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: Epiglottitis is a life-threatening condition that causes inflammation and swelling of the epiglottis, the flap of tissue that covers the entrance to the trachea. It can block the airway and cause respiratory distress. The signs and symptoms of epiglottitis include drooling, dysphagia, dysphonia, high fever, and tripod position. Epiglottitis is rare in infants and more common in children aged 2-6 years.

Choice B reason: Bronchiolitis is a viral infection that causes inflammation and mucus production in the bronchioles, the smallest airways in the lungs. It can impair gas exchange and cause respiratory distress. The signs and symptoms of bronchiolitis include sneezing, coughing, nasal congestion, wheezing, tachypnea, retractions, and apneic spells. Bronchiolitis is common in infants and children under 2 years of age, especially during the winter months.

Choice C reason: Influenza is a viral infection that affects the respiratory system. It can cause fever, chills, headache, muscle aches, fatigue, sore throat, cough, and nasal congestion. Influenza can also lead to complications such as pneumonia, otitis media, and sinusitis. Influenza is common in children and adults of all ages, especially during the flu season.

Choice D reason: Croup is a viral infection that causes inflammation and narrowing of the larynx and trachea. It can cause a characteristic barking cough, hoarseness, stridor, and respiratory distress. Croup is common in children aged 6 months to 3 years, especially during the fall and winter months.

A. "We will restrict the amount of salt in our child's food." B. "I'll limit my child's fluid intake." C. "We will give our child pancreatic enzymes with snacks and meals." D. "We'll prepare low-fat meals with limited protein for my child."

Correct Answer is C

Explanation

Choice A reason: Restricting salt in a child with CF is not advised because these children can lose excessive amounts of salt when they sweat. Maintaining adequate salt intake is important to prevent electrolyte imbalances.

Choice B reason: Limiting fluid intake is not recommended for children with CF. Adequate hydration helps to thin mucus secretions, making them easier to clear from the lungs.

Choice C reason:This is the correct choice. Pancreatic enzyme replacement therapy is essential for children with CF because it helps them digest and absorb nutrients from their food, which is critical due to the malabsorption issues associated with CF.

Choice D reason: Preparing low-fat meals with limited protein is not recommended for children with CF. They require a high-calorie diet with sufficient protein to meet their nutritional needs due to their increased metabolic rate and malabsorption issues.

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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?

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