 5-year-old patient in the pediatric intensive care unit. Which action by the student results in the nurse intervening?
 
  A.
  Auscultates lung sounds beforehand
  B.
  Cleanses catheter after suctioning
  C.
  Hyperoxygenates prior to suctioning
  D.
  Sets suction pressure to 150 mm Hg

Question 2

A nurse is assessing a critically ill child's respiratory status. The child is grunting and has nasal flaring, but the pulse oximeter reads the child's oxygen saturation at 96. Which nursing action is the priority in this situation?
 
  A.
  Conduct a thorough assessment and call the provider.
  B.
  Document the findings in the child's medical chart.
  C.
  Notify the rapid response team immediately.
  D.
  Turn up the oxygen and reassess the child in 30 minutes.

[ergserg]

Answer to Question 1

ANS: D
Suction pressure for a child is 110-130 mm Hg. The nurse should intervene and have the student reduce the pressure before suctioning. The other options are correct actions.

Answer to Question 2

ANS: A
The oxygen saturation does not correlate with the child's work of breathing. The nurse should do a more complete assessment, including vital signs, and notify the provider. Documentation should be thorough, but the nurse needs to take further action. Depending on institutional policies, notifying the rapid response team may be appropriate if the child needs further attention and the primary provider is not available. This child is too ill to just turn up the oxygen and reassess later.

[burchfield96]

Thanks for the timely response, appreciate it

[jackie]

Gracias!