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 A
Explanation
Choice A reason: Barley contains gluten, a protein that triggers an immune reaction in people with celiac disease. This reaction damages the lining of the small intestine and prevents it from absorbing nutrients. Therefore, barley should be avoided by people with celiac disease.
Choice B reason: Wheat also contains gluten and should be avoided by people with celiac disease for the same reason as barley.
Choice C reason: Rice is a gluten-free grain and can be safely consumed by people with celiac disease. Rice is a good source of carbohydrates, fiber, and vitamins.
Choice D reason: Potatoes are also gluten-free and can be safely consumed by people with celiac disease. Potatoes are a good source of potassium, vitamin C, and starch.
Correct Answer is A
Explanation
Choice A reason: Oral rehydration solution (ORS) is the best fluid for a child with acute gastroenteritis, as it contains the optimal balance of electrolytes and glucose to prevent dehydration and restore fluid balance. ORS is recommended by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) for the management of diarrhea in children.
Choice B reason: Water is not a good fluid for a child with acute gastroenteritis, as it does not contain any electrolytes or glucose and can dilute the blood sodium level, leading to hyponatremia. Water can also increase the osmotic load in the intestines and worsen diarrhea.
Choice C reason: Broth is not a good fluid for a child with acute gastroenteritis, as it is high in sodium and can cause hypernatremia and dehydration. Broth can also irritate the intestinal mucosa and increase diarrhea.
Choice D reason: Diluted apple juice is not a good fluid for a child with acute gastroenteritis, as it is high in fructose and can cause osmotic diarrhea. Apple juice can also lower the blood pH and cause metabolic acidosis.
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