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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Related Questions
Correct Answer is C
Explanation
A. “Place your child in a sitting position with her head tilted back.”: This is not recommended because it can cause the blood to flow down the back of the throat, which can lead to gagging or choking.
B. “Apply ice at the base of the nose for 5 min and then check for bleeding.”: While applying ice can help constrict the blood vessels and slow the bleeding, it’s not the most effective initial step in managing a nosebleed.
C. “Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes.”: This is the correct answer. Tilting the head forward prevents the blood from flowing down the back of the throat, and applying pressure to the nostrils can help stop the bleeding.
D. “Place your child in a supine position with a pillow under her back.”: Lying down can increase blood pressure in the veins of the nose, which can make the nosebleed worse. It’s better to keep the head elevated.
Correct Answer is A
Explanation
A. Position the child laterally: This is the correct action. During a seizure, positioning the child on their side (lateral position) can help prevent aspiration of saliva or vomit.
B. Use a padded tongue blade: This is not recommended. Inserting anything into the mouth of a person having a seizure can cause injury to the teeth or jaw.
C. Restrain the child’s arms: This is not recommended. During a seizure, it’s important not to restrain the child as it can lead to injury.
D. Attempt to stop the seizure: This is not possible. Seizures usually need to run their course. It’s important to keep the child safe during the seizure and seek medical attention if necessary.
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