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
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Related Questions
Correct Answer is B
Explanation
Deep-breathing and counting exercises can help the child relax and cope with anxiety before the procedure.
Choice A is wrong because a 30-minute teaching session may not be necessary or appropriate for a school-age child.
Choice C is wrong because it’s important to use clear and honest language when explaining the procedure to the child.
Choice D is wrong because it’s important to explain the procedure to the child in a calm and quiet environment, not in the playroom.
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.
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