Nokea
The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. What nursing action should be included in the care of the child?
- A. Force fluids.
- B. Monitor pulse oximetry.
- C. Institute seizure precautions.
- D. Encourage a high-protein diet.
Correct Answer: B
Rationale: Monitoring pulse oximetry is critical to assess oxygenation in ARDS, guiding respiratory support. Fluids are given parenterally to maintain hydration, seizures are not typical in ARDS, and a high-protein diet is not specifically beneficial compared to balanced nutrition.
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A 4-year-old girl is brought to the emergency department. She has a froglike croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should intervene in which manner?
- A. Make her lie down and rest quietly.
- B. Examine her oral pharynx and report to the physician.
- C. Auscultate her lungs and prepare for placement in a mist tent.
- D. Notify the physician immediately and be prepared to assist with a tracheostomy or intubation.
Correct Answer: D
Rationale: The symptoms suggest epiglottitis, a medical emergency requiring immediate physician notification and preparation for airway support like tracheostomy or intubation. Lying down worsens breathing, examining the throat risks obstruction, and mist tents are ineffective for epiglottitis.
The parent of an infant with nasopharyngitis should be instructed to notify the health professional if the infant shows signs or symptoms of which condition?
- A. Has a cough
- B. Becomes fussy
- C. Shows signs of an earache
- D. Has a fever higher than 37.5 C (99 F)
Correct Answer: C
Rationale: Signs of an earache in an infant with nasopharyngitis may indicate complications like otitis media or secondary bacterial infection, requiring medical evaluation. Cough and fussiness are common with viral illnesses, and a fever of 37.5 C is normal and not concerning.
An infants parents ask the nurse about preventing otitis media (OM). What information should be provided?
- A. Avoid tobacco smoke.
- B. Use nasal decongestants.
- C. Avoid children with OM.
- D. Bottle- or breastfeed in a supine position.
Correct Answer: A
Rationale: Avoiding tobacco smoke reduces the risk of otitis media and other childhood illnesses. Nasal decongestants don?t prevent OM, it?s not contagious unless other symptoms are present, and feeding in a semivertical position, not supine, helps prevent OM.
An infant has been diagnosed with staphylococcal pneumonia. Nursing care of the child with pneumonia includes which intervention?
- A. Administration of antibiotics
- B. Frequent complete assessment of the infant
- C. Round-the-clock administration of antitussive agents
- D. Strict monitoring of intake and output to avoid congestive heart failure
Correct Answer: A
Rationale: Antibiotics are essential for treating bacterial pneumonia like staphylococcal pneumonia. Frequent complete assessments are unnecessary if respiratory status is monitored, antitussives are used sparingly to allow secretion clearance, and fluid monitoring prevents dehydration, not heart failure.
The mother of a 20-month-old boy tells the nurse that he has a barking cough at night. His temperature is 37 C (98.6 F). The nurse suspects mild croup and should recommend which intervention?
- A. Admit to the hospital and observe for impending epiglottitis.
- B. Provide fluids that the child likes and use comfort measures.
- C. Control fever with acetaminophen and call if cough gets worse tonight.
- D. Try over-the-counter cough medicine and come to the clinic tomorrow if no improvement.
Correct Answer: B
Rationale: For mild croup, providing hydration with preferred fluids and comfort measures minimizes distress. Hospital admission is unnecessary without epiglottitis signs, the temperature is normal, and over-the-counter cough medicine is not recommended; parents should return if noisy breathing or drooling occurs.