In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?
Instruct the mother to play with the child for stimulation and distraction.
Administer a dose of acetaminophen as needed.
Monitor the child's oxygen saturation level via pulse oximetry.
Encourage the child to drink adequate amounts of fluids.
The Correct Answer is C
Croup is a respiratory infection that causes inflammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.
The other options are not correct because:
A. Instructing the mother to play with the child for stimulation and distraction may worsen the child's condition, as it can increase his respiratory demand and anxiety.
B. Administering a dose of acetaminophen as needed may help reduce fever or pain, but it does not address the underlying cause of croup or improve airway patency.
D. Encouraging the child to drink adequate amounts of fluids may help prevent dehydration and thin the secretions, but it does not relieve the inflammation or narrowing of the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Urinary output is not directly related to stomatitis, which is inflammation of the mouth and throat. While monitoring urinary output is important in many situations, it is not relevant in this case.
Choice B rationale:
Blood pressure while standing is not directly related to stomatitis either. This assessment is more relevant for conditions such as orthostatic hypotension, which can cause a drop in blood pressure upon standing.
Choice C rationale:
Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.
Choice D rationale:
Frequency of bowel movements is unrelated to stomatitis. This assessment is more relevant for gastrointestinal issues or constipation, not for a condition affecting the mouth and throat.
Correct Answer is A
Explanation
The correct answer is Choice A. Temperature. Choice A rationale:
The practical nurse (PN) should complete the data collection for temperature first. A large amount of sanguineous drainage on the abdominal incision dressing could indicate possible infection or a change in the client's condition. Elevated temperature may be an early sign of infection, which requires immediate attention and appropriate intervention.
Choice B rationale:
Assessing the pain scale is important, but it can be addressed after completing the data collection for temperature. Pain assessment is essential for providing appropriate pain management, but it is not the most urgent concern when there is a significant amount of drainage from the incision site.
Choice C rationale:
Checking bowel sounds is relevant in postoperative care, but it is not the priority at this moment. Abdominal incision drainage takes precedence as it may indicate a more critical issue that requires immediate attention.
Choice D rationale:
Monitoring blood pressure is essential, but it is not the most immediate concern in this scenario. A large amount of sanguineous drainage from the abdominal incision takes precedence over blood pressure monitoring at this time.
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