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 A
Explanation
Pruritus of the scalp: This is the correct answer. Pruritus, or itching, of the scalp is a common symptom of pediculosis capitis, also known as head lice.
B. Blisters on the scalp: While blisters can occur with various scalp conditions, they are not typically associated with pediculosis capitis.
C. Bald patches on the scalp: Bald patches can be a sign of conditions like alopecia areata or tinea capitis, but they are not typically associated with pediculosis capitis.
D. Dry patches on the scalp: Dry patches can be a sign of conditions like seborrheic dermatitis or psoriasis, but they are not typically associated with pediculosis capitis.
Correct Answer is B
Explanation
A. Heart rate 72/min: This is within the normal range for an adolescent.
B. Blood pressure 92/50 mm Hg: This is concerning because it’s lower than the normal range for an adolescent, which could indicate shock, a serious condition that requires immediate medical attention.
C. Respiratory rate 20/min: This is within the normal range for an adolescent.
D. Abdominal pain rated 4 on a scale of 0 to 10: While any pain is concerning, a pain level of 4 is less immediately concerning than the low blood pressure. Therefore, option B is the most concerning finding.
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