A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse prepare the child for next?

Schedule the child for a STAT magnetic resonance imaging (MRI) of the neck.

Provide a nebulizer treatment with bronchodilators.

Obtain bedside trays for intubation or tracheotomy by the healthcare provider.

Begin prescribed intravenous antibiotic administration.

Answer and Explanation

The Correct Answer is C

Choice A reason: Scheduling the child for a STAT magnetic resonance imaging (MRI) of the neck is not a priority action for the nurse. MRI is a diagnostic test that uses magnetic fields and radio waves to produce images of the internal structures of the body. MRI of the neck may be useful to rule out other causes of respiratory distress, such as tumors, abscesses, or foreign bodies, but it is not an urgent procedure. Moreover, MRI requires the child to lie still for a long time, which may be difficult or impossible for a child who is anxious and in respiratory distress.

Choice B reason: Providing a nebulizer treatment with bronchodilators is not a suitable action for the nurse. Nebulizer is a device that delivers medication in the form of a mist that can be inhaled into the lungs. Bronchodilators are medications that relax the smooth muscles of the airways and improve airflow. Nebulizer treatment with bronchodilators may be helpful for children with respiratory distress caused by asthma, bronchiolitis, or chronic obstructive pulmonary disease, but not for children with respiratory distress caused by upper airway obstruction, which is the most likely scenario for this child.

Choice C reason: Obtaining bedside trays for intubation or tracheotomy by the healthcare provider is the most appropriate action for the nurse. Intubation is a procedure that involves inserting a tube through the mouth or nose into the trachea to secure the airway and provide ventilation. Tracheotomy is a surgical procedure that involves creating an opening in the neck and inserting a tube into the trachea to bypass the upper airway obstruction. Both procedures are life-saving interventions for children with respiratory distress caused by upper airway obstruction, which is the most likely scenario for this child. The nurse should prepare the necessary equipment and assist the healthcare provider in performing these procedures.

Choice D reason: Beginning prescribed intravenous antibiotic administration is not a relevant action for the nurse. Antibiotics are medications that kill or inhibit the growth of bacteria that cause infections. Antibiotics may be indicated for children with respiratory distress caused by bacterial infections, such as pneumonia, tonsillitis, or epiglottitis, but not for children with respiratory distress caused by non-infectious causes, such as foreign bodies, anaphylaxis, or congenital anomalies. Moreover, antibiotics are not an immediate intervention for respiratory distress, as they take time to exert their effects.

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Correct Answer is C

Explanation

Choice A: Straining all urine is not a relevant instruction for the nurse to provide, as this is not related to prostatitis. This is a distractor choice.

Choice B: Maintaining contact isolation is not a necessary instruction for the nurse to provide, as prostatitis is not a contagious condition. This is another distractor choice.

Choice C: Avoiding urinary catheterization is an important instruction for the nurse to provide, as this can introduce bacteria into the urinary tract and worsen the infection. Therefore, this is the correct choice.

Choice D: Restricting oral fluid intake is not an appropriate instruction for the nurse to provide, as this can lead to dehydration and reduced urine output, which can increase the risk of urinary stasis and infection. This is another distractor choice.

A. Alcohol consumption will not produce vascular changes. B. Sodium intake can be regulated by limiting canned foods in the diet. C. Salt substitutes can help with maintaining a healthy diet. D. Weight management is promoted by taking daily walks for thirty minutes. E. Blood pressure readings should be taken at noontime. F. Uncontrolled hypertension can lead to renal damage.

Correct Answer is ["B","C","D","F"]

Explanation

Choice A reason: Alcohol consumption will not produce vascular changes is incorrect information. Alcohol consumption can increase blood pressure by causing vasoconstriction, fluid retention, and interference with antihypertensive medications. The nurse should advise the client to limit alcohol intake to no more than one drink per day for women and two drinks per day for men.

Choice B reason: Sodium intake can be regulated by limiting canned foods in the diet is correct information. Sodium intake can increase blood pressure by causing fluid retention and increasing vascular resistance. The nurse should advise the client to limit sodium intake to no more than 2300 mg per day and avoid processed foods that are high in sodium, such as canned foods, soups, sauces, and snacks.

Choice C reason: Salt substitutes can help with maintaining a healthy diet is correct information. Salt substitutes can reduce sodium intake by replacing sodium chloride with potassium chloride or other minerals. The nurse should advise the client to use salt substitutes sparingly and consult with their healthcare provider before using them if they have kidney disease or take certain medications that affect potassium levels.

Choice D reason: Weight management is promoted by taking daily walks for thirty minutes is correct information. Weight management can lower blood pressure by reducing body fat, improving blood circulation, and enhancing insulin sensitivity. The nurse should advise the client to maintain a healthy weight and engage in moderate physical activity for at least 150 minutes per week.

Choice E reason: Blood pressure readings should be taken at noontime is incorrect information. Blood pressure readings should be taken at different times of the day, preferably in the morning and evening, to monitor fluctuations and trends. The nurse should advise the client to use a home blood pressure monitor that is accurate and calibrated and follow proper techniques for measuring blood pressure.

Choice F reason: Uncontrolled hypertension can lead to renal damage is correct information. Uncontrolled hypertension can damage the blood vessels in the kidneys, leading to reduced kidney function and chronic kidney disease. The nurse should advise the client to follow their prescribed treatment plan and monitor their blood pressure regularly.

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Naxlex Comprehensive Predictor Exams

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding this client?

Correct Answer is C

Explanation

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

Correct Answer is ["B","C","D","F"]

Explanation

A 46-year-old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?

Days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client had a pulmonary embolus. Which action should the nurse take first?

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. Which action should the nurse take?

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?