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.

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Correct Answer is C

Explanation

A. Staying home for 2 weeks is excessive; typically, 24 to 48 hours of antimicrobial therapy is enough before the child is no longer contagious.

B. While discharge is a sign of infection, the child can often return to school after receiving treatment for 24 to 48 hours.

C. This is correct. Bacterial conjunctivitis is contagious, and children should stay home until they've been on antibiotics for 24 to 48 hours to reduce transmission.

D. This is incorrect; the child should stay home for 24 to 48 hours after starting treatment, as they can still be contagious during that time.

A. Croup B. Epiglottitis C. Bronchiolitis D. Laryngotracheobronchitis

Correct Answer is B

Explanation

A. Croup is a viral infection that typically presents with a barking cough and stridor, rather than difficulty swallowing and excessive drooling.

B. Epiglottitis is a life-threatening condition characterized by sudden onset of fever, drooling, difficulty swallowing, and difficulty speaking (dysphonia). It is a medical emergency and often caused by Haemophilus influenzae type B.

C. Bronchiolitis is usually caused by respiratory syncytial virus (RSV) and presents with wheezing, cough, and respiratory distress but not typically with drooling or difficulty swallowing.

D. Laryngotracheobronchitis (another name for croup) also presents with a barking cough and stridor but does not cause difficulty swallowing or drooling.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

The nurse is assessing a 2-year-old client with symptoms of excessive drooling, respiratory distress, difficulty swallowing, and difficulty speaking. Based on these assessment findings, which conditions does the nurse suspect?

Correct Answer is B

Explanation

The nurse is providing asthma education to a teen that has just been diagnosed with asthma. Which of the following statements by the client would indicate a need for further teaching? Select all that apply.

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

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?

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.

After teaching a class about the hemodynamic characteristics of congenital heart disease, the instructor determines that the teaching has been successful when the class identifies which defect as an example of a disorder involving increased pulmonary blood flow?

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?