A nurse is caring for a child that is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first?
Encourage the child to take deep breaths.
Ensure proper placement of the sensor probe.
Place the child in the Fowler's position.
Increase the oxygen flow rate.
The Correct Answer is B
A. Encourage the child to take deep breaths: While deep breaths may help improve oxygenation, the first action should be confirming that the monitoring device is correctly placed and providing accurate readings.
B. Ensure proper placement of the sensor probe: Incorrect placement of the sensor probe (e.g., on a fingernail or a cold extremity) can lead to inaccurate oxygen saturation readings. Ensuring proper placement is the priority to verify the accuracy of the reading.
C. Place the child in the Fowler's position: Fowler's position can help with breathing, but before making this change, the nurse should first verify that the pulse oximeter is working correctly.
D. Increase the oxygen flow rate: Increasing the oxygen flow rate may be necessary if the child’s oxygen saturation remains low, but the first step is to ensure the monitoring device is accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sickle Cell Disease: Sickle cell disease presents with episodes of pain, anemia, and other complications, but it does not typically cause sneezing, coughing, nasal congestion, or apneic spells.
B. Bronchiolitis: Bronchiolitis is a viral respiratory infection, most commonly caused by respiratory syncytial virus (RSV), that affects infants and young children. Symptoms include sneezing, coughing, nasal congestion, fever, and apneic episodes, which match the description in the question.
C. Croup: Croup is characterized by a barky cough, hoarseness, and stridor, usually due to viral infections such as parainfluenza. It does not typically cause apneic spells in a 3-month-old.
D. Epiglottitis: Epiglottitis presents with severe sore throat, difficulty swallowing, drooling, and stridor. It is a more acute, life-threatening condition that does not typically present with nasal congestion or apneic spells.
Correct Answer is C
Explanation
A. Inhaled steroid: Inhaled corticosteroids are used for long-term control of asthma and are not typically used during an acute asthma attack. They work by reducing inflammation, but they do not provide immediate relief of bronchoconstriction.
B. Oral leukotriene modifiers: Leukotriene modifiers are used for long-term asthma management, but they are not effective in providing quick relief during an acute asthma attack.
C. Inhaled beta agonist: Beta agonists (e.g., albuterol) are the first-line treatment for quick relief during an asthma attack. They work by relaxing the muscles around the airways to improve airflow and relieve symptoms like chest tightness and coughing.
D. Oral steroids: Oral steroids (e.g., prednisone) are used for severe asthma exacerbations, but they are not used as the first-line treatment for quick relief of symptoms like tight chest and cough. They take time to reduce inflammation.
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