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: Notifying the child's parents of his condition is important, but it is not the first action that the nurse should take. The nurse should prioritize the child's immediate needs and assess his respiratory status.
Choice B reason: Educating the child to avoid triggers is a preventive measure that can help reduce the frequency and severity of asthma attacks, but it is not helpful in an acute situation. The nurse should focus on providing relief and monitoring the child's response.
Choice C reason: Transporting the child to the emergency department may be necessary if the child does not respond to the initial interventions or if his condition worsens, but it is not the first action that the nurse should take. The nurse should first attempt to manage the child's symptoms in the office using the Asthma Action Plan.
Choice D reason: Assessing the child's peak expiratory flow and comparing it to the Asthma Action Plan is the first action that the nurse should take. This will help the nurse determine the severity of the child's asthma attack and the appropriate steps to follow. The Asthma Action Plan is a written document that provides individualized instructions for managing asthma based on the child's symptoms and peak flow readings.
Correct Answer is B
Explanation
Choice A reason: This is not appropriate because it implies that the child's current diet is inadequate or incompatible with diabetes management. It may also offend the parents and the child by disregarding their cultural and religious preferences.
Choice B reason: This is appropriate because it shows respect and sensitivity for the child's and the parents' dietary choices. It also helps the nurse to tailor the dietary education and advice according to the child's needs and preferences.
Choice C reason: This is not appropriate because it contradicts the child's and the parents' beliefs and practices. Hindus consider fruit to be sacred and offer it to their gods. They do not eat fruit after it has been offered, as it is considered prasad, or blessed food.
Choice D reason: This is not appropriate because it assumes that meat is the only or the best source of protein. It may also violate the child's and the parents' ethical or religious values, as some Hindus avoid meat or certain types of meat.
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