A nurse in an emergency department is assessing a 2-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority?
Obtain blood culture specimens.
Administer an antipyretic.
Prepare for nasotracheal intubation.
Insert an IV catheter.
The Correct Answer is C
Choice A reason: Obtaining blood culture specimens is important to identify the causative organism and guide antibiotic therapy, but it is not the priority action for a child who is in respiratory distress. The nurse should first secure the airway and stabilize the child's condition.
Choice B reason: Administering an antipyretic may help lower the fever and reduce discomfort, but it does not address the cause of the dyspnea and drooling, which may indicate epiglottitis. This is a life-threatening condition that requires immediate airway management.
Choice C reason: Preparing for nasotracheal intubation is the priority action for a child who has signs of epiglottitis, as it can prevent airway obstruction and respiratory failure. The nurse should have the equipment and personnel ready for intubation and avoid any stimulation or manipulation of the throat that can trigger laryngeal spasm.
Choice D reason: Inserting an IV catheter is necessary to administer fluids and medications, but it is not the first priority for a child who is in respiratory distress. The nurse should focus on the airway before the circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as the child will not have normal bowel movements immediately after the initial surgery. The surgery involves removing the affected part of the colon and creating a temporary ostomy, which is an opening in the abdomen that allows stool to pass into a bag. The child will need a second surgery to reconnect the bowel and close the ostomy.
Choice B reason: This statement is incorrect, as the child will not need a feeding tube after the initial surgery. The child will be able to eat and drink normally but may need to follow a low-fiber diet to avoid constipation and bowel obstruction.
Choice C reason: This statement is incorrect, as the child will not need a urinary catheter after the initial surgery. The child will be able to urinate normally but may need to drink plenty of fluids to prevent dehydration and urinary tract infections.
Choice D reason: This statement is correct, as the child's ostomy is only temporary and will be closed in a second surgery. The parent should be glad that the child will eventually have a normal bowel function and appearance. The parent should also learn how to care for the ostomy and change the bag until the second surgery.
Correct Answer is D
Explanation
Choice A reason: Cranberry juice is not a good choice for a child who has had a tonsillectomy, as it is acidic and may cause pain and irritation to the throat. The nurse should avoid offering citrus juices or carbonated beverages to the child.
Choice B reason: Vanilla milkshake is also not a good choice for a child who has had a tonsillectomy, as it is thick and may coat the throat and interfere with healing. The nurse should avoid offering dairy products or foods that are sticky or hard to swallow to the child.
Choice C reason: Cubed ice is not a good choice for a child who has had a tonsillectomy, as it may be too cold and cause vasoconstriction and bleeding. The nurse should avoid offering very cold or very hot fluids to the child.
Choice D reason: Water is the best choice for a child who has had a tonsillectomy, as it is clear, bland, and hydrating. The nurse should encourage the child to drink plenty of water to prevent dehydration and promote healing.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.