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 C
Explanation
The correct answer is Choice C.
Choice A rationale
A hemoglobin level of 6.8 g/dL is significantly lower than the normal range (9.5 to 14 g/dL) and indicates anemia. This finding does not suggest that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.
Choice B rationale
An RBC count of 5/mm³ is within the normal range (4 to 5.5/mm³) but does not specifically indicate that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.
Choice C rationale
A WBC count of 15,000/mm³ is higher than the normal range (5,000 to 10,000/mm³) but can indicate that the treatment is having a therapeutic effect. In the context of acute lymphoblastic leukemia, an elevated WBC count can be a sign that the body is responding to treatment.
Choice D rationale
A platelet count of 98,000/mm³ is lower than the normal range (150,000 to 400,000/mm³) and does not indicate that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Restricting the child’s strenuous activities for 3 days is important, but it is not the priority. Monitoring for signs of impaired circulation or complications is more critical.
Choice B rationale
Using a hair dryer on a cool setting to relieve itching can be helpful, but it is not the priority. The priority is to monitor for signs of impaired circulation.
Choice C rationale
Monitoring for pallor or swelling in the child’s affected hand is the priority because it can indicate impaired circulation or compartment syndrome, which are serious complications that require immediate attention.
Choice D rationale
Examining the child for skin irritation at the cast edges is important to prevent complications, but it is not the priority over monitoring for circulation and potential complications. .
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