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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
A) Incorrect - Providing a regular diet tray is important for the client's nutritional needs, but it is not as urgent as assessing vital signs or administering Albuterol in response to the client's acute symptoms.
B) Correct- This action is a priority after any assessment or intervention. Vital signs provide important information about the client's overall condition, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
C) Incorrect - Applying oxygen is important, but its priority depends on the client's vital signs and oxygen saturation, which should be assessed first.
D) Correct- Administering Albuterol as ordered is crucial for addressing the client's acute breathing difficulty. Albuterol is a bronchodilator that helps alleviate asthma symptoms, and timely administration is essential.
E) Incorrect - Performing a pulmonary function test is valuable for assessing lung function, but it's not an immediate concern compared to addressing the client's breathing difficulty.
Correct Answer is C
Explanation
- An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the stool. It is usually oil-based and contains 90-120 ml of solution.
- The temperature of the enema solution affects the effectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue³. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work.
- The ideal temperature for an enema solution is close to the client’s body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions.
Option A is incorrect because the client’s comfort level may not reflect the optimal temperature for the enema.
Option B is incorrect because the temperature of the enema does affect its effectiveness and safety.
Option D is incorrect because the temperature is too high and can cause harm to the client.
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