A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which action is the nurse's priority?
Insert an IV catheter.
Prepare for nasotracheal intubation.
Administer an antipyretic.
Obtain blood culture specimens.
The Correct Answer is B
Insert an IV catheter: While this might be necessary later, it’s not the immediate priority. The child’s breathing difficulty is the most urgent concern.
B. Prepare for nasotracheal intubation: This is the correct answer. The child’s severe dyspnea indicates a serious breathing problem. Nasotracheal intubation can help ensure the child’s airway remains open.
C. Administer an antipyretic: While this might help reduce the child’s fever, it won’t address the immediate life-threatening issue, which is the child’s difficulty breathing.
D. Obtain blood culture specimens: This could be helpful in diagnosing the cause of the child’s symptoms, but it’s not the immediate priority. The first concern should be stabilizing the child’s condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “Your baby’s heart is beating fast in an attempt to cool down his body”: This is not accurate. While the body does have mechanisms to cool itself down, such as sweating, an increased heart rate is not typically one of them.
B. “The fever is causing an increase in your baby’s heart rate”: This is the correct answer. Fever can cause an increase in metabolic rate, which can lead to an increased heart rate as the body works harder to fight off illness.
C. “As your baby begins to fall asleep, his heart rate will decrease”: While it’s true that heart rate can decrease during sleep, this doesn’t address the cause of the increased heart rate in this situation.
D. “This is within the expected range for your baby”: This is not accurate. A heart rate of 190/min and a temperature of 40° C (104° F) are both higher than normal for a 2-month-old infant and could indicate a serious condition that needs medical attention.
Correct Answer is A
Explanation
“I will give my son the enzymes between meals.”: This statement indicates a need for further teaching. Pancreatic enzymes should be given with meals and snacks, not between them, to aid in the digestion of food.
B. “The enzymes probably won’t cause many adverse effects.”: This is correct. Pancreatic enzymes are generally well-tolerated with few side effects.
C. “I will put the enzyme crystals in his applesauce.”: This is correct. Pancreatic enzymes can be mixed with a small amount of applesauce or other soft foods to make them easier to swallow.
D. “The enzymes help him digest fat.”: This is correct. Pancreatic enzymes aid in the digestion of fats, proteins, and carbohydrates.
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