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 should take the enzymes before or with meals, not after. Taking the enzymes after meals may reduce their effectiveness and cause malabsorption of nutrients.
Choice B reason: This statement is incorrect, as the child should take the enzymes within 30 minutes before meals, not 2 hours. Taking the enzymes too early may cause them to be inactivated by the stomach acid and lose their function.
Choice C reason: This statement is incorrect, as the child does not take the enzymes to improve her metabolism, but to replace the deficient pancreatic enzymes that are needed for digestion. The child has cystic fibrosis, a genetic disorder that affects the exocrine glands and causes thick mucus to block the ducts of the pancreas.
Choice D reason: This statement is correct, as the child takes the enzymes to help digest the fat in foods, as well as other nutrients such as protein and carbohydrates. The enzymes contain lipase, amylase, and protease, which break down fat, starch, and protein respectively.
Correct Answer is A
Explanation
Choice A reason: This is the best option to prevent the toddler from touching or injuring the surgical site. The nurse should apply soft padded restraints and check the circulation and skin integrity of the wrists frequently.
Choice B reason: Offering fluids through a straw is not recommended for a toddler who has had a cleft palate repair, as it can cause suction and pressure in the mouth that can disrupt the sutures. The nurse should offer fluids with a cup or a spoon.
Choice C reason: Implementing a soft diet is not appropriate for a toddler who has had a cleft palate repair, as it can cause irritation and infection in the mouth. The nurse should provide clear liquids for the first 24 hr and then advance to full liquids as tolerated.
Choice D reason: Administering opioids for pain is not the first choice for a toddler who has had a cleft palate repair, as it can cause respiratory depression and constipation. The nurse should use nonpharmacological methods such as distraction, comfort, and reassurance first, and then administer acetaminophen or ibuprofen as prescribed.
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