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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is B
Explanation
A. A urinary output of 100 mL/hr is within the expected range for a 10-year-old and does not indicate septic shock. In early septic shock, urinary output is often preserved or mildly decreased.
B. An elevated temperature (fever) is a hallmark of early septic shock as the body mounts an inflammatory response to infection. Fever often accompanies early sepsis in pediatric patients.
C. Blood pressure may remain normal or slightly elevated in early septic shock due to compensatory mechanisms. A BP of 130/90 mm Hg is not a defining feature.
D. A heart rate of 60/min is abnormally low for a 10-year-old and could indicate late-stage shock or other complications. In early septic shock, tachycardia (elevated heart rate) is typically observed.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.