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.

Answer and Explanation

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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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.

A. "My child will take the enzymes following meals." B. "My child will take the enzymes 2 hours before meals. C. "My child will take the enzymes to improve her metabolism." D. "My child will take the enzymes to help digest the fat in foods."

Correct Answer is D

Explanation

A. “My child will take the enzymes following meals.”: This is incorrect. Pancreatic enzymes should be taken with meals, not after, to help with the digestion of food.
B. “My child will take the enzymes 2 hours before meals.”: This is incorrect. Pancreatic enzymes should be taken with meals, not before, to help with the digestion of food.
C. “My child will take the enzymes to improve her metabolism.”: While pancreatic enzymes do aid in digestion, which is a part of metabolism, this statement is not specific enough to indicate a correct understanding of the purpose of the enzymes.
D. “My child will take the enzymes to help digest the fat in foods.”: This is the correct answer. Pancreatic enzymes help break down fats, proteins, and carbohydrates in food, aiding in their digestion and absorption in the intestines. This is particularly important in conditions like cystic fibrosis, where the pancreas does not produce enough of these enzymes naturally.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father as nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which following statements indicates that the mother understands the teaching?

Correct Answer is D

Explanation

A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that teaching is necessary when the mother states which of the following?

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A nurse is assisting with the admission of a child who has measles. Which of the following isolation precautions should the nurse initiate?

A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following should the nurse plan to take?

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