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 A

Explanation

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.

A. Kawasaki disease B. Tricuspid Atresia C. Tetralogy of Fallot D. Patent Ductus Arteriosus (PDA)

Correct Answer is D

Explanation

A. Kawasaki disease typically presents with fever, rash, and conjunctivitis, not a machine-like murmur or the other cardiovascular findings.

B. Tricuspid Atresia involves a defect in the tricuspid valve and presents with cyanosis and poor circulation, but not a machine-like murmur.

C. Tetralogy of Fallot involves a murmur due to pulmonary stenosis and VSD but would not produce a "machine-like" murmur, which is characteristic of PDA.

D. Patent Ductus Arteriosus (PDA) results in a continuous "machine-like" murmur due to abnormal blood flow between the aorta and pulmonary artery, along with findings of pulmonary congestion and right ventricular hypertrophy.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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:

Correct Answer is D

Explanation

Tetralogy of Fallot (TOF) involves which defects? Select all that apply.

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?

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 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.

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

The nurse is reinforcing education to the parents of a toddler diagnosed with bronchiolitis. The nurse informs the parents that which of the following is the most common cause of bronchiolitis?

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?