A 5-year old is brought to the ED with a temperature of 99°F (37.5°C), a barky cough, stridor and hoarseness. Which nursing intervention should the nurse prepare for?
Informing the child's parents about a tonsillectomy.
Immediate IV placement.
A tracheostomy set at the bedside.
Cool mist and respiratory treatment of racemic epinephrine
The Correct Answer is D
A. Informing the child's parents about a tonsillectomy:
Tonsillectomy is not the immediate intervention for the symptoms described. This intervention is not necessary at this point.
B. Immediate IV placement:
While hydration may be necessary, immediate IV placement is not the primary intervention for a child with croup presenting with stridor and hoarseness.
C. A tracheostomy set at the bedside:
While croup can cause airway obstruction, preparing for a tracheostomy is not the initial intervention. Less invasive measures are typically attempted first.
D. Cool mist and respiratory treatment of racemic epinephrine:
This is the correct intervention. Croup, often caused by viral infections, can result in swelling of the upper airway, leading to the characteristic barky cough, stridor, and hoarseness. Administration of cool mist and racemic epinephrine can help reduce airway swelling and alleviate symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Ask the patient to wait a little longer for the medicine to work.
This option may not be appropriate, especially if the child is experiencing significant pain. It's essential to address the child's pain promptly rather than asking them to wait, as adequate pain management is crucial for the child's well-being.
B. Review whether the morphine dose is therapeutic for his weight.
While reviewing the dose for the child's weight is important, it may not be the immediate next step in this situation. If the child is experiencing pain that persists after one hour, the priority is to address the immediate pain concern. The nurse can later review the medication orders and dosages in collaboration with the healthcare provider.
C. Call the physician immediately.
This is the most appropriate next step in this scenario. If the child is experiencing pain despite having received morphine one hour ago, contacting the physician is important to discuss the current situation, assess the need for additional pain management, and potentially make adjustments to the treatment plan.
D. Encourage the child to use television as a form of distraction.
Distraction can be a helpful complementary measure for managing pain, but it may not be sufficient in this case if the pain persists. The primary focus should be on addressing the pain through appropriate medical interventions, and calling the physician is a more urgent step.
Correct Answer is ["3"]
Explanation
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is commonly used to assess pain in preverbal children. Each category is scored on a scale from 0 to 2, and the total scores range from 0 to 10. Let's assess the given observations:
Face: occasional grimace (score 1)
Leg: relaxed (score 0)
Activity: squirming, tense (score 2)
Cry: no cry (score 0)
Consolability: content, relaxed (score 0)
Now add the scores together: 1 (Face) + 0 (Leg) + 2 (Activity) + 0 (Cry) + 0 (Consolability) = 3
Therefore, the FLACC score for this preverbal child is 3. This score indicates a moderate level of pain.
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