A school nurse is caring for a child who has asthma and begins to have difficulty breathing. Which of the following actions should the nurse take?
Administer two puffs of albuterol.
Place the child in the supine position.
Encourage the use of a flutter mucus clearance device.
Instruct the child to perform controlled breathing exercises.
The Correct Answer is A
Choice A rationale:
Administer two puffs of albuterol. This is the correct answer because albuterol is a bronchodilator that helps to relieve acute asthma symptoms by opening up the airways. In a child experiencing difficulty breathing due to asthma, prompt administration of albuterol can help alleviate the symptoms and improve breathing.
Choice B rationale:
Place the child in the supine position. Placing the child in the supine position can further compromise their breathing, especially in a situation of asthma exacerbation. This position can restrict the airways and make breathing more difficult, so it is not an appropriate action.
Choice C rationale:
Encourage the use of a flutter mucus clearance device. While mucus clearance devices can be helpful for individuals with chronic respiratory conditions, such as cystic fibrosis, it is not the priority action for a child experiencing acute asthma symptoms. The immediate focus should be on relieving the airway constriction and addressing the breathing difficulty.
Choice D rationale:
Instruct the child to perform controlled breathing exercises. Controlled breathing exercises might be useful for anxiety and panic management, but in an acute asthma episode, the child's primary need is to open up the airways and improve breathing. Albuterol administration takes precedence over breathing exercises in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This statement reflects an accurate understanding of varicella (chickenpox) transmission and infection control. The lesions of varicella contain the virus and are contagious until they have crusted over. Allowing the child to go to the playroom only after the lesions have crusted helps prevent the spread of the virus to other individuals.
Choice B rationale:
This statement is incorrect because waiting for the crusts to fall off the lesions before bathing the child is not necessary. In fact, keeping the lesions clean and maintaining proper hygiene through gentle bathing can help prevent secondary bacterial infections.
Choice C rationale:
This statement is incorrect because bedrest for 3 days is not necessary for a child with varicella. While it's important to minimize contact with others during the contagious phase, physical activity can be gradually resumed as long as the lesions have crusted to prevent transmission.
Choice D rationale:
This statement is incorrect. Once a person has had chickenpox (varicella), they develop immunity to the virus and do not need to wear a mask when visiting someone with active varicella. This is because they are already immune to the virus due to their prior infection.
Correct Answer is D
Explanation
Choice A rationale:
Acute otitis media is not a risk factor for physical maltreatment. It's an ear infection and does not directly contribute to the risk of physical abuse. The child's medical history should be assessed for factors that are more closely related to abuse.
Choice B rationale:
Myopia, or nearsightedness, is also not a risk factor for physical maltreatment. Myopia is a visual impairment and is not related to the risk of abuse. The nurse should focus on identifying factors that might indicate an increased likelihood of abuse.
Choice C rationale:
Prematurity can be a risk factor for various health issues in a child, but it is not directly linked to physical maltreatment. While preterm infants might have unique medical needs, being born prematurely does not inherently increase the risk of physical abuse.
Choice D rationale:
Correct Answer. Being adopted can be considered a potential risk factor for physical maltreatment. Children who are adopted might face certain challenges related to attachment, identity, and adjustment. It's important for healthcare providers to be vigilant and assess the child's situation comprehensively to ensure their safety and well-being.
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