A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which action is the nurse's priority?
Insert an IV catheter.
Prepare for nasotracheal intubation.
Administer an antipyretic.
Obtain blood culture specimens.
The Correct Answer is B
Insert an IV catheter: While this might be necessary later, it’s not the immediate priority. The child’s breathing difficulty is the most urgent concern.
B. Prepare for nasotracheal intubation: This is the correct answer. The child’s severe dyspnea indicates a serious breathing problem. Nasotracheal intubation can help ensure the child’s airway remains open.
C. Administer an antipyretic: While this might help reduce the child’s fever, it won’t address the immediate life-threatening issue, which is the child’s difficulty breathing.
D. Obtain blood culture specimens: This could be helpful in diagnosing the cause of the child’s symptoms, but it’s not the immediate priority. The first concern should be stabilizing the child’s condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer 0.9% sodium chloride IV solution: While hydration is important, it’s not the first step in managing a child with suspected epiglottitis.
B. Initiate IV antibiotics: Antibiotics are typically used in the treatment of epiglottitis, but they are not the first step. The first step should be to prevent the spread of the infection.
C. Place the child on droplet precautions: This is the correct answer. Epiglottitis is a potentially life-threatening condition caused by infection. Droplet precautions can help prevent the spread of the infection to others.
D. Assist with obtaining an x-ray of the child’s neck: While an x-ray can help confirm the diagnosis of epiglottitis, it’s not the first step. The first step should be to prevent the spread of the infection.
Correct Answer is D
Explanation
A. Assist the client to a side-lying position: This is not typically necessary for administering nasal decongestant drops. The client can be in an upright position with the head tilted back to allow the drops to flow into the nasal passages.
B. Instruct the client to stay in the same position for 2 min: While it’s beneficial for the client to remain with their head tilted back for a short time after the drops have been administered, a specific time frame of 2 minutes is not typically necessary. The medication will start working regardless.
C. Hold the dropper 2 cm (1 in) above the naris: The dropper should be close to the naris, but not touching it to maintain hygiene and prevent contamination of the dropper. However, holding it 2 cm above may cause the drops to miss the nasal passage and not be as effective.
D. Tell the client to blow her nose gently before the instillation: This is the correct action. Clearing the nasal passages before administering the drops ensures that the medication can reach the affected areas. This is achieved by gently blowing the nose. Therefore, option D is the most appropriate action for the nurse to take.
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