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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Red currant jelly stools are typically associated with intussusception, not pyloric stenosis. In pyloric stenosis, the stool would not have this appearance.

Choice B reason: Distended neck veins are not a clinical manifestation of pyloric stenosis. They are more commonly associated with cardiac or respiratory issues.

Choice C reason: Projectile vomiting is a classic symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, which prevents stomach contents from passing into the small intestine.

Choice D reason: A bulged abdomen is not specific to pyloric stenosis. While the abdomen may appear full, 'bulged' is not the precise term used to describe the manifestation in pyloric stenosis.

A. 13% weight loss B. Bulging anterior fontanel C. Bradypnea D. Capillary refill 3 seconds

Correct Answer is A

Explanation

Choice A reason: A 13% weight loss is a sign of severe dehydration in infants. Dehydration occurs when the body loses more fluid than it takes in. Acute gastroenteritis can cause vomiting and diarrhea, which can lead to fluid loss and dehydration.

Choice B reason: A bulging anterior fontanel is not a sign of dehydration, but rather a sign of increased intracranial pressure. The anterior fontanel is the soft spot on the top of the infant's head. It should be flat or slightly concave, not bulging or sunken.

Choice C reason: Bradypnea is not a sign of dehydration, but rather a sign of respiratory depression. Bradypnea is abnormally slow breathing, usually less than 12 breaths per minute in infants. Dehydration can cause tachypnea, which is abnormally fast breathing, usually more than 60 breaths per minute in infants.

Choice D reason: A capillary refill of 3 seconds is not a sign of dehydration, but rather a sign of normal perfusion. Capillary refill is the time it takes for the color to return to the nail bed after pressing on it. A normal capillary refill is less than 2 seconds. Dehydration can cause delayed capillary refill, which is more than 2 seconds.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 6-week-old infant who has pyloric stenosis. Which of the following clinical manifestations should the nurse expect?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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