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 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.

A. "Give your infant an oral rehydration solution." B. "Burp your baby more frequently during feedings." C. "Bring your baby in to the clinic today." D. "Try switching to a different formula."

Correct Answer is C

Explanation

Choice A reason: This statement is incorrect, as giving an oral rehydration solution to an infant who is projectile vomiting may worsen the dehydration and electrolyte imbalance. The nurse should advise the parent to stop feeding the infant and seek medical attention.

Choice B reason: This statement is incorrect, as burping the baby more frequently during feedings may not prevent the projectile vomiting, which is caused by a mechanical obstruction of the stomach, not by air swallowing. The nurse should assess the parent for signs of pyloric stenosis, such as a palpable olive-shaped mass in the right upper quadrant of the abdomen.

Choice C reason: This statement is correct, as bringing the baby in to the clinic today is the best course of action for an infant who is projectile vomiting, which is a sign of a serious condition such as pyloric stenosis, a narrowing of the opening between the stomach and the small intestine. The nurse should inform the parent that the infant needs immediate evaluation and treatment to prevent complications such as dehydration, malnutrition, and metabolic alkalosis.

Choice D reason: This statement is incorrect, as trying switching to a different formula may not help the infant who is projectile vomiting, which is not related to the type of formula, but to a structural problem in the gastrointestinal tract. The nurse should not suggest changing the formula without consulting the provider.

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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

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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