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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Choice B is correct because weight management is an important factor in preventing and controlling hypertension. Taking daily walks for thirty minutes can help reduce weight and lower blood pressure.

Choice C is correct because salt substitutes can help with maintaining a healthy diet by reducing sodium intake. Sodium intake is associated with increased blood pressure and should be limited to less than 2,300 mg per day.

Choice E is correct because sodium intake can be regulated by rinsing canned foods in water. Canned foods often contain high amounts of sodium as a preservative and rinsing them can remove some of the excess sodium.

Choice F is correct because uncontrolled hypertension can lead to renal damage. Hypertension can cause damage to the blood vessels and impair the function of the kidneys, leading to chronic kidney disease or failure.

Choice A is incorrect because alcohol consumption can produce vascular changes that increase blood pressure. Alcohol intake should be limited to no more than one drink per day for women and two drinks per day for men.

Choice D is incorrect because blood pressure readings should not be taken at noontime. Blood pressure readings should be taken at the same time each day, preferably in the morning before breakfast or in the evening before dinner.

A. Remove the catheter and palpate the client's bladder for residual distention. B. Remove the catheter and replace with an indwelling catheter. C. Allow the bladder to empty completely or up to 1,000 mL of urine. D. Clamp the catheter for thirty minutes and then resume draining.

Correct Answer is C

Explanation

Choice A: Remove the catheter and palpate the client's bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.

Choice B: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.

Choice C: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.

Choice D: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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","E","F"]

Explanation

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)

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