What is the best intervention for the nurse caring for a child experiencing an acute asthma attack?
Offer plenty of fluids, particularly carbonated beverages.
Place the child in a humidified cool mist tent with oxygen.
Administer sedatives as ordered to decrease anxiety.
Position the child with arms resting on the overbed table.
The Correct Answer is D
Choice A rationale
Offering plenty of fluids is important for hydration and thinning secretions in asthma, but carbonated beverages can cause gastric distension and worsen respiratory distress by pressing on the diaphragm, making them unsuitable. Furthermore, this intervention does not directly address the acute bronchoconstriction that defines an asthma attack.
Choice B rationale
While humidified oxygen might be indicated for hypoxemia, a cool mist tent is not the primary intervention for acute asthma. The core problem is bronchoconstriction, which requires bronchodilators to open the airways. A cool mist tent offers general comfort but does not provide specific therapeutic relief for the underlying pathophysiology.
Choice C rationale
Administering sedatives to a child experiencing an acute asthma attack is generally contraindicated. Sedation can depress respiratory drive, worsen hypoventilation, and mask signs of worsening respiratory distress, potentially leading to respiratory arrest, especially when the child's respiratory effort is already compromised.
Choice D rationale
Positioning the child with arms resting on the overbed table, often referred to as the "tripod position," allows for the use of accessory respiratory muscles (e.g., sternocleidomastoid, scalenes) to facilitate breathing. This position optimizes lung expansion and reduces the work of breathing by providing a stable base for shoulder girdle muscles to pull up the chest cage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Oseltamivir, an antiviral neuraminidase inhibitor, is most effective when administered within 48 hours of influenza symptom onset. It works by inhibiting the viral neuraminidase enzyme, preventing the release of new virions from infected cells, thereby reducing viral spread and shortening the duration and severity of illness, if given early.
Choice B rationale
Rest is indeed important for recovery from influenza, as it conserves energy and allows the immune system to combat the infection. However, decreasing fluid intake is contraindicated; adequate hydration is crucial to prevent dehydration, especially with fever, and to help thin respiratory secretions, facilitating their clearance.
Choice C rationale
Influenza is a viral infection; therefore, antibiotics, which target bacterial pathogens, are ineffective against the influenza virus itself. Administering antibiotics would be inappropriate and could contribute to antibiotic resistance without providing therapeutic benefit for the viral illness, unless a secondary bacterial infection is suspected.
Choice D rationale
Admission to an acute care facility is generally reserved for severe cases of influenza, such as those with respiratory distress, hypoxemia, or significant comorbidities. For a patient whose symptoms started only 24 hours prior and without severe complications, outpatient management with antiviral therapy is typically sufficient.
Correct Answer is B
Explanation
Choice A rationale
Black and tarry stools (melena) typically indicate upper gastrointestinal bleeding, where digested blood causes the dark color. This is not a characteristic of steatorrhea, which is caused by the presence of undigested fat. Steatorrhea results from pancreatic enzyme insufficiency, a common feature of cystic fibrosis.
Choice B rationale
Steatorrheaic stools are classically described as frothy, foul-smelling, and fatty due to the malabsorption of fats. The lack of pancreatic lipase, a characteristic of cystic fibrosis, prevents proper fat digestion. This undigested fat is then excreted, leading to stools that are bulky, pale, and often float due to their high fat content.
Choice C rationale
Clay-colored stools are indicative of a lack of bile pigment, suggesting an obstruction of the bile ducts or liver dysfunction. While liver involvement can occur in cystic fibrosis, clay-colored stools are not the primary descriptor for steatorrhea resulting from pancreatic insufficiency.
Choice D rationale
Orange or green stools are not typical descriptions for steatorrhea. Orange stools can sometimes be due to certain medications or foods, while green stools can result from rapid transit through the digestive system, where bile has not had time to be fully broken down. Neither describes the characteristic appearance of fatty stools.
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