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A 7-year-old child with a history of asthma is brought to the emergency department with an acute asthma exacerbation. The child is wheezing and using accessory muscles to breathe. What is the nurse's priority intervention?
- A. Administer a nebulized bronchodilator
- B. Obtain an arterial blood gas
- C. Start the child on oxygen therapy
- D. Notify the healthcare provider
Correct Answer: A
Rationale: In a 7-year-old child with an acute asthma exacerbation showing signs of wheezing and increased work of breathing, the priority intervention for the nurse is to administer a nebulized bronchodilator immediately. Bronchodilators help dilate the airways, relieve bronchospasm, and improve breathing, which is crucial in managing an acute asthma attack and preventing further respiratory distress.
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The infant scheduled for reduction of intussusception passes a soft-formed brown stool the day before the procedure. What intervention should the nurse implement?
- A. Instruct the parents that the infant needs to be NPO.
- B. Notify the healthcare provider of the passage of brown stool.
- C. Obtain a stool specimen for laboratory analysis.
- D. Ask the parents about recent changes in the infant's diet.
Correct Answer: B
Rationale: Notifying the healthcare provider is crucial when an infant scheduled for intussusception reduction passes a soft-formed brown stool as it may indicate spontaneous reduction of the intussusception. The healthcare provider needs to be informed to assess if the procedure is still necessary or if further evaluation is required.
The nurse is caring for a 4-year-old child who is hospitalized with pneumonia. The child is receiving IV antibiotics and oxygen therapy. The nurse notes that the child's respiratory rate is 40 breaths per minute, and the oxygen saturation is 92%. What is the nurse's priority action?
- A. Increase the child's oxygen flow rate
- B. Notify the healthcare provider
- C. Encourage the child to take deep breaths
- D. Auscultate the child's lung sounds
Correct Answer: D
Rationale: In this scenario, the child is hospitalized with pneumonia, receiving IV antibiotics and oxygen therapy. With a high respiratory rate and decreased oxygen saturation, auscultating the child's lung sounds is the priority action. This assessment can provide crucial information about the child's respiratory status, such as the presence of adventitious sounds or decreased air entry, which can guide further interventions and help in evaluating the effectiveness of the current treatments.
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?
- A. Administer morphine sulfate.
- B. Start IV fluids.
- C. Place the infant in a knee-chest position.
- D. Provide 100% oxygen by face mask.
Correct Answer: C
Rationale: In a situation where an infant with tetralogy of Fallot is acutely cyanotic and hyperpneic, the priority action should be to place the infant in a knee-chest position. This position helps increase systemic vascular resistance, improving pulmonary blood flow and subsequently ameliorating the cyanosis and hyperpnea. It is a non-invasive and effective intervention that can be promptly implemented by the nurse to address the immediate respiratory distress.
A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment of the girl is most important for the nurse to obtain?
- A. Understanding of the quality control process used to troubleshoot the pump
- B. Interpretation of fingerstick glucose levels that influence diet selections
- C. Knowledge of her glycosylated hemoglobin A1c levels for the past year
- D. Ability to perform the pump for basal insulin with mealtime boluses
Correct Answer: A
Rationale: In a patient transitioning to an insulin pump, understanding the quality control process to troubleshoot the pump is essential for ensuring proper and safe management of diabetes. This knowledge enables the individual to identify and address any issues that may arise with the pump, helping maintain optimal glycemic control and prevent complications.
The infant scheduled for reduction of intussusception passes a soft-formed brown stool the day before the scheduled procedure. Which intervention should the nurse implement?
- A. Instruct the parents that the infant needs to be NPO.
- B. Notify the healthcare provider of the passage of brown stool.
- C. Obtain a stool specimen for laboratory analysis.
- D. Ask the parents about recent changes in the infant's diet.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.