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 D
Explanation
Choice A rationale:
Insulin administration is not appropriate in this situation. The child's symptoms (slurred speech, diaphoresis, low blood glucose reading) indicate hypoglycemia, which is a state of low blood sugar. Administering insulin, which lowers blood glucose further, would exacerbate the hypoglycemia and could lead to more severe symptoms or even unconsciousness.
Choice B rationale:
Metformin is not indicated in this scenario. Metformin is an oral medication used to treat type 2 diabetes, not type 1 diabetes mellitus. The child in the scenario has type 1 diabetes, which is characterized by an absolute deficiency of insulin production.
Choice C rationale:
Offering a 6 oz diet soft drink is not the appropriate intervention for hypoglycemia. Diet soft drinks do not contain significant amounts of sugar, which is needed to rapidly raise the child's blood glucose levels. In cases of hypoglycemia, a source of quickly absorbable sugar, such as a regular soft drink or fruit juice, is recommended.
Choice D rationale:
Administering a 6 oz regular soft drink is the appropriate intervention in this situation. The child is experiencing hypoglycemia, which means their blood glucose levels are dangerously low. Regular soft drinks contain rapidly absorbable sugar that can quickly raise the child's blood glucose levels, alleviating the symptoms of hypoglycemia. The child's symptoms, including slurred speech and diaphoresis, are indicative of a need for immediate intervention to raise blood sugar levels.
Correct Answer is A
Explanation
Choice A rationale:
Obtain the specimen by swabbing the infant's rectum using a sterile culture swab. This is the correct choice. When collecting a stool specimen from an infant, the rectal swab method is commonly used. A sterile culture swab helps prevent contamination and ensures accurate results for detecting the presence of ova and parasites in the stool.
Choice B rationale:
Place a urine collection device on the infant until the specimen is obtained. This choice is not appropriate for collecting a stool specimen. A urine collection device is used for collecting urine, not stool. The specimen for ova and parasites needs to be taken directly from the rectum or diaper to accurately identify any infestations.
Choice C rationale:
Transfer the specimen to the collection container using povidone-iodine-soaked gauze. While povidone-iodine is an antiseptic, it is not typically used to transfer stool specimens. Using a sterile swab or a clean, dry container is more suitable for collecting and transporting stool samples to the lab.
Choice D rationale:
Maintain the specimen at room temperature after collection until it is transferred to the lab. Stool specimens for ova and parasites usually require refrigeration to prevent the degradation and growth of potential pathogens. Room temperature might lead to the overgrowth of bacteria and parasites, affecting the accuracy of test results.
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