The nurse is assessing a 4-year old client who was sent to the emergency department from urgent care. Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are:

Temp: 39 C (102.2 F)

HR: 188

RR: 46

02: 81%

What is the priority action for the nurse to take at this time?

Keep the child him and call for emergency airway equipment

Assess the throat for a cherry red epiglottis

Place the child on a knee to chest position

Obtain IV access and start IV fluids

Answer and Explanation

The Correct Answer is A

A. The child is showing signs of severe respiratory distress, likely due to epiglottitis. The priority is to keep the child calm to avoid further airway obstruction and to prepare for emergency airway management.

B. While assessing the throat for epiglottitis is important, direct visualization of the throat can cause spasm and worsen airway obstruction.

C. The knee-to-chest position is typically used in cases of respiratory distress in infants (e.g., with RSV), but not in this case.

D. While IV access and fluids may be necessary, the immediate priority is securing the airway.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Aortic stenosis (AS) typically causes a difference in blood flow across the aortic valve but does not usually require assessment of upper and lower extremity blood pressures.

B. Transposition of the Great Vessels (Arteries) results in cyanosis and abnormal circulatory flow but does not require upper and lower extremity blood pressure monitoring.

C. Coarctation of the Aorta (COA) is characterized by narrowing of the aorta, often resulting in higher blood pressure in the upper extremities compared to the lower extremities. Measuring both helps identify this condition.

D. Tetralogy of Fallot (TOF) involves right ventricular outflow obstruction, VSD, overriding aorta, and right ventricular hypertrophy, but upper and lower extremity blood pressures are not typically used for diagnosis.

Correct Answer is []

Explanation

Potential Condition: Viral Pneumonia

High fever (39.88°C/103.8°F), severe fatigue, chills, productive cough, and dyspnea suggest a respiratory infection. Bilateral lung consolidation on x-ray is consistent with viral pneumonia. Negative bacterial culture supports a viral rather than bacterial etiology. Elevated WBC count (12,300/mm³) is slightly above normal, which can occur with viral infections. Crackles in upper lobes, diminished breath sounds in lower lobes are common findings in pneumonia.

Actions to Take (Correct Choices)

Cluster client care to allow for rest: Viral pneumonia leads to fatigue and respiratory distress. Minimizing exertion conserves energy and improves recovery.

Administer prescribed antipyretic: Reduces fever, improves comfort, and helps decrease metabolic demand on the body.

Incorrect Actions and Rationale:

Replace pancreatic enzymes – This is necessary for cystic fibrosis, not viral pneumonia.

Maintain airborne precautions – Airborne precautions are required for tuberculosis (TB), not viral pneumonia. Pneumonia typically requires droplet precautions only if caused by a pathogen like influenza.

Obtain a peak respiratory flow rate – More relevant for asthma, not pneumonia.

Parameters to Monitor (Correct Choices)

Level of fatigue: Fatigue indicates worsening illness or improvement. Increasing exhaustion may suggest hypoxia or worsening pneumonia.

Oxygen saturation levels: 92% on room air is borderline low, requiring monitoring for worsening hypoxemia. Oxygen therapy may be needed if saturation drops further.

Incorrect Parameters:

Allergen triggers – Relevant for asthma, not viral pneumonia.

Diet high in protein and calcium – Important for cystic fibrosis, but not a primary concern for pneumonia management.

Blood glucose levels – More relevant for diabetes or steroid therapy, not viral pneumonia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In which congenital heart defect would the nurse need to take upper and lower extremity blood pressures?

Correct Answer is C

Explanation

Correct Answer is []

Explanation

The nurse is assessing a client diagnosed with ventricular septal defect (VSD), the nurse is aware that many infants with these conditions also receive a diagnosis of which of the following?

The nurse is providing home care instructions to the parent of a 9-year-old child diagnosed with bacterial conjunctivitis. Topical antimicrobial therapy is prescribed for the child. Which statement by the parent indicates that the teaching has been effective?

A nurse is caring for a child who has acute otitis media. Which of the following classic assessment findings should the nurse expect?

A 4-year-old child is diagnosed with otitis media. The parent asks the nurse about the causes of this illness. Which risk factors would the nurse include in response to this parent? Select all that apply.

The nurse is caring for a child diagnosed with Kawasaki disease. Keeping the pathophysiology in mind, the nurse carefully monitors the child for which complication?

While assessing a newborn with respiratory distress, the nurse auscultates a machine-like heart murmur. Other findings are a widened pulse pressure. pulmonary congestion and right ventricular hypertrophy. The nurse suspects that the newborn has:

The primary health care provider prescribes patching for a child with amblyopia of the right eye, and the nurse instructs the parent regarding this procedure. What would the nurse include in the instructions?