A 13 year old adolescent is brought to the Emergency Department after a near-drowning/submersion event. The child is coughing and having difficulty breathing. 02 saturation is 90% in room air, RR=26/min, HR=102/min. What is the priority intervention for the nurse to take?
Administer sedation
Check capillary refill
Have the child sit in an upright position
Administer oxygen at 2L/min via face mask
The Correct Answer is D
A. Sedation is not a priority; maintaining adequate oxygenation is critical first.
B. Capillary refill can be assessed but is not an immediate intervention.
C. Sitting upright can aid breathing but does not directly address hypoxia.
D. Administering oxygen helps correct hypoxemia, which is the immediate priority in respiratory distress.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Children with autism typically benefit from a consistent schedule rather than a flexible one.
B. Imaginative play with supervision ensures the child’s safety and helps with social skills, as some children with autism may struggle with peer interaction.
C. A reward system for positive behavior can reinforce desired actions and help manage challenging behaviors.
D. Consistent rules help provide structure, which is generally beneficial for children with autism.
Correct Answer is B
Explanation
A. Blood pressure may fluctuate but is less sensitive as an early indicator of fluid resuscitation efficacy.
B. A decrease in heart rate is a sign of improved hydration status, as tachycardia is often a compensatory response to hypovolemia.
C. Weight is not used as an immediate indicator for fluid resuscitation adequacy.
D. Urine output should increase with adequate fluid resuscitation; a decrease in urine output would indicate worsening.
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