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 C
Explanation
A. Promote bed rest without additional pain interventions to allow natural resolution of the crisis is incorrect. While rest can help conserve energy, pain management is a priority in vaso-occlusive crises. Unmanaged pain can lead to stress-induced complications, prolonged hospital stays, and decreased oxygenation, which may worsen sickling.
B. Limit fluid intake to prevent fluid overload and minimize risk of pulmonary edema during the crisis is incorrect. Hydration is critical during a vaso-occlusive crisis because dehydration increases blood viscosity and promotes further sickling. Limiting fluids can exacerbate the crisis rather than help it.
C. Administer prescribed opioids promptly and encourage oral hydration as tolerated to manage pain and reduce sickling episodes is correct. Prompt administration of opioids (e.g., morphine or hydromorphone) addresses the severe pain associated with vaso-occlusive crises, while hydration helps maintain blood volume and decreases the likelihood of additional sickling. These interventions are central to reducing morbidity and preventing complications such as organ damage or prolonged hypoxia.
D. Delay opioid administration to assess the child's pain threshold and avoid potential opioid dependence is incorrect. Pain should be treated promptly in vaso-occlusive crises. Delaying analgesia increases suffering, can worsen hypoxia, and may lead to more severe complications. Concerns about long-term opioid dependence are secondary to immediate pain control and patient safety.
Correct Answer is D
Explanation
A. Limiting family involvement to scheduled visiting hours is incorrect because family-centered care promotes unrestricted or flexible family presence. Restricting involvement contradicts the idea that the family plays a continuous and central role in the child’s life.
B. Encouraging the family to follow unit routines without modification is incorrect because family-centered care values collaboration and flexibility. Care should be adapted to meet the needs of the child and family, not force the family to conform to rigid hospital routines.
C. Assuming the healthcare team is the primary source of support for the child is incorrect because, in family-centered care, the family—not the healthcare team—is recognized as the primary and constant source of support, comfort, and advocacy for the child.
D. Involving the family in care planning and decision-making for the child is correct because it acknowledges that the family is the constant in the child’s life. This approach respects the family’s knowledge of the child, promotes collaboration, and supports continuity of care across healthcare settings.
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