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 A

Explanation

A. Give the child acetaminophen for discomfort: This is the correct answer. After a cardiac catheterization, the child may experience some discomfort. Acetaminophen is a safe and effective medication for pain relief in children.

B. Assist the child to take a tub bath for the first 3 days: This is not typically recommended. The child should avoid full immersion in water (like a bathtub) until the catheterization site has fully healed to prevent infection.

C. Offer the child clear liquids for the first 24 hr: While it’s important for the child to stay hydrated, there’s no need to restrict the child’s diet to clear liquids after a cardiac catheterization unless specifically instructed by the healthcare provider.

D. Keep the child home for 1 week: While some rest and recovery time at home is necessary after a cardiac catheterization, a full week may not be necessary. The exact duration would depend on the child’s individual recovery and should be determined by the healthcare provider.

A. Stop the enema and document that the client did not tolerate the procedure. B. Allow the client to expel some fluid before continuing. C. Encourage the client to bear down. D. Lower the height of the solution container.

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.

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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

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