The parents of a 7-year-old child bring her to the emergency department. They tell the nurse that she awoke with a tympanic temperature of 39.2 (102.2°), an extremely sore throat, drooling, and difficulty swallowing. Which of the following actions is the nurse's priority?

Obtain culture specimens.

Administer an antipyretic.

Prepare for intubation.

Insert an IV catheter.

Answer and Explanation

The Correct Answer is C

A. While obtaining culture specimens is important, the priority in this case is managing the child’s airway, as drooling and difficulty swallowing suggest potential airway obstruction.

B. Administering an antipyretic is not the priority; airway management is more urgent in this situation.

C. The priority is to prepare for intubation, as the child’s symptoms suggest possible epiglottitis, which can cause rapid airway obstruction. Securing the airway is critical.

D. Inserting an IV catheter is important for hydration and medication administration, but airway management is the immediate priority.

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Correct Answer is D

Explanation

A. Pulmonary atresia involves a blockage of blood flow to the lungs, but it does not specifically lead to differences in blood pressure in the extremities.

B. Tetralogy of Fallot involves four defects, but it does not directly correlate with differences in blood pressure between the extremities.

C. A ventricular septal defect can cause heart failure, but it typically doesn’t affect blood pressure in the extremities.

D. Coarctation of the aorta is a congenital defect where the aorta is narrowed, leading to higher blood pressure in the upper extremities and lower blood pressure in the lower extremities. This is why blood pressures are measured in all four extremities to identify this condition.

A. Have the child sit with her head tilted forward and hold pressure on her nose for 10 min. B. Apply ice at the base of the nose for 5 min and then check for bleeding. C. Place the child in a sitting position with her head tilted back. D. Place the child in a supine position with a pillow under her back.

Correct Answer is A

Explanation

A. The child should sit upright with the head tilted forward to prevent blood from flowing down the throat, which could cause choking or aspiration. Applying pressure on the nostrils for 10 minutes is an effective method for stopping most nosebleeds.

B. While ice may help constrict blood vessels, it is not the primary intervention for a nosebleed. Holding pressure is more effective.

C. Tilting the head back can cause blood to flow into the throat and potentially lead to choking or vomiting.

D. Lying the child supine increases the risk of blood flowing into the throat and airway, making it unsafe.

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The parents of a 7-year-old child bring her to the emergency department. They tell the nurse that she awoke with a tympanic temperature of 39.2 (102.2°), an extremely sore throat, drooling, and difficulty swallowing. Which of the following actions is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a newly-admitted infant diagnosed with "failure to thrive." The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order?

Correct Answer is D

Explanation

A parent calls the pediatric clinic to report that her child has a bloody nose. The nurse should give the parent which of the following instructions to stop the bleeding?

Correct Answer is A

Explanation

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