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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Feeding the infant every 4 hours is not a specific instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. However, feeding the infant frequently is important to promote hydration and elimination of bilirubin through urine and stool.
Choice B reason: Performing diaper changes under the light is not a recommended instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to turn off the light and cover the infant's eyes with protective goggles or patches during diaper changes to prevent eye damage or irritation.
Choice D reason: Covering with a receiving blanket is not an appropriate instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to keep the infant unclothed except for a diaper and eye protection during phototherapy to maximize skin exposure to the light and increase its effectiveness.
Correct Answer is A
Explanation
Choice A: Observing the insertion site of the suprapubic catheter is an essential assessment for the home health nurse, as this can help detect any signs of infection, inflammation, or leakage. Therefore, this is the correct choice.
Choice B: Palpating the flank area is not a necessary assessment for the home health nurse, as this is not related to the suprapubic catheter. This is a distractor choice.
Choice C: Measuring abdominal girth is not a relevant assessment for the home health nurse, as this is not affected by the suprapubic catheter. This is another distractor choice.
Choice D: Assessing the perineal area is not an important assessment for the home health nurse, as this is not involved in the suprapubic catheter. This is another distractor choice.
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