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A nurse is caring for a school-age child in the pediatric unit.

Exhibits

A nurse is reviewing the child’s medical record. Based on the exhibits provided, which of the following is the most appropriate initial nursing action?

A.

Increase the oxygen flow rate to 4 liters per minute.

B.

Administer a bronchodilator as prescribed.

C.

Encourage the child to drink more fluids.

D.

Notify the provider of the child’s condition.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

 

Increasing the oxygen flow rate to 4 liters per minute may improve oxygenation temporarily, but it does not address the underlying cause of the child’s respiratory distress. Additionally, increasing oxygen flow without a provider’s order can be unsafe.

 

Choice B rationale:

 

Administering a bronchodilator as prescribed can help relieve bronchospasm and improve airflow. However, it is essential to notify the provider first to ensure that the bronchodilator is appropriate for the child’s current condition.

 

 

Choice C rationale:

 

Encouraging the child to drink more fluids is important for hydration, especially if the child has a fever and dry skin. However, it is not the most immediate action needed to address the child’s respiratory distress.

 

Choice D rationale:

 

Notifying the provider of the child’s condition is the correct answer. The child is showing signs of respiratory distress, including nasal flaring, cyanosis, and increased respiratory rate. Promptly informing the provider ensures that appropriate medical interventions can be initiated to stabilize the child’s condition.

 


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Related Questions

Correct Answer is A,C,B,D

Explanation

Using a metered-dose inhaler (MDI) correctly is all about timing and technique to ensure the medication actually reaches the lungs instead of just hitting the back of the throat. Here is the correct sequence of steps the nurse should teach the child: Choice A: Depress the canister while inhaling slowly. The child should start a slow, deep breath and press the canister at the beginning of that inhalation to draw the mist deep into the airways. Choice C: Hold breath for 10 seconds. Once the inhalation is complete, holding the breath allows the tiny droplets of medicine to settle into the lower lungs rather than being immediately exhaled. Choice B: Remove the inhaler from the mouth. After the breath-hold, the device is removed before exhaling to ensure no moisture from the breath gets into the mouthpiece. Choice D: Exhale slowly through the nose. A controlled exhale completes the process and prepares the child for a second puff if one was prescribed. Pro-Tips for Pediatric Use Shake it up: Always remind the child to shake the inhaler for 3-5 seconds before use. The "Wait" Rule: If a second puff of the same medication is needed, it’s best to wait about 30–60 seconds between inhalations. Spacer Benefits: For many children, using a spacer is highly recommended because it eliminates the need for perfect "press-and-breathe" coordination.

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale

Increasing fluid intake is not appropriate as it does not address the issue of vomiting and can lead to fluid overload.

Choice B rationale

Giving an antiemetic is not recommended without consulting a healthcare provider as it may interact with digoxin.

Choice C rationale

Administering the next dose as prescribed is the correct action. If a dose is vomited, it should not be repeated, and the next dose should be given at the regular time.

Choice D rationale

Mixing the medication with 8 oz of formula is not recommended as it can affect the absorption and effectiveness of the medication.

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