A 2-year-old child has had a common cold for 4 days. The caregiver calls the nurse in the emergency department at 2 a.m. on a cold winter night to say that the child has awakened with a barking cough and an elevated temperature; the child seems blue around the mouth. The nurse would appropriately recommend what action to the caregiver?
“Put a cool mist humidifier or vaporizer in the room to see if that relieves the cough. Call back if there is no relief in an hour.”
“Bring the child to the emergency room immediately.”
“Bundle the child up and take the child out into the cold for a few minutes. Call back if the exposure to the cold air does not provide relief.”
“Turn on all of the hot water taps in the bathroom and close the door. Take the child into the steam-filled room for 15 minutes. If there is no relief, bring the child to the emergency room.”
The Correct Answer is B
Choice A reason: A cool mist humidifier may help croup but is inadequate for a child with a barking cough, fever, and cyanosis (blue around the mouth), indicating severe respiratory distress. Immediate ER evaluation is critical, making this insufficient and incorrect for the urgent symptoms described in the scenario.
Choice B reason: A barking cough, fever, and cyanosis suggest severe croup or airway obstruction, requiring urgent medical evaluation. Bringing the child to the ER immediately ensures timely intervention for potential respiratory compromise, aligning with pediatric emergency protocols, making it the correct recommendation for the caregiver.
Choice C reason: Cold air exposure may temporarily relieve croup but is unsafe for a cyanotic child with fever, indicating severe distress. Immediate ER care is needed to address potential airway issues, making this risky and incorrect for managing the child’s critical symptoms in this urgent situation.
Choice D reason: Steam may help mild croup but delays care for a child with cyanosis, signaling severe respiratory compromise. Immediate ER evaluation is essential to prevent deterioration, making this inadequate and incorrect compared to the urgent need for professional assessment in the emergency department.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Intravenous administration isn’t inherently safer, as it carries risks like infection or extravasation. Less trauma from fewer injections is accurate, making this incorrect, as it overstates safety compared to the true benefit of reduced physical and emotional trauma in pediatric IV medication delivery.
Choice B reason: Intravenous medication reduces the need for multiple injections, minimizing physical and emotional trauma for children. This aligns with pediatric nursing principles for patient comfort, making it the correct statement about the advantage of IV administration compared to repeated intramuscular or subcutaneous injections.
Choice C reason: IV medications are absorbed rapidly, not slowly, due to direct bloodstream delivery. Less trauma from fewer injections is the true benefit, making this incorrect, as it misrepresents the pharmacokinetics of intravenous administration in the context of pediatric medication delivery.
Choice D reason: IV medication is delivered into veins, not fatty tissue, which describes subcutaneous injections. Reduced trauma from fewer injections is accurate, making this incorrect, as it confuses IV administration with another route in the nurse’s understanding of medication delivery methods.
Correct Answer is C
Explanation
Choice A reason: Caregiver holding may comfort but is unreliable for keeping a wiggly 5-year-old still, risking IV dislodgement. A clove-hitch restraint ensures arm stability while allowing some movement, making this less safe and incorrect for maintaining IV security during antibiotic infusion in a resistant child.
Choice B reason: Mummy restraints are excessive for an IV, restricting the whole body and potentially distressing a 5-year-old. A clove-hitch restraint targets the arm, balancing safety and comfort, making this overly restrictive and incorrect for the specific need to secure the IV site in this scenario.
Choice C reason: A clove-hitch restraint secures the arm, preventing IV dislodgement in a resistant 5-year-old while allowing some movement. Loosening every 2 hours ensures circulation, aligning with pediatric nursing safety standards for IV therapy, making it the correct method for ensuring safety during infusion.
Choice D reason: A papoose board is used for short procedures, not prolonged IV infusions, and releasing immediately negates its purpose. A clove-hitch restraint maintains IV security over time, making this impractical and incorrect for ensuring safety during the antibiotic infusion period for the child.
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