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 D
Explanation
The accessory nerve is tested by evaluating the function of the trapezius and sternocleidomastoid muscles.
The trapezius muscle is tested by asking the patient to shrug their shoulders with and without resistance.
Choice A is wrong because following a light in the six cardinal positions tests the function of cranial nerves III, IV, and VI.
Choice B is wrong because moving their tongue in all directions tests the function of cranial nerve XII.
Choice C is wrong because showing their teeth while smiling tests the function of cranial nerve VII.
Correct Answer is B
Explanation
The trigeminal nerve is responsible for sensation in the face and motor functions such as biting and chewing.
Symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve.
Choice A is wrong because it assesses the vestibulocochlear nerve, not the trigeminal nerve.
Choice C is wrong because it assesses the glossopharyngeal and vagus nerves, not the trigeminal nerve.
Choice D is wrong because it assesses the olfactory nerve, not the trigeminal nerve.
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