A nurse in an emergency department is assessing a 2-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority?

Obtain blood culture specimens.

Administer an antipyretic.

Prepare for nasotracheal intubation.

Insert an IV catheter.

Answer and Explanation

The Correct Answer is C

Choice A reason: Obtaining blood culture specimens is important to identify the causative organism and guide antibiotic therapy, but it is not the priority action for a child who is in respiratory distress. The nurse should first secure the airway and stabilize the child's condition.

Choice B reason: Administering an antipyretic may help lower the fever and reduce discomfort, but it does not address the cause of the dyspnea and drooling, which may indicate epiglottitis. This is a life-threatening condition that requires immediate airway management.

Choice C reason: Preparing for nasotracheal intubation is the priority action for a child who has signs of epiglottitis, as it can prevent airway obstruction and respiratory failure. The nurse should have the equipment and personnel ready for intubation and avoid any stimulation or manipulation of the throat that can trigger laryngeal spasm.

Choice D reason: Inserting an IV catheter is necessary to administer fluids and medications, but it is not the first priority for a child who is in respiratory distress. The nurse should focus on the airway before the circulation.

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Correct Answer is B

Explanation

Choice A reason: This statement is incorrect, as reports of thirst are not a manifestation of hemorrhage following a tonsillectomy. Thirst may be caused by dehydration, dry mouth, or fever, which are common after surgery.

Choice B reason: This statement is correct, as frequent swallowing is a manifestation of hemorrhage following a tonsillectomy. Swallowing may indicate that the child is bleeding from the surgical site and trying to clear the blood from the throat. The nurse should inspect the child's mouth and throat for signs of bleeding and notify the provider.

Choice C reason: This statement is incorrect, as mouth breathing is not a manifestation of hemorrhage following a tonsillectomy. Mouth breathing may be due to nasal congestion, pain, or swelling, which are expected after surgery.

Choice D reason: This statement is incorrect, as reports of pain are not a manifestation of hemorrhage following a tonsillectomy. Pain is a normal and expected outcome after surgery and should be managed with analgesics and comfort measures.

A. My child will take the enzymes following meals. B. My child will take the enzymes 2 hours before meals. C. My child will take the enzymes to improve her metabolism. D. My child will take the enzymes to help digest the fat in foods.

Correct Answer is D

Explanation

Choice A reason: This statement is incorrect, as the child should take the enzymes before or with meals, not after. Taking the enzymes after meals may reduce their effectiveness and cause malabsorption of nutrients.

Choice B reason: This statement is incorrect, as the child should take the enzymes within 30 minutes before meals, not 2 hours. Taking the enzymes too early may cause them to be inactivated by the stomach acid and lose their function.

Choice C reason: This statement is incorrect, as the child does not take the enzymes to improve her metabolism, but to replace the deficient pancreatic enzymes that are needed for digestion. The child has cystic fibrosis, a genetic disorder that affects the exocrine glands and causes thick mucus to block the ducts of the pancreas.

Choice D reason: This statement is correct, as the child takes the enzymes to help digest the fat in foods, as well as other nutrients such as protein and carbohydrates. The enzymes contain lipase, amylase, and protease, which break down fat, starch, and protein respectively.

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A nurse in an emergency department is assessing a 2-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which of the following findings is a manifestation of this postoperative complication?

Correct Answer is B

Explanation

A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements by the mother indicates that she understands the teaching?

Correct Answer is D

Explanation

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A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?

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A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

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