A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula.
When planning care for this child, what principle of oxygen administration should the nurse keep in mind?

Avoid administering oxygen at high levels for extended periods.

Increase the oxygen rate during sleep to compensate for a slower respiratory rate.

Taking a sedative at bedtime slows the respiratory rate, which decreases oxygen needs.

Oxygen is less toxic when it is humidified with a hydration source.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Oxygen therapy is a crucial part of the management for patients with severe pneumonia. However, prolonged administration of high concentrations of oxygen can potentially lead to oxygen toxicity, resulting in damage to the cells of the lungs. This is due to the production of

reactive oxygen species which can damage cell structures. Therefore, it is important to avoid administering oxygen at high levels for extended periods.
Choice B rationale
While it might seem logical to increase the oxygen rate during sleep due to a slower respiratory rate, this is not typically recommended. The body’s oxygen requirements do not significantly change during sleep and increasing the oxygen rate could potentially lead to hyperoxia.
Choice C rationale
Sedatives can indeed slow the respiratory rate, but this does not decrease oxygen needs. In fact, it could potentially lead to respiratory depression and hypoxia, especially in a patient with a respiratory illness like pneumonia.
Choice D rationale
Humidification of oxygen can improve patient comfort, especially with high flow rates, by preventing dryness in the nasal passages. However, it does not make oxygen less toxic.

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Correct Answer is A

Explanation

Choice A rationale
When a client’s blood pressure cannot be measured due to casts on both arms and the client’s position, the most appropriate action for the nurse is to document why the blood pressure cannot be accurately measured at the present time. This is because accurate measurement of blood pressure is crucial for monitoring the client’s health status and making appropriate clinical decisions. If the blood pressure cannot be measured accurately, it is important to document this fact along with the reasons why, so that other healthcare professionals are aware of the situation and can take appropriate action.
Choice B rationale
Advising the UAP to document the last blood pressure obtained on the client’s graphic sheet is not the most appropriate action in this situation. While it might provide some information about the client’s previous blood pressure readings, it does not address the current inability to measure the blood pressure. Furthermore, it could potentially lead to confusion or misinterpretation of the client’s current health status.
Choice C rationale
Demonstrating how to palpate the popliteal pulse with the client supine and the knee flexed is not the most appropriate action in this situation. While palpating the popliteal pulse can provide some information about the client’s circulatory status, it does not provide a measure of blood pressure. Furthermore, this action might not be feasible or appropriate depending on the client’s condition and the presence of casts on both arms.
Choice D rationale
Estimating the blood pressure by assessing the pulse volume of the client’s radial pulses is not the most appropriate action in this situation. While pulse volume can provide some information about the client’s circulatory status, it does not provide a measure of blood pressure. Furthermore, this method of estimating blood pressure is not as accurate or reliable as direct measurement.

Correct Answer is ["100"]

Explanation

Step 1: The child is receiving gentamicin 60 mg every 8 hours IV, which is to be infused over 30 minutes. The medication is delivered by the pharmacy diluted in a 50 ml bag of saline.

Step 2: We need to find the infusion pump’s regulation in mL/hour.

Step 3: Since the medication is to be infused over 30 minutes, we convert this to hours by dividing by 60. So, 30 minutes is 0.5 hours.

Step 4: The rate of infusion is then the total volume (50 mL) divided by the time in hours (0.5 hours).

Step 5: So, the infusion pump’s regulation is (50 mL ÷ 0.5 hours) = 100 mL/hour.

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A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula. When planning care for this child, what principle of oxygen administration should the nurse keep in mind?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is A

Explanation

Correct Answer is ["100"]

Explanation

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A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula.
When planning care for this child, what principle of oxygen administration should the nurse keep in mind?