A 9-year-old patient is admitted to the pediatric unit with a diagnosis of status asthmaticus. Upon entering the hospital room, the nurse observes that the child is sitting and leaning forward on an overbed table. The patient's SpO2 is 93%. The nurse should take which action next?
Allow the patient to remain in the chosen position.
Place the patient in semi-Fowler's.
Administer 100% oxygen via a face mask.
Encourage consumption of cool, clear fluids.
The Correct Answer is B
Choice A rationale:
Allowing the patient to remain in the chosen position is inappropriate as the patient's position indicates distress. This choice should not be chosen.
Choice B rationale:
Placing the patient in semi-Fowler's position is the correct action. This position optimizes lung expansion and promotes easier breathing, which is crucial in managing status asthmaticus.
Choice C rationale:
Administering 100% oxygen via a face mask might be necessary eventually, but optimizing positioning takes precedence. Semi-Fowler's position should be established first.
Choice D rationale:
Encouraging consumption of cool, clear fluids is not the immediate priority in managing status asthmaticus. Respiratory support and positioning are more crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.
Choice B rationale:
Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.
Choice C rationale:
Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.
Choice D rationale:
Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.
Correct Answer is C
Explanation
Choice A rationale:
Fever and hypertension are not typical findings in moderate dehydration. Dehydration often leads to hypotension rather than hypertension, and fever is not a direct consequence of dehydration.
Choice B rationale:
Increased specific gravity can be a sign of dehydration, but it is not as specific or sensitive as tachypnea (rapid breathing) and tachycardia (elevated heart rate), which occur due to the body's compensatory mechanisms in response to dehydration.
Choice C rationale:
Tachypnea and tachycardia are key indicators of moderate dehydration in infants. The body tries to maintain perfusion by increasing the heart rate and respiratory rate. These signs are more reliable indicators of dehydration than specific gravity or fever.
Choice D rationale:
Bulging posterior fontanel is not a typical finding in dehydration. A sunken fontanel might be more indicative of dehydration, as fluid shifts from the intracellular to the extracellular space.
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