The nurse notices he has labored breathing, a cough, and an oxygen saturation of 90 Which of the following would be the priority?
Having the child sit up straight in a chair.
Administering 100
Providing sedation as ordered.
Checking his capillary refill time.
The Correct Answer is B
Choice A rationale
While positioning the child upright can help improve lung expansion and ease breathing, it is not the most immediate priority when a child has significant signs of respiratory distress, including labored breathing and a low oxygen saturation of 90. The immediate need is to increase the partial pressure of oxygen in the blood to prevent hypoxemia and potential organ damage.
Choice B rationale
The child is showing signs of hypoxemia and respiratory compromise (labored breathing, cough, oxygen saturation 90) following a near-drowning incident. Oxygen administration is the priority intervention to increase arterial oxygen saturation and ensure adequate oxygen delivery to tissues. A saturation of 90 is a clinical sign of respiratory insufficiency requiring supplemental oxygenation.
Choice C rationale
Sedation should be avoided in a child with respiratory distress unless agitation is significantly interfering with ventilatory efforts or necessary procedures. Sedatives can further depress respiratory drive, potentially worsening hypoventilation and the existing hypoxemia, which would be detrimental to the child's recovery in this critical scenario.
Choice D rationale
Checking capillary refill time is an assessment of peripheral perfusion, which is important but secondary to immediate oxygenation and ventilation support. While circulatory status is critical, addressing the life-threatening hypoxemia, as indicated by the 90 oxygen saturation, takes precedence in the initial management of a respiratory emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["36"]
Explanation
Step 1 is to convert the patient's weight from pounds to kilograms. 59 pounds ÷ 2.2 kg/pound = 26.8181. kg. We will use the unrounded number for the next step.
Step 2 is to calculate the daily fluid requirement based on the Holliday-Segar method. The patient weighs 26.8181. kg, which is more than 20 kg. Fluid for the first 10 kg: 10 kg × 100 mL/kg = 1000 mL. Fluid for the second 10 kg: 10 kg × 50 mL/kg = 500 mL. Remaining weight: 26.8181. kg - 20 kg = 6.8181. kg. Fluid for the remaining weight: 6.8181. kg × 20 mL/kg = 136.3636. mL.
Step 3 is to calculate the total daily fluid requirement. 1000 mL + 500 mL + 136.3636. mL = 1636.3636. mL.
Step 4 is to round the final answer to the nearest whole number. 1636.3636. mL rounded to the nearest whole number is 1636. The daily fluid requirement is 1636 mL.
Correct Answer is D
Explanation
Choice A rationale
Providing false reassurance, such as stating "he will be okay," is not therapeutic because the outcome is uncertain, especially during active resuscitation efforts. The nurse must maintain honesty and support while acknowledging the gravity of the situation. Offering simple presence and resource information is much more supportive and appropriate for the family.
Choice B rationale
This response inappropriately questions the parents' actions and implies blame or judgment during an emotionally devastating crisis. Such a statement is highly unsupportive, unprofessional, and potentially damaging to the therapeutic relationship. The focus must remain on providing comfort, support, and necessary information to the grieving family.
Choice C rationale
Although it attempts to validate their feelings of fear, this response focuses on a specific, potentially guilt-inducing detail (the driving) which is likely irrelevant to the immediate need for support. It may exacerbate parental guilt during a critical time. A supportive response should be broad and non-judgmental, addressing their general distress and needs.
Choice D rationale
This statement is the most appropriate and therapeutic response, as it conveys non-judgmental presence, validation of the family's difficult emotional state, and an offer to provide information and answer questions. It establishes the nurse as a supportive resource for the family during a time of extreme crisis and uncertainty, which is the primary nursing role.
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