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.
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Related Questions
Correct Answer is B
Explanation
The Herpes zoster (shingles) vaccination is recommended for adults aged 60 years and older, regardless of whether they have had shingles or chicken pox before. The vaccine can reduce the risk of developing shingles and its complications, such as postherpetic neuralgia.
The other options are not correct because:
a. The vaccine is useful even if the person has had a case of shingles before, as shingles can recur in some people. The vaccine can prevent or reduce the severity of future episodes.
c. The person needs to get this vaccination even if they have had chicken pox, as shingles is caused by the reactivation of the same virus that causes chicken pox (varicella-zoster virus). The vaccine can boost the immunity against the virus and prevent it from reactivating.
d. The vaccination does not minimize outbreaks of cold sores, as cold sores are caused by a different virus (herpes simplex virus). The vaccine has no effect on this virus or its symptoms.
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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