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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Stop the enema and document that the client did not tolerate the procedure: This action might be necessary in some cases, but it’s not the first action to take. The nurse should first try to alleviate the client’s discomfort.
B. Allow the client to expel some fluid before continuing: This action could potentially relieve some discomfort, but it’s not the most effective initial response. The cramping is likely due to the speed at which the fluid is entering, not the amount of fluid already administered.
C. Encourage the client to bear down: This action is not typically recommended during an enema administration as it could increase discomfort.
D. Lower the height of the solution container: This is the correct action. Lowering the height of the solution container will decrease the speed at which the fluid is entering the client’s rectum, which can help alleviate cramping and discomfort. Therefore, option D is the most appropriate action for the nurse to take.
Correct Answer is C
Explanation
A. “I can fit my hand between the baby and the car seat harness.”: This indicates that the harness is too loose. A properly adjusted harness should be snug, with no slack allowing a hand to fit between the baby and the harness.
B. “Our car seat is front-facing in the back seat.”: For a 6-month-old infant, the car seat should be rear-facing, not front-facing. The American Academy of Pediatrics recommends that children remain rear-facing as long as possible, at least until they reach the highest weight or height allowed by their car safety seat’s manufacturer.
C. “Our car seat is an infant model and is anchored in the car.”: This is the correct answer. An infant car seat should be properly anchored in the car for safety.
D. “The car seat is rear-facing in the front passenger seat.”: It’s not safe to place a rear-facing car seat in the front seat of a vehicle. In the event of an accident, airbags can injure or kill a child in a rear-facing car seat. The safest place for a child’s car seat is in the back seat of the vehicle.
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