A nurse in the emergency department is assessing a toddler who has hyperpyrexia, severe dyspnea, and is drooling.
Which of the following actions should the nurse take first?
Administer an antibiotic to the toddler.
Obtain a blood culture from the toddler.
Insert an IV catheter for the toddler.
Prepare the toddler for nasotracheal intubation.
The Correct Answer is D
The nurse should prepare the toddler for nasotracheal intubation first because the toddler is experiencing severe dyspnea and drooling, which are signs of airway obstruction.
Nasotracheal intubation will help to secure the toddler’s airway and improve their breathing.
Choice A is wrong because administering an antibiotic is not the priority intervention for a toddler with airway obstruction.
Choice B is wrong because obtaining a blood culture is not the priority intervention for a toddler with airway obstruction.
Choice C is wrong because inserting an IV catheter is not the priority intervention for a toddler with airway obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A preschool-age child who has a muffled voice and no spontaneous cough should be assessed first.
These symptoms may indicate epiglottitis, which is a life-threatening condition that requires immediate medical attention.

Choice A, B and D are also important but not as urgent as choice C. A toddler with nephrotic syndrome and facial edema, an adolescent with Crohn’s disease and recent weight loss, and a school-age child with diabetes mellitus and a blood glucose of 200 mg/dL should be assessed after the preschool-age child with a muffled voice and no spontaneous cough.
Correct Answer is ["B","C","E"]
Explanation

This laboratory test can contribute to confirming a diagnosis of rheumatic fever.
Choice A is wrong because Blood urea nitrogen (BUN) is not used to diagnose rheumatic fever.
Choice D is wrong because Partial thromboplastin time (PTT) is not used to diagnose rheumatic fever.
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