A mother calls her pediatrician's office concerned about her 7-month-old son. She gave him peanuts for the second time for lunch and he has vomited three times is coughing and looks flushed. What is the priority of the nurse?
Give Benadryl PO and monitor for the next 2 hours
Recommend symptomatic treatment for the cough
Tell the mother to call 911
Administer CPR to the child
The Correct Answer is C
The symptoms described, including vomiting, coughing, and looking flushed, are concerning for a potentially severe allergic reaction, which can be life-threatening. This could be indicative of anaphylaxis, a severe allergic reaction that requires immediate medical attention.
Administering CPR (Option D) is not appropriate at this point unless the child becomes unresponsive and stops breathing, which would be a very late sign of anaphylaxis. In such a situation, CPR would be necessary, but the primary focus should be on calling 911 and obtaining immediate medical assistance.
Option A, giving Benadryl, can be part of the treatment for an allergic reaction, but it should not be the first or only action taken in a severe allergic reaction. Immediate medical evaluation and potential administration of epinephrine are more critical.
Option B, recommending symptomatic treatment for the cough, is not appropriate in this situation. The priority is recognizing the potential severity of the allergic reaction and seeking immediate emergency care.
Therefore, the nurse should advise the mother to call 911 to ensure that the child receives prompt medical attention and assessment for anaphylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Assessing pulses is a critical step immediately after a cardiac catheterization procedure because it helps determine the adequacy of blood flow to the extremities and any potential vascular complications. Cardiac catheterization involves the insertion of a catheter through blood vessels, which can temporarily affect blood flow. Checking pulses in the affected limb (e.g., the leg or arm where the catheter was inserted) is essential to detect any signs of vascular compromises, such as decreased or absent pulses, which could indicate complications like arterial thrombosis or embolism. Prompt recognition of such issues is crucial for timely intervention to prevent potential complications or limb damage.
The other options are also important but should be addressed after the initial assessment of pulses:
A. Pain: Assessing pain is important, but it should come after checking pulses. If the child reports pain, it could indicate discomfort or complications related to the procedure, which may require further evaluation and intervention.
C. Catheterization report: Reviewing the catheterization report is necessary for a comprehensive understanding of the procedure and its findings, but it is not the immediate priority when assessing the child's post-procedure condition.
D. Hemoglobin and hematocrit levels: Checking hemoglobin and hematocrit levels is important to monitor for potential bleeding complications that may occur during or after the procedure, but it is a secondary assessment compared to evaluating pulses. If there are significant changes in these levels, they may require further investigation and intervention.
In summary, assessing pulses is the initial priority after a cardiac catheterization procedure in order to promptly identify any vascular issues or complications that need immediate attention.
Correct Answer is B
Explanation
Tetralogy of Fallot is a congenital heart defect characterized by four specific abnormalities:
Ventricular septal defect (VSD): This is a hole in the wall (septum) between the two lower chambers (ventricles) of the heart.
Overriding aorta: The aorta is positioned over both the left and right ventricles, which allows oxygen-poor (deoxygenated) blood from the right ventricle to be pumped into the aorta and to the body.
Pulmonic stenosis (PS): This is a narrowing of the pulmonary valve or artery that restricts blood flow from the right ventricle to the lungs.
Right ventricular hypertrophy: The right ventricle becomes thicker and more muscular as it works harder to pump blood against the narrowed pulmonary valve or artery.
Options A, C, and D describe different congenital heart conditions and defects, but they are not associated with Tetralogy of Fallot:
A. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus are not part of the constellation of defects seen in the Tetralogy of Fallot.
C. Describing the aorta exiting from the right ventricle and pulmonary artery exiting from the left ventricle with two noncommunicating circulations is characteristic of transposition of the great arteries, not Tetralogy of Fallot.
D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle describe a different congenital heart condition, not Tetralogy of Fallot.
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