Question

A nurse in a pediatric emergency department is planning care for an Based on the information in the adolescent's medical record, which of adolescent. the following actions should the nurse plan to take? Select all that apply. Nurses' Notes Administer a levalbuterol metered dose inhaler. 2245: Obtain consent for a pericardiocentesis. Adolescent arrived via stretcher by Emergency Medical Prepare for chest tube insertion. Transport (EMT) following a motor-vehicle crash. Place the adolescent in supine position. EMT personnel report: Apply supplemental oxygen. Client was found conscious at the scene inside of the vehicle with airbag deployed, wearing a seat belt. Vital signs: heart rate: 94/min, respiratory rate 20/min, blood pressure 100/60 mm Hg 18-gauge peripheral IV inserted in left antecubital. Guardians contacted and report the child has no medical conditions. 2300 Adolescent reports sharp pain in chest. Rates pain as 6 on a scale of 0 to 10 . Respirations fast and shallow. Diminished breath sounds in left lung. S1 and S2 regular and rapid. A nurse in a pediatric emergency department is planning care for an Based on the information in the adolescent's medical record, which of adolescent. the following actions should the nurse plan to take? Select all that apply. Vital Signs Administer a levalbuterol metered dose inhaler. 2300 Obtain consent for a pericardiocentesis. Temperature 38.0

∘
C(100.4
∘
F) Prepare for chest tube insertion. Heart rate 110/min Place the adolescent in supine position. Respiratory rate 30/min Blood pressure 90/60 mmHg Apply supplemental oxygen. Oxygen saturation 94% on room air A nurse in a pediatric emergency department is planning care for an Based on the information in the adolescent's medical record, which of adolescent. the following actions should the nurse plan to take? Select all that apply. Diagnostic Results Administer a levalbuterol metered dose inhaler. Chest x-ray: Obtain consent for a pericardiocentesis. Air present in left pleural space; suggestive of pneumothorax. Prepare for chest tube insertion. CT scan recommended for definitive diagnosis. Place the adolescent in supine position. Apply supplemental oxygen.

Answer 1

The nurse should prepare for chest tube insertion, apply supplemental oxygen, and consider placing the adolescent in a supine position if appropriate. Consent for a pericardiocentesis and administering levalbuterol are not indicated based on the given clinical scenario.

Step-by-step explanation:

A nurse in a pediatric emergency department is planning care for an adolescent who has been in a motor-vehicle crash.

The patient's symptoms suggest a pneumothorax based on the findings of diminished breath sounds in the left lung and air present in the left pleural space on the chest x-ray. The actions the nurse should plan to take include:

Prepare for chest tube insertion: To remove the air from the pleural space and allow the lung to re-expand.

Apply supplemental oxygen: To treat the hypoxemia as indicated by the oxygen saturation of 94% on room air.

Place the adolescent in a supine position: Only if it does not cause further respiratory distress, and if not contraindicated based on the patient's condition.

Obtaining consent for a pericardiocentesis is not supported by the information provided, as there is no evidence of a pericardial effusion or cardiac tamponade at this time.

Administering a levalbuterol metered dose inhaler may be appropriate for bronchospasm or asthma but is not indicated here based solely on the provided information.