A nurse in the emergency department is assessing a toddler who has hyperpyrexia, severe dyspnea, and is drooling.
Which of the following actions should the nurse take first?
Administer an antibiotic to the toddler.
Obtain a blood culture from the toddler.
Insert an IV catheter for the toddler.
Prepare the toddler for nasotracheal intubation.
The Correct Answer is D
The nurse should prepare the toddler for nasotracheal intubation first because the toddler is experiencing severe dyspnea and drooling, which are signs of airway obstruction.
Nasotracheal intubation will help to secure the toddler’s airway and improve their breathing.
Choice A is wrong because administering an antibiotic is not the priority intervention for a toddler with airway obstruction.
Choice B is wrong because obtaining a blood culture is not the priority intervention for a toddler with airway obstruction.
Choice C is wrong because inserting an IV catheter is not the priority intervention for a toddler with airway obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should initiate droplet isolation precautions when admitting a child who has acute epiglottitis.
Epiglottitis is commonly caused by Haemophilus influenzae type B and can be transmitted through respiratory droplets.
Choice A is wrong because obtaining a throat culture is not recommended when epiglottitis is suspected, as it can cause further obstruction of the airway.
Choice C is wrong because assisting the child into a supine position can worsen the airway obstruction.
Children with epiglottitis prefer to sit upright with the chin extended and mouth open.
Choice D is wrong because checking oxygen saturation every 4 hours may not be frequent enough for a child with acute epiglottitis who may require continuous monitoring of oxygen saturation.
Correct Answer is C
Explanation
The correct answer is choice C. Elevate the infant’s head to a 10° angle during feedings.
This position can help prevent milk from coming out of the infant’s nose and reduce the risk of choking.
Choice A is wrong because watery eyes are not an indication to discontinue feeding.
Choice B is wrong because babies with cleft palate should be burped more frequently, but not so often as to interrupt good feeding behaviors.
Choice D is wrong because the amount of formula an infant needs varies and should be determined by a pediatrician.
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