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 B
Explanation
Choice A rationale:
Administer pain medication. Administering pain medication is important for the preschooler's comfort, but it is not the nurse's priority action in this scenario. The priority is to ensure adequate circulation to the extremities, which can be assessed by checking capillary refill.
Choice B rationale:
Check capillary refill. This is the correct answer because the nurse's priority is to assess the child's circulation and tissue perfusion. In 90-90 traction, there is a risk of impaired circulation to the extremities due to the positioning. Checking capillary refill provides information about the adequacy of blood flow to the capillaries and is crucial for early detection of any circulation problems.
Choice C rationale:
Cleanse and dress the pin sites. While caring for the pin sites is important to prevent infection, it is not the priority action at this moment. Ensuring proper circulation and perfusion takes precedence over pin site care.
Choice D rationale:
Reposition the child every 2 hr. Repositioning the child is important to prevent complications associated with immobility, but it is not the nurse's priority action in this situation. The primary concern is to assess and address any circulation issues.
Correct Answer is D
Explanation
Answer: d. Apply suction in 3 to 4-second increments.
Rationale:
- a. Instill 2 mL of 0.9% sodium chloride prior to suctioning:While saline instillations may be used in some cases,it is not universally recommended for infants with tracheostomies and depends on the specific situation and healthcare provider's protocol.The priority in this case is to quickly clear the partial mucus occlusion to prevent respiratory distress.
- b. Select a catheter that fits snugly into the tracheostomy tube:This isincorrect.Selecting a catheter that fits tightly can damage the delicate tracheal mucosa and increase the risk of bleeding.A smaller-diameter catheter that allows for gentle passage is preferred.
Opens in a new window
www.researchgate.net
Tracheostomy tube and different catheter sizes
- c. Use a clean technique when performing suctioning:This is absolutely essential for all suctioning procedures to minimize the risk of infection.However,it is not the specific action that addresses the immediate concern of clearing the partial mucus occlusion.
- d. Apply suction in 3 to 4-second increments:This is thecorrectapproach for suctioning an infant with a tracheostomy.Applying short,intermittent suction bursts minimizes the risk of hypoxia and tissue trauma while effectively removing secretions.
Therefore, the most important action for the nurse to take is to apply suction in short, 3-4 second bursts to effectively clear the mucus occlusion while minimizing risks to the infant.
Additional Points:
- The nurse should use sterile suction equipment and sterile technique throughout the procedure.
- The suction pressure should be set at the lowest effective level,typically 80-120 mmHg.
- The nurse should monitor the infant for signs of respiratory distress,such as increased work of breathing,retractions,and oxygen desaturation,before,during,and after suctioning.
- If the mucus occlusion is not cleared after several attempts,the nurse should seek assistance from ahealthcareprovider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today