You enter a two-year-old patient's room and see the pulse oximeter reading 55% oxygen saturation. Your first action would be to:
Call the physician.
Place the patient on 10 L/min oxygen per nasal cannula.
Assess the patient.
Administer oxygen and monitor vital signs while calling the physician.
The Correct Answer is D
Choice A reason: Calling the physician is not the first action because it would delay the immediate intervention of oxygen administration, which is critical for a patient with hypoxia. The physician should be notified after initiating oxygen therapy and assessing the patient's condition.
Choice B reason: Placing the patient on 10 L/min oxygen per nasal cannula is not the first action because it is too high of a flow rate for a two-year-old patient, and it could cause oxygen toxicity or barotrauma. The appropriate oxygen delivery device and flow rate should be determined based on the patient's age, weight, and clinical status.
Choice C reason: Assessing the patient is not the first action because it would also delay the immediate intervention of oxygen administration. The patient's pulse oximetry reading indicates severe hypoxia, which requires prompt treatment to prevent organ damage or death. The patient should be assessed after initiating oxygen therapy and monitoring vital signs.
Choice D reason: Administering oxygen and monitoring vital signs while calling the physician is the correct answer because it provides the most effective and timely response to the patient's hypoxia. Oxygen administration improves the patient's oxygen saturation and tissue perfusion, while vital sign monitoring helps to evaluate the patient's response to therapy and identify any complications. Calling the physician informs them of the situation and allows them to order further interventions or tests as needed.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The child has a high fever is not a correct answer because fever is not a specific sign of croup. Fever can occur in many respiratory infections, such as bronchiolitis, pneumonia, or tonsillitis.
Choice B reason: Wheezing is heard audibly is not a correct answer because wheezing is not a characteristic feature of croup. Wheezing is more common in asthma or bronchiolitis, which affect the lower airways.
Choice C reason: It is bacterial in nature is not a correct answer because croup is usually caused by a virus, such as parainfluenza, adenovirus, or respiratory syncytial virus. Bacterial croup is rare and more severe, requiring hospitalization and antibiotics.
Choice D reason: It has a harsh, barking cough is the correct answer because it is the most distinctive symptom of croup. The cough is caused by the inflammation and narrowing of the larynx and trachea, which produce a sound similar to a seal's bark.
Correct Answer is A
Explanation
Choice A: 100 mg PO q8 hours - This would give a total of 300 mg per day. Given the child's weight of 11 kg, this results in a dosage of about 27 mg/kg/day, which is within the safe range of 20-40 mg/kg/day.
Choice B: 350 mg PO q8 hours - This would give a total of 1050 mg per day. This results in a dosage of about 95 mg/kg/day, which is more than twice the upper limit of the safe range.
Choice C: 220 mg PO q8 hours - This would give a total of 660 mg per day. This results in a dosage of about 60 mg/kg/day, which is above the safe range.
Choice D: 500 mg PO q8 hours - This would give a total of 1500 mg per day. This results in a dosage of about 136 mg/kg/day, which is more than three times the upper limit of the safe range.
Therefore, the only safe dosage among these options is 100 mg PO q8 hours. Always remember to double-check dosages and consult with a healthcare professional if you're unsure. Safety is paramount when it comes to medication administration.
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