A nurse is caring for a school-age child in the pediatric unit.
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?
Increase the oxygen flow rate to 4 liters per minute.
Administer a bronchodilator as prescribed.
Encourage the child to drink more fluids.
Notify the provider of the child’s condition.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Blood should not be stored at room temperature for more than 30 minutes. The second unit should be stored in a blood bank refrigerator until needed.
Choice B rationale
Each unit of blood should be infused within 4 hours to reduce the risk of bacterial contamination.
Choice C rationale
RBCs should be administered using filtered IV tubing to prevent the infusion of clots and other debris.
Choice D rationale
Dextrose 5% in water should not be used during the infusion of packed RBCs as it can cause hemolysis. .
Correct Answer is D
Explanation
The correct answer is D. Varicella.
Choice A rationale
Rotavirus vaccination is typically administered in infancy, not at 5 years of age. The rotavirus vaccine is given to infants to protect against rotavirus infections, which can cause severe diarrhea and dehydration in young children. By the age of 5, children have usually completed the rotavirus vaccination series.
Choice B rationale
Hepatitis B vaccination is also typically completed in infancy. The hepatitis B vaccine is given to infants to protect against hepatitis B virus infection, which can cause chronic liver disease and liver cancer. By the age of 5, children who are up-to-date with their immunizations have usually completed the hepatitis B vaccination series.
Choice C rationale
Haemophilus influenzae type b (Hib) vaccination is typically completed by 15 months of age. The Hib vaccine protects against infections caused by Haemophilus influenzae type b, such as meningitis, pneumonia, and epiglottitis. By the age of 5, children who are up-to-date with their immunizations have usually completed the Hib vaccination series.
Choice D rationale
The second dose of the varicella vaccine is usually given at 4-6 years of age. The varicella vaccine protects against chickenpox, a highly contagious viral infection that causes an itchy
rash and fever. Administering the second dose of the varicella vaccine at this age helps ensure that the child has adequate immunity against chickenpox.
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