The parents of a 7-year-old child bring her to the emergency department. They tell the nurse that she awoke with a tympanic temperature of 39.2 (102.2°), an extremely sore throat, drooling, and difficulty swallowing. Which of the following actions is the nurse's priority?

Obtain culture specimens.

Administer an antipyretic.

Prepare for intubation.

Insert an IV catheter.

Answer and Explanation

The Correct Answer is C

A. While obtaining culture specimens is important, the priority in this case is managing the child’s airway, as drooling and difficulty swallowing suggest potential airway obstruction.

B. Administering an antipyretic is not the priority; airway management is more urgent in this situation.

C. The priority is to prepare for intubation, as the child’s symptoms suggest possible epiglottitis, which can cause rapid airway obstruction. Securing the airway is critical.

D. Inserting an IV catheter is important for hydration and medication administration, but airway management is the immediate priority.

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Correct Answer is D

Explanation

A. Asking the client to look away may reduce anxiety for some, but it does not minimize discomfort or promote understanding.

B. Using a larger needle would likely increase discomfort and is not consistent with atraumatic care, which aims to minimize pain.

C. Administering the injection quickly might reduce discomfort but does not address the child’s emotional needs or ensure proper understanding of the procedure.

D. Explaining the procedure in simple terms helps the child understand what will happen, reducing fear and promoting cooperation. This is an important aspect of atraumatic care.

A. Pulmonary stenosis B. Overriding aorta C. Right ventricular hypertrophy D. Coarctation of the aorta E. Ventral septal defect

Correct Answer is ["A","B","C","E"]

Explanation

A. Pulmonary stenosis is one of the characteristic features of TOF, causing obstruction to blood flow to the lungs.
B. Overriding aorta is a defining feature of TOF, where the aorta is positioned over the ventricular septal defect, leading to mixing of oxygenated and deoxygenated blood.
C. Right ventricular hypertrophy occurs in TOF due to increased workload on the right ventricle caused by pulmonary stenosis.
D. Coarctation of the aorta is not part of Tetralogy of Fallot; it is a separate congenital defect.
E. A ventricular septal defect is the hole between the ventricles in TOF, leading to the mixing of oxygenated and deoxygenated blood.

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The parents of a 7-year-old child bring her to the emergency department. They tell the nurse that she awoke with a tympanic temperature of 39.2 (102.2°), an extremely sore throat, drooling, and difficulty swallowing. Which of the following actions is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

An acute care nurse is caring for a pediatric client diagnosed with diabetes mellitus who receives insulin injections. Which of the following actions by the nurse demonstrates atraumatic care?

Correct Answer is D

Explanation

Correct Answer is ["A","B","C","E"]

Explanation

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