In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?
Instruct the mother to play with the child for stimulation and distraction
Administer a dose of acetaminophen as needed
Monitor the child's oxygen saturation level via pulse oximetry.
Encourage the child to drink adequate amounts of fluids
The Correct Answer is C
Croup is a respiratory infection that causes inflammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily, and observe the color and amount of urine when assessing a client for signs and symptoms of fluid volume excess. These actions can help detect changes in the cardiovascular, renal, and fluid balance systems that may indicate fluid overload, such as tachycardia, bounding pulse, weight gain, edema, oliguria, or dark urine.
The other options are not correct because:
b. Checking fingernails for the presence of clubbing is not relevant for assessing fluid volume excess, as clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and nails.
e. Comparing muscle strength of both arms is not relevant for assessing fluid volume excess, as muscle weakness is not a specific sign of fluid overload, but may be caused by various factors such as electrolyte imbalance, nerve damage, or fatigue.
Correct Answer is D
Explanation
A) Incorrect- While the history of vomiting is important to assess, it may not be the most crucial information to gather at this point, as the client is postoperative and the focus is on immediate postoperative care.
B) Incorrect- While assessing for fluid intake is important, the client's refusal of ice chips is not an urgent concern compared to other potential complications, such as pain management, oxygenation, and fluid balance.
C) Incorrect- These assessments are important, but the client's history of right hemicolectomy and the current infusion and medication administration require closer attention to fluid balance, pain control, and oxygenation.
D) Correct- While all options are important to consider, the most critical information in this scenario is assessing peripheral pulses and the range of motion of both legs. A right hemicolectomy involves abdominal surgery and decreased or absent peripheral pulses along with a limited range of motion could indicate impaired circulation, thrombosis, or other post-operative complications. These findings might necessitate prompt intervention to prevent potential complications.
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