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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Barking cough is not a finding that indicates the effectiveness of the treatment. Barking cough is a sign of inflammation of the larynx and trachea, which causes a hoarse and harsh sound. It is a common symptom of acute laryngotracheobronchitis, also known as croup.

Choice B reason: Decreased stridor is a finding that indicates the effectiveness of the treatment. Stridor is a high-pitched, wheezing sound that occurs when the airway is narrowed or obstructed. It is a sign of respiratory distress and hypoxia. The cool mist tent helps to humidify and soothe the airway, reducing the swelling and inflammation.

Choice C reason: Decreased temperature is not a finding that indicates the effectiveness of the treatment. Decreased temperature could be a sign of hypothermia or sepsis, which are serious complications that require immediate attention. The normal temperature range for a toddler is 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice D reason: Improved hydration is not a finding that indicates the effectiveness of the treatment. Improved hydration is a sign of adequate fluid intake and output, which are important for maintaining electrolyte balance and preventing dehydration. However, hydration status does not directly affect the airway inflammation or obstruction.

A. Reports of thirst B. Frequent swallowing C. Mouth breathing D. Reports of pain

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings should indicate to the nurse that the treatment is effective?

Correct Answer is B

Explanation

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 caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take?

A nurse is caring for a 6-week-old infant who has pyloric stenosis. Which of the following clinical manifestations should the nurse expect?

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

A nurse on the pediatric unit is assessing an infant who is 2 months old. Which of the following findings should the nurse report to the provider?

A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should instruct the parent to avoid giving which of the following food choices to the child?

A nurse is caring for a child who is 2 hours postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?

A nurse is preparing to develop a plan of care for a school-aged child who has been diagnosed with sickle cell anemia. Which of the following findings should the nurse include in the plan of care?

A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse plan to take to prevent aspiration? Select all that apply