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 C
Explanation
Choice A reason: Having a decongestant available to give the child when an attack occurs is not a correct answer because decongestants are not recommended for children under 6 years old. They can cause side effects such as increased heart rate, irritability, and insomnia.
Choice B reason: Having the child sleep in a dry room is not a correct answer because dry air can worsen the inflammation and swelling of the airway. Moist air can help soothe the throat and reduce the coughing.
Choice C reason: Keeping the child's room humidified is the correct answer because humidified air can help loosen the mucus and ease the breathing. A cool-mist humidifier or a steamy bathroom can provide humidification.
Choice D reason: Giving the child an antibiotic at bedtime is not a correct answer because antibiotics are not effective for croup, which is usually caused by a virus. Antibiotics can also cause adverse reactions such as rash, diarrhea, and allergic reactions.
Correct Answer is D
Explanation
Choice A reason: The child's current vital signs are consistent with vital signs over the past 4 hours. This does not indicate that the child is in pain, as the vital signs may be within normal range or stable.
Choice B reason: The child becomes quiet when held and cuddled. This may indicate that the child is comforted by the nurse's presence and touch, not that the child is in pain.
Choice C reason: The child has just returned from the recovery room. This may indicate that the child is still under the influence of anesthesia or sedation, not that the child is in pain.
Choice D reason: The child is lying rigidly in bed and not moving. This is a sign of pain in children, as they may try to avoid movement or stimulation that could worsen their pain. The nurse should assess the child's pain level and administer pain medication as prescribed.
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