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 A
Explanation
Choice A reason: This is the most appropriate action because it respects the youth's autonomy and maturity, and allows for timely and necessary intervention. Assent is the agreement of a minor to participate in a medical decision, and it is usually sufficient in emergency situations when parental consent is not available.
Choice B reason: This is not the most appropriate action because it may delay the surgery and put the youth at risk of further complications. Another relative may not have the legal authority to consent for the youth, and may not be reachable in time.
Choice C reason: This is not the most appropriate action because it does not address the underlying problem of the injury. Pain medications may provide temporary relief, but they may also mask the symptoms and interfere with the surgery.
Choice D reason: This is not the most appropriate action because it may jeopardize the youth's health and safety. Waiting for parents to obtain consent may result in irreversible damage or even death. The youth's best interest should be the priority in this case.
Correct Answer is D
Explanation
Choice A reason: This is not the correct answer because Synagis® is a monoclonal antibody that is given as a prophylaxis to prevent severe RSV infection in high-risk infants. It is not effective as a treatment for RSV bronchiolitis.
Choice B reason: This is not the correct answer because antiviral medication is not routinely recommended for RSV bronchiolitis, as it has not been shown to improve outcomes. Limiting fluids and giving antitussives may also be harmful, as they can cause dehydration and suppress the cough reflex.
Choice C reason: This is not the correct answer because IV antibiotics are not indicated for RSV bronchiolitis, which is a viral infection. Antibiotics may increase the risk of antibiotic resistance and adverse effects.
Choice D reason: This is the correct answer because oxygen mist therapy can help humidify the air and relieve the respiratory distress. IV fluids can prevent dehydration and maintain electrolyte balance. Hand washing can prevent the spread of RSV infection to other patients and staff.
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