A 2-year-old toddler was rescued after being submerged in a bathtub for approximately 3 minutes and brought to the emergency department. The child is currently awake but irritable, with a respiratory rate of 38 breaths per minute, oxygen saturation of 91% on room air, and a temperature of 35.5°C (95.9°F). The nurse notes mild intercostal retractions and fine crackles on lung auscultation. Laboratory results show mild metabolic acidosis. Which nursing action should the nurse prioritize during the first hour of care?
Begin intravenous fluid bolus immediately to correct metabolic acidosis.
Administer humidified oxygen and monitor respiratory status closely, preparing for possible deterioration.
Prepare the child for immediate endotracheal intubation and mechanical ventilation.
Initiate antipyretic therapy to address hypothermia and prevent fever.
The Correct Answer is B
A. Begin intravenous fluid bolus immediately to correct metabolic acidosis is incorrect because mild metabolic acidosis in a drowning victim is typically secondary to hypoxia. The first priority is ensuring adequate oxygenation and ventilation; fluids may be necessary later for shock or hypotension but are not the immediate priority unless signs of hypovolemia are present.
B. Administer humidified oxygen and monitor respiratory status closely, preparing for possible deterioration is correct because submersion injuries can result in secondary pulmonary injury, including noncardiogenic pulmonary edema, hypoxia, and respiratory distress. The child is showing mild hypoxemia (SpO2 91%), retractions, crackles, and mild metabolic acidosis, indicating early post-drowning respiratory compromise. Oxygen therapy, close monitoring, and preparation for escalation (intubation if needed) are the highest priority interventions in the first hour.
C. Prepare the child for immediate endotracheal intubation and mechanical ventilation is incorrect because the child is currently awake, maintaining airway, and only mildly hypoxic. Immediate intubation is not indicated unless there is worsening respiratory distress, severe hypoxia, or altered mental status.
D. Initiate antipyretic therapy to address hypothermia and prevent fever is incorrect because the child is hypothermic (35.5°C), not febrile. Hypothermia should be corrected with passive or active warming measures, not antipyretics. Fever prevention is not the first priority in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administering an antiemetic at least 30 minutes before chemotherapy begins is correct because prevention is more effective than treatment after symptoms appear. Administering antiemetics prophylactically helps reduce the severity and incidence of chemotherapy-induced nausea and vomiting, improving patient comfort and adherence to treatment.
B. Encouraging the child to remain NPO until nausea subsides is incorrect because prolonged fasting does not prevent chemotherapy-induced nausea and may contribute to dehydration and nutritional deficits, especially important in children undergoing cancer treatment.
C. Encouraging drinking large amounts of fluids is incorrect because forcing large volumes may worsen nausea or vomiting. Fluid intake should be adequate but balanced to prevent discomfort.
D. Administering an antiemetic after the child has nausea is incorrect because reactive treatment is less effective than prophylactic administration. Once severe nausea and vomiting have occurred, they are harder to control and can impact hydration, nutrition, and overall treatment tolerance.
Correct Answer is D
Explanation
A. Instruct parents to feed the infant large volumes less frequently is incorrect because large feedings increase gastric distention and can worsen reflux. Small, frequent feedings are preferred.
B. Advise parents to allow the infant to sleep on their stomach is incorrect because placing infants on their stomach increases the risk of sudden infant death syndrome (SIDS) and is not recommended. Infants should be placed on their back for sleep.
C. Recommend thickening all infant feedings with cereals is partially correct for some infants, but thickening should be guided by a healthcare provider, as it is not appropriate for all infants and can pose risks if done incorrectly.
D. Educate parents to position the infant at a 30-degree angle for 30 minutes after feeding and avoid propping bottles during feedings is correct because upright positioning after feedings uses gravity to reduce reflux and prevents aspiration. Avoiding bottle propping reduces the risk of choking, overfeeding, and increased reflux episodes.
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